Effect of ceftazidime/avibactam plus fosfomycin combination on 30 day mortality in patients with bloodstream infections caused by KPC-producing Klebsiella pneumoniae: results from a multicentre retrospective study

Introduction

The primary outcome of the study was to evaluate the effect on 30 day mortality of the combination ceftazidime/avibactam + fosfomycin in the treatment of bloodstream infections (BSIs) caused by KPC-producing Klebsiella pneumoniae (KPC-Kp).

Materials and methods

From October 2018 to March 2021, a retrospective, two-centre study was performed on patients with KPC-Kp BSI hospitalized at Sapienza University (Rome) and ISMETT-IRCCS (Palermo) and treated with ceftazidime/avibactam-containing regimens. A matched cohort (1:1) analysis was performed. Cases were patients receiving ceftazidime/avibactam + fosfomycin and controls were patients receiving ceftazidime/avibactam alone or in combination with in vitro non-active drugs different from fosfomycin (ceftazidime/avibactam ± other). Patients were matched for age, Charlson comorbidity index, ward of isolation (ICU or non-ICU), source of infection and severity of BSI, expressed as INCREMENT carbapenemase-producing Enterobacteriaceae (CPE) score.

Results

Overall, 221 patients were included in the study. Following the 1:1 match, 122 subjects were retrieved: 61 cases (ceftazidime/avibactam + fosfomycin) and 61 controls (ceftazidime/avibactam ± other). No difference in overall mortality emerged between cases and controls, whereas controls had more non-BSI KPC-Kp infections and a higher number of deaths attributable to secondary infections. Almost half of ceftazidime/avibactam + fosfomycin patients were prescribed fosfomycin without MIC fosfomycin availability. No difference in the outcome emerged after stratification for fosfomycin susceptibility availability and dosage. SARS-CoV-2 infection and ICS ≥ 8 independently predicted 30 day mortality, whereas an appropriate definitive therapy was protective.

Conclusions

Our data show that fosfomycin was used in the treatment of KPC-Kp BSI independently from having its susceptibility testing available. Although no difference was found in 30 day overall mortality, ceftazidime/avibactam + fosfomycin was associated with a lower rate of subsequent KPC-Kp infections and secondary infections than other ceftazidime/avibactam-based regimens.

Comparison Between Drug Costs for the Systemic Treatment of Metastatic Lung Cancer, Overall Survival Gain and Economic Growth in Brazil

Background: Systemic treatment of patients with metastatic lung cancer is considered a major advancement in the field of oncology. Although undeniable progress has been made in the treatment of such patients, affordability of the more recently implemented treatments, for people in the less developed parts of the world has been questioned. Aim: To expose the disparity between cancer drugs costs, survival gain and economic growth in a developing country (Brazil), using first line therapy to metastatic lung cancer (nonsquamous only without driver mutations) as an example. Methods: First we analyzed the costs of all included first-line systemic therapy regimens from NCCN guidelines for metastatic lung cancer (nonsquamous and no driver mutation identified) over the last two decades, dividing the therapy in five broad categories, each one corresponding to a “generation” of treatment. The following regimens were considered: single-agent chemotherapy (cisplatin), first-generation platinum doublet (cisplatin/carboplatin + etoposide), second-generation platinum doublet (cisplatin/carboplatin + vinorelbine/gemcitabine/docetaxel/paclitaxel), third-generation platinum doublet (cisplatin/carboplatin + pemetrexed) and immunotherapy (pembrolizumab). After that, we identified in the pivotal studies, how much median overall survival cumulative gain was obtained in each generation of treatment in comparison with the last one. Then we compiled the data and compared, in graphics, with economic metrics observed for Brazil during the same period, such as nominal gross domestic product (GDP) growth, GDP per capita and inflation. Results: It was observed that the current choice of first line therapy for metastatic nonsquamous lung cancer, without driver mutation: cisplatin + pemetrexed or immunotherapy (for patients with high PD-L1 expression), now costs more than 130 to 200 times the price of single-agent cisplatin. Median overall survival has been increased from 4-6 months to around 10-12 months (all patients considered) or 30 months (for patients with high PD-L1 expression), with small incremental gains for each generation of treatment. In comparison, Brazilian GDP had an increase of 85% during the same time span, while GDP per capita increased 45%. Conclusion: The exponential rising in the price of the drugs surpassed much of the economic growth of Brazil in the last two decades. Although the observed median overall survival has been steadily increasing during the same time span, reaching now an impressive mark of 30.2 months (for patients with a high level of PD-L1 expression), it is not in the same pace as the cost of the drugs. This provides major questions about affordability and access to such treatments, especially in developing countries with larger populations, even if their economy is rapidly growing.

Intensive Alternating Combination Chemotherapy and High Dose Chest Radiotherapy in Small Cell Lung Cancer

Sixty-nine patients, 32 with limited and 37 with extensive small cell lung cancer (SCLC), were admitted to the present study. Patients with limited disease underwent alternating combination chemotherapy consisting of CAV (cyclophosphamide, adriamycin, vincristine) and PE (cisplatin and etoposide) regimens and concurrent high dose thoracic radiotherapy (6,000 cGy); prophylactic brain irradiation (3,000 cGy) was administered to complete responders. Patients with extensive disease received the same alternating chemotherapy but not radiotherapy. In the 25 evaluable patients with limited disease we obtained an objective response (OR) in 80% with a complete response (CR) in 54% and partial response (PR) in 24%, stable disease (SD) in 4% and progressive disease (PD) in 16%. Median duration of response was 9.5 months for CR and 8.5 months for PR. Median survival was 14 months for all patients with 12% long-term survivors. Toxicity was acceptable. In the 32 evaluable patients with extensive disease we observed 65.6% OR with 18.7% CR and 46.8% PR, 9.3% minimal response and 25% PD. Median duration of response was 7 months for CR and 8 months for PR. Median survival was 10 months for all patients. The treatment was well tolerated. Our study did not show a therapeutic advantage for alternating combination chemotherapy in SCLC and failed to show the use of high dose chest radiotherapy in combined modality for limited disease.

Combating Implant Infections. Remarks by a Women's Team

Research on implant infections requires cooperative efforts and integration between basic and clinical expertises. An international group of women scientists is acting together in this field. The main research topics of the participants of this group are described. Formation of bacterial biofilms, antibiotic resistance and production of virulence factors like adhesins and toxins are investigated. New biomaterials, coatings and drugs designed to inhibit microbial adhesion are evaluated, and infection-resistant biomaterials are under study, such as a novel heparinizable polycarbonate-urethane (Bionate) or incorporation of diamino-diamide-diol (PIME) to reduce bacterial attachment. The correlation between biofilm production and the accessory-gene-regulator (agr) is investigated in Staphylococcus aureus. The ability to form biofilm has also been shown to be one of the important virulence factors of Enterococcus faecalis, favouring colonization of inert and biological surfaces. The study of quorum sensing has led to the discovery of a quorum sensing inhibitor termed RIP that suppresses staphylococcal biofilm and infections. The immune response and the local defence mechanisms of the host against implant-associated infections, activation and infiltration of immunocompetent cells into the sites of infection have been studied in patients with implant-associated osteomyelitis. Production of monoclonal antibodies (mAbs) as possible vaccines against the staphylococcal collagen-binding MSCRAMMs is in progress. (Int J Artif Organs 2008; 31: 858–64)

Relevance of multidrug-resistant Pseudomonas aeruginosa infections in cystic fibrosis

Multidrug-resistant (MDR) Pseudomonas aeruginosa is an important issue for physicians who take care of patients with cystic fibrosis (CF). Here, we review the latest research on how P. aeruginosa infection causes lung function to decline and how several factors contribute to the emergence of antibiotic resistance in P. aeruginosa strains and influence the course of the infection course. However, many aspects of the practical management of patients with CF infected with MDR P. aeruginosa are still to be established. Less is known about the exact role of susceptibility testing in clinical strategies for dealing with resistant infections, and there is an urgent need to find a tool to assist in choosing the best therapeutic strategy for MDR P. aeruginosa infection. One current perception is that the selection of antibiotic therapy according to antibiogram results is an important component of the decision-making process, but other patient factors, such as previous infection history and antibiotic courses, also need to be evaluated. On the basis of the known issues and the best current data on respiratory infections caused by MDR P. aeruginosa, this review provides practical suggestions to optimize the diagnostic and therapeutic management of patients with CF who are infected with these pathogens.

Methicillin-resistant Staphylococcus aureus infections: A review of the currently available treatment options

This review is the result of discussions that took place at the 5th MRSA Working Group Consensus Meeting and explores the possible treatment options available for different types of infections due to methicillin-resistant Staphylococcus aureus (MRSA), focusing on those antibiotics that could represent a valid alternative to vancomycin. In fact, whilst vancomycin remains a viable option, its therapy is moving towards individualised dosing. Other drugs, such as the new lipoglycopeptides (oritavancin, dalbavancin and telavancin) and fifth-generation cephalosporins (ceftaroline and ceftobiprole), are showing good in vitro potency and in vivo efficacy, especially for patients infected with micro-organisms with higher vancomycin minimum inhibitory concentrations (MICs). Tedizolid is an attractive agent for use both in hospital and community settings, but the post-marketing data will better clarify its potential. Daptomycin and linezolid have shown non-inferiority to vancomycin in the treatment of MRSA bacteraemia and non-inferiority/superiority to vancomycin in the treatment of hospital-acquired pneumonia. Thus, several options are available, but more data from clinical practice, especially for invasive infections, are needed to assign specific roles to each antibiotic and to definitely include them in the new antibacterial armamentarium.

Occipital Plagiocephaly

After the “Back to Sleep” campaign, promoted in 1992 by the American Academy of Paediatrics to prevent the Sudden Infant Death Syndrome (SIDS), it was recommended to place babies in a supine sleeping position. The incidence of SIDS has fallen dramatically since 1992, whereas there has been a major increase in the incidence of occipital plagiocephaly (OP). We report the data relative to the OP cases observed in the Paediatric Department of Padua Hospital between 1998 and 2003. 122 (63%) of the 194 cases of craniosynostosis observed presented OP. The 64 children that took part to the study were contacted and underwent neurological examination with an evaluation of skull shape and previous radiograms. We proposed to parents a questionnaire to define the risk factors and estimate the skull deformity over time. 58 of the 64 children presented positional plagiocephaly (PP), six had synostotic plagiocephaly (SP). Since 1998 there has been a progressive increase in cases of PP. There is a male prevalence (65%), but no side prevalence. Firstborns accounted for 33 (51%), whereas 11 were preterm infants (17%). 82% had a gestational age between the 38th and 40th week. The mean value of the Apgar Index was 8 at the first minute and 9 at the 5th minute. At birth the clinical presentation was: occipital flattening already present at birth in 23 children, preferential head orientation in 18, congenital torticollis in 12, ear asymmetry in 12, frontal bossing in ten. We noticed a mild developmental delay in 8 children (13%). The maximum degree of cranial asymmetry was observed in two peaks in cases of PP: at the third and fourth months (34 cases) and then at the sixth and seventh months (13 cases). The SP presented a progressive exacerbation of the deformity until surgery (done at the sixth to seventh months). PP improved by hygienic postural norms in six months; only three patients required surgery for aesthetic reasons. We observed a strict correlation between side of flattening and sleep head position ( χ2 test, p-value=2,256e-09) and a higher degree of occipital flattening at birth in patients with associated congenital torticollis (Mann-Whitney test, p-value=0.002744). In conclusion, OP is a common condition but essentially benign; it does not cause medical consequences but aesthetic problems. It is necessary to recognize the mild deformity in the newborns so as to intervene early with hygienic postural norms that can correct the asymmetry. The diagnosis is largely clinical and only in case of doubt are radiological examinations required (ultrasonography for sutures, 3D CT scans).

Effects of competition and cooperation interaction between agents on networks in the presence of a market capacity

A network effect is introduced taking into account competition, cooperation, and mixed-type interaction among agents along a generalized Verhulst-Lotka-Volterra model. It is also argued that the presence of a market capacity undoubtedly enforces a definite limit on the agent's size growth. The state stability of triadic agents, i.e., the most basic network plaquette, is investigated analytically for possible scenarios, through a fixed-point analysis. It is discovered that: (i) market demand is only satisfied for full competition when one agent monopolizes the market; (ii) growth of agent size is encouraged in full cooperation; (iii) collaboration among agents to compete against one single agent may result in the disappearance of this single agent out of the market; and (iv) cooperating with two rivals may become a growth strategy for an intelligent agent.

In vivo development of daptomycin resistance in vancomycin-susceptible methicillin-resistant Staphylococcus aureus severe infections previously treated with glycopeptides

Our aim was to describe the clinical and microbiological features of four cases of severe vancomycin-susceptible methicillin-resistant Staphylococcus aureus (MRSA) infections in which the vancomycin non-susceptibility development and daptomycin resistance occurred under therapy with teicoplanin (three cases) and daptomycin switched to vancomycin (one case). Clinical data were retrospectively reviewed. On nine clinical epidemiologically unrelated daptomycin-susceptible (DAP-S) and daptomycin-resistant (DAP-R) MRSA, we performed: (i) DAP-VAN-TEC-CFX-RIF minimum inhibitory concentrations (MICs); (ii) glycopeptide resistance detection (GRD) by δ-hemolysis; (iii) glycopeptide population analysis; (iv) molecular characterization by PFGE-MLST-SCCmec-agr-typing; (v) rpoB and mprF single nucleotide polymorphisms (SNPs); (vi) dltA-mprF-atl-sceD expression by real-time quantitative polymerase chain reaction (qPCR). Three out of the four patients did not survive despite salvage treatment; two died with active MRSA infection and one died because of Stenotrophomonas maltophilia sepsis. The fourth patient, in which a reversion to a DAP-S phenotype occurred, survived with daptomycin plus trimethoprim/sulfamethoxazole and oxacillin treatment, and endovascular device removal. Daptomycin resistance development was preceded by a stable heterogeneous vancomycin-intermediate S. aureus (hVISA) or VISA phenotype acquisition, while in one case, daptomycin resistance was preceded by an unstable daptomycin heteroresistance (hDAP) behavior reverting to DAP-S during vancomycin plus rifampin therapy followed by high doses of daptomycin. All DAP-R strains showed hVISA or DAP-R traits, including mutations and/or up-regulation of genes involved in cell wall turnover and cell membrane perturbation. In our study, daptomycin resistance arose during glycopeptide therapy. The emergence of DAP-R isolates was preceded by a stable VISA or hVISA phenotype or by instability reverting to a DAP-S heteroresistant phenotype. Daptomycin, as first-line therapy for the treatment of severe MRSA infections, should be used at optimal dosage combined with other agents such as beta-lactams, to prevent daptomycin resistance occurrence.

Streptococcus salivarius 24SMB administered by nasal spray for the prevention of acute otitis media in otitis-prone children

This paper reports the results of the first study in which Streptococcus salivarius 24SMB, a safe α-haemolytic strain capable of producing bacteriocin-like substances with significant activity against acute otitis media (AOM) pathogens, was intranasally administered in an attempt to reduce the risk of new episodes of AOM in otitis-prone children. In this prospective, randomized, double-blind, placebo-controlled study, 100 children aged 1-5 years with histories of recurrent AOM were randomized 1:1 to receive an intranasal S. salivarius 24SMB or placebo twice daily for 5 days each month for 3 consecutive months. Fifty treated children and 47 who received placebo who were compliant with study protocol were followed monthly for 6 months. The number of children who did not experience any AOM was higher among the children treated with the S. salivarius 24SMB preparation than among those in the placebo group (30.0 vs 14.9%; p = 0.076). Moreover, the number of children who received antibiotics during the study period was lower among the children treated with S. salivarius 24 SMB than among those who received placebo (70 vs 83.0%; p = 0.13). Compared with the children who were not colonized by S. salivarius 24SMB after treatment, the number of colonized children who experienced any AOM was significantly lower (42.8 vs 13.6%; p = 0.03). Similar results were observed when the children treated with antibiotics for AOM were analysed (67.8 vs 95.5%; p = 0.029). This study revealed the ability of intranasally administered S. salivarius 24SMB to reduce the risk of AOM in otitis-prone children.

Colonization, safety, and tolerability study of the Streptococcus salivarius 24SMBc nasal spray for its application in upper respiratory tract infections

Streptococcus salivarius, a non-pathogenic species and the predominant colonizer of the oral microbiota, finds a wide application in the prevention of upper respiratory tract infections, also reducing the frequency of their main pathogens. In this pilot study, the primary objective was to evaluate the safety and tolerability of a nasal spray, S. salivarius 24SMBc, as a medical device in a clinical study involving 20 healthy adult subjects. The secondary aim was to determine the ability of colonization assessed by molecular fingerprinting. Twenty healthy adult subjects, aged between 30 and 54 years, without a medical history of recurrent otitis media, were enrolled. All patient characteristics fulfilled the inclusion criteria. All subjects were treated daily for 3 days with the nasal spray containing S. salivarius 24SMBc at a concentration of 5 × 10(9) colony-forming units (CFU)/ml. The persistence of S. salivarius in the nasopharynx was investigated by the antagonism test and random amplified polymorphic DNA polymerase chain reaction (RAPD-PCR). The tolerability and safety were clinically assessed by clinical examinations during treatment. Our results demonstrate the capability of S. salivarius 24SMBc to colonize the rhinopharynx tissues in 95% of subjects and persist in 55% of them after 6 days from the last dose of the formulation, maintaining a concentration of 10(5) CFU/ml. The treatment was well tolerated by all healthy patients and no adverse effects were found. The topical application of streptococcal probiotics is a relatively undeveloped field but is becoming an attractive approach for both prevention and therapy, especially for pediatric age patients. S. salivarius 24SMBc possess characteristics making this strain suitable for use in bacteriotherapy.

Role of empirical and targeted therapy in hospitalized patients with bloodstream infections caused by ESBL-producing Enterobacteriaceae

BACKGROUND

Bloodstream infection (BSI) due to extended-spectrum β-lactamase (ESBL) producing Enterobacteriaceae are a major cause of in-hospital mortality. The effect on survival of empirical and targeted antibiotic therapy in these patients remains controversial.

METHODS

A prospective cohort study was conducted analyzing data from 94 patients (age 59 ± 21 years) with BSI due to ESBL producing strains (Sixty-one E. coli, 26 K. pneumoniae, 4 Proteus spp and 3 Enterobacter spp).

RESULTS

Risk factors associated with 21-day mortality at univariate analysis were: recent administration of antibiotic therapy (p=0.049), higher SOFA score (p=0.05), ICU stay (p <0.01), hypotension at presentation (p =0.001) or septic shock (p <0.001) and bacteremia from source other than urinary tract (p=0.03). Regardless of antibiotic class used, no differences in survival were noted between patients receiving or not adequate initial antimicrobial treatment (37.1% vs 23.7% p=0.23); on the other hand, compared with the administration of other in vitro active antibiotics, the use of carbapenem as definitive therapy was associated with a significantly lower 21-day mortality (54.3% vs 28.5% p=0.02).

CONCLUSIONS

These findings suggest that the administration of an adequate initial therapy is not associated with mortality in hospitalized patients with BSI due to Enterobacteriaceae. The severity of clinical conditions at presentation and the administration of carbapenems as definitive therapy seems to be really important in affecting the outcome of patients with BSI due to ESBL producing strains.

Chronic urticaria with high IgE levels: first results on oral cyclosporine A treatment

INTRODUCTION

Chronic Urticaria is a difficult to define condition from the nosographic standpoint, with complex pharmacological management, that heavily impacts the life of the patient. Some forms show not to be responsive to anti H1 anti-histaminic and require other treatments. One of these can be the treatment with Cyclosporine A (CsA).

MATERIALS AND METHODS

This study, open and sequential, reports the results of short-term treatment over a sample of adults (21 patients) of both sexes, all suffering from chronic urticaria with IgE levels higher than 200 mU/ml treated with 4 mg/kg/die of CsA.

RESULTS

The results obtained show a reduction in the levels of total IgE and a significant improvement in symptoms; there were no adverse effects.

CONCLUSIONS

Cyclosporine is an excellent treatment for chronic urticaria because it reduces the activity of T lymphocytes and reduction of the histamine release from the mast cells and basophils.

In vivo multiclonal transfer of bla(KPC-3) from Klebsiella pneumoniae to Escherichia coli in surgery patients

During active surveillance at the Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT, Palermo, Italy) with the CARBA screening medium, five pairs of Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae and Escherichia coli strains were isolated in each of five colonized patients. In each patient, lateral gene transfer was demonstrated by comparing K. pneumoniae and E. coli strains, both possessing KPC-3, Tn4401a and pKpQIL-IT elements. The isolates were found to be multiclonal by multilocus sequence typing (sequence type (ST) 512 related to ST258, and ST307 belonging to a clonal complex different from the habitual sequence clone ST258 isolated in Italy) and pulsed-field gel electrophoresis. The results of our study highlight the easy transfer of KPC among Enterobacteriaceae colonizing the human intestine, and the active and careful surveillance required to identify and prevent the spread of these multidrug-resistant microorganisms.

Activity of Telithromycin Against Multi-Drug ResistantStreptococcus pneumoniaeand Molecular Characterization of Macrolide and Tetracycline Resistance Determinants

The antistreptococcal activity of telithromycin and 11 different comparators was evaluated in 26 multi-drug resistant (MDR) Streptococcus pneumoniae strains collected during 2002-2003 as part of the ongoing PROTEKT (Prospective Resistant Organism Tracking and Epidemiology for the Ketolide Telithromycin) Italian Surveillance Program. The strains were characterized for their susceptibility to antibiotics both at the phenotypic and genotypic levels; furthermore, the association of erm(B), mef(A) class and tet(M) genes, as well as the mobile elements carrying them were determined. The strains in this study were resistant to penicillin (MIC > or = 2 mg/l) in 23.1% of cases, resistant to tetracycline in 88.4%, to cotrimoxazole in 34.6% and cefuroxime in 26.9% while only telithromycin and levofloxacin retained 100% activity against all microorganisms. Co-existence of different resistance determinants was found in 19.2% of all isolates collected in our laboratory, coming from southern Italy. Twenty-three isolates showing the MLSB phenotype of resistance possessing the erm(B) gene (88.5%), associated with tet(M), were carried on the same Tn1545-like element, while two isolates showing the M phenotype possessing the mef(A) gene alone, were carried on Tn1207.1. In only one strain were mef(E) and tet(M) together carried on Tn2009.

Molecular dynamics simulations for CO2 spectra. IV. Collisional line-mixing in infrared and Raman bands

Ab initio calculations of the shapes of pure CO2 infrared and Raman bands under (pressure) conditions for which line-mixing effects are important have been performed using requantized classical molecular dynamics simulations. This approach provides the autocorrelation functions of the dipole vector and isotropic polarizability whose Fourier-Laplace transforms yield the corresponding spectra. For that, the classical equations of dynamics are solved for each molecule among several millions treated as linear rigid rotors and interacting through an anisotropic intermolecular potential. Two of the approximations used in the previous studies have been corrected, allowing the consideration of line-mixing effects without use of any adjusted parameters. The comparisons between calculated and experimental spectra under various conditions of pressure and temperature demonstrate the quality of the theoretical model. This opens promising perspectives for first principle ab initio predictions of line-mixing effects in absorption and scattering spectra of various systems involving linear molecules.

The effectiveness of oral goat colostrum in the treatment of patients with type 2 diabetes mellitus: our preliminary experience

INTRODUCTION

The properties of colostrum were recognized and investigated more thoroughly in the first half of the eighties, when the immune factors and growth factors it contains were pointed out. Numerous studies show that the administration of colostrum benefits the subjects with type 2 diabetes mellitus as it gradually regulates appetite, improves utilization of nutrients, especially glucose, and leads to a significant decrease in body fat.

MATERIALS AND METHODS

The following study is aimed at verifying a possible reduction in the use of insulin in 27 subjects with type 2 diabetes, treated with goat colostrum in the form gastro-resistant tablets of 300 mg (4/die).

RESULTS

In subjects with type 2 diabetes treated with insulin, the administration of colostrum has obtained a significant reduction of insulin dosage and normalization of blood glucose levels.

CONCLUSIONS

The effects of colostrum are presumably linked to increased levels of IGF-1 that improves the utilization of glucose, stimulates glycogen and protein synthesis.

Impact and Oral Immunotherapy on Quality of Life in Children with Cow Milk Allergy: A Pilot Study

Quality of life is negatively affected in children with food allergy. Oral immunotherapy is an approach to food allergy that leads to patient desensitization by administering gradually increasing amounts of a given food allergen. The aim of this pilot study is to evaluate how oral immunotherapy affects quality of life in children allergic to cow milk proteins. Thirty children (aged 3–12 years) with cow milk allergy were recruited. Their parents were provided with a validated disease specific quality of life questionnaire (the food allergy quality of life questionnaire – parent form, FAQLQ-PF) before and again 2 months after completing an oral immunotherapy protocol with cow milk. A significant improvement in all the investigated domains - emotional impact, food anxiety and social and dietary limitations - was found. The separate analysis of the different age groups demonstrated that the emotional impact and the food-related anxiety improved in children older than 4, while the social domains improved in each age group. In this pilot experience, oral immunotherapy significantly improves quality of life in children with cow milk allergy. The improvement seems particularly evident in children over 4 years old, who are most likely to benefit from the oral immunotherapy approach. Further placebo-controlled studies are needed to confirm these preliminary results.

Changing Italian nosocomial-community trends and heteroresistance in Staphylococcus aureus from bacteremia and endocarditis

Bloodstream infections due to Staphylococcus aureus (BSI) are serious infections both in hospitals and in the community, possibly leading to infective endocarditis (IE). The use of glycopeptides has been recently challenged by various forms of low-level resistance. This study evaluated the distribution of MSSA and MRSA isolates from BSI and IE in 4 Italian hospitals, their antibiotic susceptibility—focusing on the emergence of hVISA—and genotypic relationships. Our results demonstrate that the epidemiology of MRSA is changing versus different STs possessing features between community-acquired (CA)- and hospital-acquired (HA)-MRSA groups; furthermore, different MSSA isolated from BSI and IE were found, with the same backgrounds of the Italian CA-MRSA. The hVISA phenotype was very frequent (19.5%) and occurred more frequently in isolates from IE and in both the MSSA and MRSA strains. As expected, hVISA were detected in MRSA with vancomycin minimum inhibitory concentrations (MICs) of 1–2 mg/l, frequently associated with the major SCCmec I and II nosocomial clones; this phenotype was also detected in some MSSA strains. The few cases of MR-hVISA infections evaluated in our study demonstrated that 5 out of 9 patients (55%) receiving a glycopeptide, died. Future studies are required to validate these findings in terms of clinical impact.

Intra-abdominal infections: etiology, epidemiology, microbiological diagnosis and antibiotic resistance

Intra-abdominal infections (IAIs) are commonly encountered in clinical practice. The etiology of these infections, often polymicrobial in nature, can be variable and usually includes organisms derived from the gut microbiota. in community-acquired IAIs enterobacteria predominate (mostly Escherichia coli) in combination with anaerobes (mostly Bacteroides fragilis). In nosocomial IAIs, which can complicate abdominal surgery, other pathogens can also play a role, such as Pseudomonas aeruginosa, Acinetobacter baumannii, Staphylococcus aureus, Enterococcus spp. and Candida spp. Diagnostic microbiology of IAIs is complex and plays a relevant role, especially in some situations (e.g. presence of foreign bodies, potential presence of resistant or uncommon pathogens, nosocomial infections in subjects with risk factors). Antibiotic resistance issues are currently encountered in most pathogenic species causing IAIs. Resistance affects all major classes of antimicrobial agents, often involving multiple classes and resulting in complex resistance phenotypes for which only a very limited number of drugs remain active.

Cefditoren versus community-acquired respiratory pathogens: time-kill studies

The time-kill method was used to determine the bactericidal activity of cefditoren compared with oral cephalosporins, amoxicillin, amoxicillin/clavulanate and levofloxacin against a randomly selected group of strains isolated from community-acquired respiratory tract infections (CARTIs). Cefditoren was the only agent showing significant bactericidal activity (>or=3 log(10 )reduction of viable cells) within 4 h against all Streptococcus pneumoniae strains, both penicillin-susceptible (PEN S) or -resistant (PEN R), as well as against Streptococcus pyogenes, and Moraxella catarrhalis. Against beta-lactamase positive strains of Haemophilus influenzae, cefditoren was comparable to the quinolone and more active than other cephalosporins at 24 h. Cefditoren showed the best killing kinetic profiles and this observation may be important when choosing an oral third-generation cephalosporin as initial or sequential therapy.

Successful Treatment of Disseminated Cerebritis Complicating Methicillin-resistant Staphylococcus aureus Endocarditis Unresponsive to Vancomycin Therapy with Linezolid

A unique case of community acquired methicillin resistant Staphylococcus aureus (MRSA) sepsis, with endocardial and cerebral metastatic seeding, caused by a strain representative of the Italian clone, is described. The patient was a 47-y-old man without apparent risk factors for endocarditis and for MRSA infection who developed coma with multiple cerebritis lesions under vancomycin plus amikacin therapy. He was eventually cured with the addition of linezolid to the initial antimicrobial regimen. This observation seems to confirm previous reports of the efficacy of linezolid for the treatment of central nervous system infections caused by multidrug resistant Gram-positive bacteria. To our knowledge, this is the first report of MRSA disseminated cerebritis, a nearly always fatal disease, cured with this oxazolidinone drug. The increase in community acquired MRSA may have some impact on empirical treatment of serious infections caused by this organism.

[Evolution in the antibiotic susceptibility and resistance]

Over the last decade the proliferation of antibiotic-resistant pathogens has been a growing problem, especially in some geographic areas, making useless most of the classical antibiotic therapies. The rapid emergence of resistant bacteria is the result of different factors as the intrinsic microbial complexity, the growing attitude to travel of humans, animals and goods, the use of antibiotics outside hospitals, and the lack of precise therapeutic chooses for high risk group of patients. The antibiotic-resistance becomes certainly a serious problem when a resistant pathogen, and often multi-resistant today, is present in an infective site. In fact in a recent estimate of the Centre for Disease Control and Prevention (CDC) about 90.000 deaths per year in the USA are attributable to bacterial infections and in particular to resistant pathogens. It appears clear that the clinic relevance of this problem is the decimation of the sensible germs of the normal flora that leads to the upper hand of the only resistant bacteria. The antibiotic therapy, in fact, select the resistance and each bacteria has developed a particular strategy to survive: mutations of the genetic content or acquisition of resistance genes from the external. Among the Gram positive bacteria, besides methicillin resistant Staphyloccocus aureus, there are other pathogens such as coagulase-negative staphylococci (CoNS), Enterococcus faecium and Enterococcus faecalis, some species of streptococci and multiresistant Corynebacterium. The CoNS, eg. S. epidermidis, S. hominis and S. haemolyticus, are recognized as new important nosocomial pathogens and are not only responsible of invasive infections but have become in few years resistant to oxacillin (more than 60%) and multiresistant. The unsuspected fragility of glycopeptides, which for 40 years have been the most important treatment against infections due to Gram-positive bacteria, has posed the need for new antimicrobial molecules. Among the therapeutic possible options there are linezolid, tygecyline and daptomycin, but new other molecules are appearing in the clinical use like ceftobiprole and dalbavancin.

Antibacterial activity of cefditoren against major community-acquired respiratory pathogens recently isolated in Italy

In this study we evaluated the in vitro activities of cefditoren--a broad-spectrum oral cephalosporin--and other comparator agents against 2,396 fresh isolates from community-acquired respiratory tract infections, collected from 6 clinical Italian microbiology laboratories. On penicillin-susceptible pneumococci and Streptococcus pyogenes, cefditoren demonstrated to be the most active antibiotic (MIC(90)values of 0.03 and 0.06 mg/L respectively), showing only a slight decrease in potency on penicillin-intermediate and resistant pneumococci (MIC(90)value 0.5 mg/L, 1.0 mg/L respectively). All the other comparators displayed MIC(90 )values of 4 - 8 mg/L for penicillins and of 4 to >64 mg/L for the oral cephalosporins. Cefditoren and levofloxacin were the most active against MSSA (MIC(90)0.5 mg/mL). Cefditoren displayed a uniformly potent inhibitory activity (MIC(90)of 0.03 mg/L) against all strains of Haemophilus influenzae, regardless of their ampicillin resistance (mediated or not by beta-lactamase production), while against Moraxella catarrhalis MIC(90)values were higher against beta-lactamase-positive (0.25 mg/L). Cefditoren was active also against Klebsiella pneumoniae and Escherichia coli : in this case its activity was comparable with that of levofloxacin. In conclusion, cefditoren, due to its potent activity, is a new effective therapeutic option for the treatment of respiratory tract infections.

Vascular catheter-associated infections: a microbiological and therapeutic update

The increasing incidence of central venous catheter (CVC)-related infections can be ascribed to the wider indications to central venous catheterization, to the higher attention to this issue paid by clinicians and microbiologists, and to the patient population referred to hospitals, increasingly characterized by different degrees of immunosuppression and often in critical clinical conditions. This phenomenon implies a higher health care burden and higher related costs, as well as a significant attributable mortality, that varies however according to the pathogen involved. The microorganisms most frequently involved in CVC-related infections are coagulase-negative staphylococci, Staphylococcus aureus, aerobic Gram-negative bacilli, and Candida albicans. In the management of suspected or proven central venous catheter-related infections, several issues need to be addressed: the need to remove the device or the possibility of salvage, the immediate start of calculated antibiotic therapy or the possibility of waiting for results of microbiological diagnostics and proceeding to etiologically-guided therapy. The preferred conservative method is the "Antibiotic-Lock technique" (ALT), based on the endoluminal application of antibacterials at extremely high concentrations in situ for a period of time long enough to ensure bactericidal activity. On the other hand, immediate catheter removal and initiation of appropriate calculated therapy immediately after an adequate diagnostic work-up are strongly recommended in a clinical setting of severe sepsis or septic shock.

First Report of Leaf Spot and Blight of Strelitzia reginae Caused by Burkholderia gladioli in Italy

During the summer of 2005, a new disease of bird of paradise (Strelitzia reginae Aiton) was observed on young seedlings (2 to 3 months old) in a nursery located in Giarre (Catania) in eastern Sicily. Symptoms included brown, water-soaked leaf spots that first appeared after seedling emergence and then gradually enlarged and became necrotic. Occasionally, during wet conditions, seedlings were completely blighted, resulting in total loss. The disease was observed on 10% of the 3,000 plants present in one nursery. A single bacterial colony was consistently isolated on King's medium B (KB) supplemented with 0.01% cycloeximide from surface-sterilized, brownish lesions and water-soaked leaf tissues. The isolates were purified on nutrient agar (NA). Three bacterial strains isolated from three different symptomatic plants were used for pathogenicity and identification tests on S. reginae plants. Five plants were inoculated per bacterial strain by spraying the leaves with a buffer phosphate suspension (0.1 M) at 10⁶ CFU/ml prepared from KB plates incubated for 24 h at 28°C and wounding the leaves (four wounds per leaf) with a sterile needle. The same number of noninoculated plants was used as control. All plants were covered with plastic bags and maintained in a greenhouse at 25 ± 1°C with 95 to 100% relative humidity until symptoms occurred 3 to 4 days later. All three bacterial strains tested were virulent and caused symptoms identical to those observed in the nursery. No symptoms were observed in control plants. Koch's postulates were fulfilled by the reisolation of the three strains from inoculated plants. The strains were gram-negative, aerobic rods, grew aerobically, were white and nonmucoid on yeast dextrose calcium carbonate agar, nonfluorescent on KB, produced diffusible nonfluorescent pigment on KB, and were oxidase and urease negative. All strains utilized glucose, arabinose, mannose, mannitol, N-acetylglucosamine, gluconate, caprate, malate, citrate, and phenyl acetate and none of the strains produced indole or acidified glucose. Using the API 20NE test strips (bioMérieux, Marcy l'Etoile, France) incubated at 28°C for 24 to 48 h, all strains were initially identified as Burkholderia cepacia. On the basis of the nutrient profiles revealed by the BIOLOG system (Microlog System Release 4.2, Hayward, CA), the strains were identified as B. gladioli (Severini 1913) Yabuuchi et al. 1993. The index of probability was 100% and the index of similarity was 0.75%. For molecular identification of strains, 16S rDNA was amplified by using species-specific primers Eub-16-1 and Gl-16-2₄₅₇, obtaining a polymerase chain reaction (PCR) product of 463 bp (1). PCR analysis indicated that the strains belong to B. gladioli. Other bacteria have been previously reported in Italy as pathogens of Strelitzia spp. (2,3). To our knowledge, this is the first outbreak of leaf spot and blight caused by B. gladioli on S. reginae. References: (1) A. Bauernfeind et al. J. Clin. Microbiol. 37:1335, 1999. (2) P. Bella et al. J. Plant Pathol. 82:159, 2000; (3) G. Polizzi et al. Plant Dis. 89:1010, 2005.