Rev Esp Quimioter 2009;22(1):20-24

Compliance rate of antibiotic therapy in patients with acute pharyngitis is very low, mainly when thrice-daily antibiotics are given

C. Llor ,  N. Sierra ,  S. Hernández ,  C. Bayona ,  M. Hernández ,  A. Moragas y O. Calviño 

  

Objective. To assess drug-compliance observed among patients with suspected streptococcal pharyngitis treated with twice-daily antibiotic regimens (b.i.d.) and others with thrice-daily regimens (t.i.d.).

Methods. A prospective study in the primary care setting was designed in which patients with pharyngitis and three or more Centor criteria, non-allergic to beta-lactam agents, treated with several b.i.d and t.i.d antibiotic regimens based on doctor’s choice, were recruited. Patient compliance was assessed with electronic monitoring.

Results. A total of 113 patients were enrolled (64 in the t.i.d. group and 49 in the b.i.d. group). Mean openings ranged from 70.3 to 83.3% of the total amount of pills. All the parameters analysed indicated significantly worse compliance with the t.i.d. regimens. Eleven patients allocated to the t.i.d. group took at least 80 % of the pills (17.2 %), this being significantly lower than those who received b.i.d. antibiotics (59.2%; p<0.001). The percentage of patients who opened the Medication Event Monitoring System (MEMS) container the satisfactory number of times a day was systematically lower among t.i.d. regimens, this being statistically significant from day three (p<0.05). Patients assigned to t.i.d. regimens more frequently forgot the afternoon dose.

Conclusion. Compliance rate was very low, mainly when patients are given t.i.d antibiotic regimens. This may lead to storage of antibiotics and subsequent selfmedication. New strategies addressed to improve drugcompliance with antibiotics among outpatients are therefore necessary.

  

Key words: Compliance. Pharyngitis. Streptococcal infection. Amoxicillin. Penicillin. Antibiotic.

Rev Esp Quimioter 2009;22(1):20-24  [pdf]  

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Rev Esp Quimioter 2009;22(1):10-19

Multicenter national survey on infection management in patients with penicillin allergy

R. Serrano ,  J. A. Capdevila ,  J. Mensa y J. Barberán ,  R. Oltra

   

Introduction. Beta-lactam antibiotics are widely prescribed to treat many infections because of efficacy, spectrum and safety. Their use is limited in patients with resistant microbial agents and in those with a history of penicillin allergy (HPA) because of cross-reactivity risk. Accurate clinical assessment of possible HPA requires specialized resources not always available in clinical practice. We intended to get to know the opinion of Spanish physicians about frequency and methods of evaluation of the patients with HPA as well as the preferences in the use of antimicrobial alternatives for common infectious diseases in patients with HPA.

Methods. Multicentric cross-sectional descriptive study ran by the Infectious Diseases Study Group of the Spanish Society for Internal Medicine based on the accomplishment of a survey of 10 questions of opinion to specialist doctors who work in Spanish medical centers.

Results. A total of 311 doctors responded to the survey (92.2% Internal Medicine specialists) distributed by all the Spanish territory. An average of 10.7% of patients self-reported having HPA although only an average of 10.8 % of them gave documentation on the matter. Patients were sent for specific allergy tests in an average of 33.6 %. Desensitization treatments were performed in 4.3 % of cases. The preferences for alternative antibiotic therapy to beta-lactan widely varied according to the infectious picture and the communitarian or nosocomial origin, and they included quinolones, macrolides, glycopeptides, lincosamides, oxazolidinones and tigecycline.

Conclusions. Perception about frequency and evaluation of patients with HPA is very variable, but in more than half the cases it is above 10 % of the patients. Yet, only one third are sent for in-depth study for allergy confirmation, and less than 5% are desensitized. Nosocomial infections and the possibility of multiresistant bacteria make substantially difficult the management of patients with HPA.

Key words:Beta-lactam antibiotics. Hypersensibility. Drug allergies. Tigecycline. Desensitization treatment.   

Rev Esp Quimioter 2009;22(1):10-19 [pdf]   

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Rev Esp Quimioter 2009;22(1):4-9

Management in the emergency room of patients requiring hospital treatment of community-acquired pneumonia

D. Martínez ,  V. Álvarez Rodríguez ,  M. Martínez Ortiz de Zárate ,  M. Rivas ,  M. J. Giménez ,  L. Aguilar ,  M. J. Ruiz Polaina ,  J. Barberán ,  J. Prieto ,  on behalf of the CAPEM study Group 

  

Introduction. To identify factors influencing decisions in initial management of community-acquired pneumonia (CAP) admitted to hospital through Emergency departments.

Methods. Records of CAP adult patients admitted to 24 Spanish hospitals in January-Mars 2003 were reviewed. Patients sent for ambulatory treatment were excluded.

Results. 341 patients (67.0 ± 24.6 years; 65.3 % males) were included; 39 % were taking antibiotics at attendance. PSI was (% patients): I-II (19.7 %), III (14.7 %), and IV-V (65.6 %). Comorbidities were: COPD (37.2 %), heart disease (24.6 %), hypertension (17 %), diabetes mellitus (10.8 %), and malignancies (10 %). Pneumococcal/Legionella urinary antigens were performed in 34.0 %/42.2 % patients. Fewer (p ≤ 0.006) rapid tests were performed in class IV-V (p = 0.001), with higher (p ≤ 0.01) pneumococcal positive results in class V. Initial treatment was fluoroquinolone (37.5 %), beta-lactam + macrolide (26.4 %), beta-lactam (22.9 %), macrolide (4.7 %), and others (8.5 %). Patients referred to Internal Medicine had higher heart disease (p = 0.06) and hypertension (p = 0.001) as comorbidity than those at Short-Stay Units or Pneumology. COPD patients were equally distributed between Internal Medicine and Pneumology, with differences vs. Short-Stay Units.

Conclusions. Rapid diagnostic tests were underused, maybe due to broad empirical treatments covering drug-resistant pneumococci and L. pneumophila (regardless PSI and comorbidity). Presence of comorbidities or positive results in rapid diagnostic tests seems to influence the medical ward to which the patient is referred to, but not initial treatment.

  

Key Words: Legionella urinary test. Pneumococcal urinary test. Community-acquired pneumonia. Empirical treatment. Emergency room.

Rev Esp Quimioter 2009;22(1):4-9  [pdf]   

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Rev Esp Quimioter 2008;21(Núm. Ext. 1):26-34

Pharmacoeconomics of infection in the intensive care unit

S. Grau ,  F. Álvarez-Lerma 

  

The intensive care unit (ICU) services are areas that have a need for greater use of economic resources, including the frequent use of higher priced drugs, standing out among them those corresponding to antimicrobial agents. This situation has led many hospital sites to include the ICU within those units needing special monitoring in regards to the use of drugs and the introduction of cost-containment programs in the ICU. It is possible that indiscriminate restriction in the financial cost section aimed at antimicrobial agents may mean that these drugs may be prescribed more inappropriately, a practice that has been related with greater mortality of patients with severe infections. Thus, the pharmacoeconomics of infection in the ICU should be analyzed through the study of different aspects and not only from the strict analysis of direct cost of the antimicrobial agents. In the present review, the cost of infection in the ICU has been analyzed, contemplating a series of perspectives that are considered essential and demonstrating, at all times, that evaluation of the cost of acquiring the antimicrobial agent as the only element for its choice should be avoided. The analysis was made by evaluating cost of infection in the ICU, the strategies for the control of use and cost of antibiotics in the ICU, importance of adequate early empiric treatment, the costs associated with the development of bacterial resistances and pharmacoeconomic studies.

 

Key words: Pharmacoeconomics. ICU. Infection. Pharmacoeconomic studies. Antibiotic policy. Early antibiotic treatment.

Rev Esp Quimioter 2008;21(Núm. Ext. 1):26-34  [pdf]   

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Rev Esp Quimioter 2008;21(Núm. Ext. 1):14-25

Up-date on the treatment of serious fungal infections

M. Borges Sá 

  

Introduction. In recent years, there has been an exponential increase in the incidence of severe fungal infections with elevated morbidity-mortality. An attempt is currently being made to obtain faster and more reliable diagnostic tests for a certainty diagnosis and to be able to use clinical criteria to identify patients who could be candidates to receive early antifungal treatment and thus be able to improve the prognosis.

Sources. For the purposes of this article, we reviewed the indexed literature for the last 15 years. We used different key words: invasive fungal infection (IFI), invasive aspergillosis, candidemia, and candidiasis, emerging fungi, prophylaxis and antifungal treatment (empiric, directed and pre-emptive treatment).

Development. The approach to antifungal treatment is also undergoing significant changes. These go from the appearance of new molecules, new generations of other already known ones and also changes in the more «traditional» approach in its use. This article is structured on the use slope of antifungal agents in non-neutropenic critical patients from their prophylaxis, empiric treatment, aimed towards new strategies (pre-emptive treatment or early therapy or combined use of antifungal agents). Furthermore, an attempt is being made to obtain simple scores to indicate their early onset in patients with high risk of IFI.

Conclusions. The combination of rapid identification of patients with risk (scores), faster diagnostic methods and finally more effective antifungal treatment with the providing of new antifungal agents and/or strategies will be essential to try to decrease the elevated morbidity-mortality in severe patients.

  

Key words:Invasive fungal infections. Candidemia. Invasive aspergilosis. Antifungal therapy. Pre-emptive treatment.

Rev Esp Quimioter 2008;21(Núm. Ext. 1):14-25  [pdf] 

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Rev Esp Quimioter 2008;21(Núm. Ext. 1):9-13

New therapeutic options for the treatment of multiresistant bacteria in the ICU

F. Barcenilla Gaite ,  A. Jover Sáenz ,  M. Vallverdú Vidal ,  D. Castellana Perelló 

  

The number of new antimicrobial drugs in the health care clinical practice has decreased gradually and significantly in the last 15 years. At the same time, there has been an increase in the appearance of microorganisms with resistance to conventional antibiotics, above all in intensive care units (ICU). Within this group, Methicillin-resistant Staphylococcus aureus (MSRA) and methicillin-resistant coagulase- negative staphylococci, vancomycin-resistant enterococci, Pseudomonas aeruginosa and Acinetobacter baumanii resistant to carbapenemics and extended-spectrum ß-lactamase-producing (ESBL) Enterobacteria are the most important. These pathogens are frequently also resistant to other groups of antibiotics such as aminoglycosides, fluoroquinolones and macrolides. New recently introduced antimicrobial agents are available to combat these resistances. These are active mainly against gram positive bacteria resistant strains and in a more timely way against gram negative ones or both. Among the first group, the following stand out: daptomycin (a lipopeptide bactericide for parenteral use) and linezolid (oxazolidinone with bacteriostatic activity for parenteral and oral use). On its part, ertapenem (a carbapenem parenteral bactericide) and tigecyclin (a parenteral bacteriostatic tetracycline) are active against ESBL enterobacteria, the latter also being active against non-fermented gram positives and gram negatives, except for P. aeruginosa. Possibly, the introduction of these new compounds and other futures ones pending introduction will not only improve antimicrobial diversification but also serve to limit the spreading of these microorganisms.

 

Key words: Multiresistant microorganisms. Daptomycin. Linezolid. Ertapenem. Tigecyclin. Therapeutic strategy.

Rev Esp Quimioter 2008;21(Núm. Ext. 1):9-13 [pdf] 

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Rev Esp Quimioter 2008;21(Núm. Ext. 1):7-8

 Epidemiological aspects of mycosis in the critical patient

J. Pemán García 

  

Fungemia, generally causes by Candida spp., is the most frequent deep mycoses in the critical patient and is many times clinically undistinguishable from bacterial septicemia. Less frequently, respiratory or disseminated mycosis produced by Aspergillus or other filamentous fungi, such as Scedosporium, Fusarium, Pneumocystis, Acremonium or zygomycetes have been described. Currently, invasive candidiasis is the fourth cause of nosocomial infection in Europe and the USA. Furthermore, in the SCOPE study, Candida is the third microorganism isolated from the blood culture in the ICU and the mortality that can be attributed to it reaches 25 %-38 %. Currently, the incidence of candidemia has been estimated to be 2 cases per every 1,000 admissions in the mixed critical units and 9.9 cases in the critical surgical units. On its part, invasive aspergillosis is observed in 1.25 % of the patients admitted to the ICU and mostly affects patients with chronic bronchopathy treated with glucocorticoids. It is considered as an indicator of bad prognosis and is associated to very high mortality rates (40%-100 %).

 

Key words:  UCI. Candidemia. Fungemia. Aspergillosis.

Rev Esp Quimioter 2008;21(Núm. Ext. 1):7-8 [pdf] 

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Rev Esp Quimioter 2008;21(Núm. Ext. 1):2-6

Problematic bacteria

J. L. Muñoz Bellido 

  

Introduction. Because of the special characteristics of the critical patients, infections are one of the primary complications they suffer so that multiresistant microorganisms take on a special importance in this type of patient.

Sources. Search in Medline using the words ICU (Intensive Care Unit), multidrug resistant, critical patient.

Development. Glycopeptide resistant enterococci show a reduced prevalence in our setting and the VISA and hVISA are isolated sporadically. MRSA is, on the other hand, a major problem. In 2003-2005, it was already accounting for 28%-38% of the S. aureus isolated in the ICU, with a high percentage of fluoroquinolone (>90%) and macrolide (>65%) co-resistance. The extended-spectrum beta-lactamase producing enterobacteria (BLEE) also are a growing problem, worsened by their frequent co-resistance with fluoroquinolones, about 30% according to some studies. Carbapenem resistance in A. baumannii has doubled in recent years, with values greater than 50%, almost always associated to enzymes of the OXA group. P. aeruginosa also maintains high resistance values (25%-30% of resistance to imipenem, ceftazidime or ciprofloxacin), but more stable. However, high rates of multi-resistance are also observed, now about 50% of the isolations of imipenem resistant P. aeruginosa are also to fluoroquinolones. As a whole, recent studies show that the multiresistance has multiplied in recently years by 5 in P. aeruginosa and by 7 in A. baumannii. Conclusions. Multiresistant bacteria infections are one of the greatest problems to combat in critical patients and control of their spreading and the development of active antimicrobials against them is one of the principal challenges at present.

  

Key words: Critical patients. Intensive Care Unit (ICU). Multi-resistant bacteria. Nosocomial infection. Resistance 

 

Rev Esp Quimioter 2008;21(Núm. Ext. 1):2-6 [pdf]  

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Rev Esp Quimioter 2008;21(4):234-258

Guidelines for the treatment on infections caused by methicillin-resistant Staphylococcus aureus

J. Mensa ,  J. Barberán ,  P. Llinares ,  J.J. Picazo ,  E. Bouza ,  F. Álvarez-Lerma ,  M. Borges Sá ,  R. Serrano ,  C. León ,  Xavier Guirao Garriga ,  J Arias ,  E Carreras ,  M Sanz ,  J. Á. García Rodríguez 

  

Infections due to methicillin-resistant Staphylococcus aureus (MRSA) have undergone important changes in the last five years that have influenced the choice of therapy: i) increase of their frequency in hospital-associated settings and, more recently, in community settings; ii) better knowledge of clinical implications of the pharmacokinetic and pharmacodynamic properties of vancomycin; iii) improvement of current standard methods for rapid detection of MRSA in clinical samples; iv) clear evidence that vancomycin is losing efficacy against MRSA with MIC > 1 μg/mL; and v) appearance of new antibiotics suitable for use in these infections (linezolid, daptomycin, tigecyclin). Under this situation guidelines for the treatment of common infections caused by MRSA appear to be necessary to improve the efficacy and reduce the mortality.

 

Key words: Methicillin-resistant S. aureus (MRSA). MRSA guidelines. New antibiotics.

Rev Esp Quimioter 2008;21(4):234-258 [pdf] 

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Rev Esp Quimioter 2008;21(4):224-233

Hepatotoxicity by antibiotics: update in 2008

M. Roble ,  R. J. Andrade 

  

Although antibiotics are the most commonly incriminated drugs in instances of hepatotoxicity in medical literature. However, it is mainly due to its wide prescription and the absolute risk of hepatotoxicity related to antibiotic use is thought to be low. Nevertheless, among the different penicillins, amoxicillin-clavulanate is the single leading drug involved in hepatotoxicity in cohorts of patients with druginduced liver injury (DILI), representing between 12.8% to 14% of the cases. It is the most frequent cause of hospitalization for DILI. The incidence of amoxicillin-clavulanate induced hepatotoxicity has been estimated to be 9.91 per 100 000 users and its clinical presentation varies, the type of injury strongly influenced by age, with the hepatocelullar pattern predominating in younger patients and the cholestatic/mixed ones in older subjects. Among macrolides, erythromycin is a classical example of drug capable of inducing cholestatic injury. Recently, concern has arisen regarding telithromycin, a new generation macrolide, is hepatotoxic came from the identification of several cases of DILI related to this drug, with a typical signature, including abrupt commence of fever, abdominal pain, jaundice and ascites in some cases. Tetracyclines, especially in intravenous high doses, may be associated with dose-dependent microvesicular steatosis, and minocycline has been involved in an autoimmune like type I hepatitis. Quinolones, in spite of their extensive use in patients with cirrhosis and biliary infections, have been very rarely associated with hepatotoxicity.

 

Keywords: Hepatotoxicity. Antibiotics. Amoxicillin-clavulanate. Age.

 

Rev Esp Quimioter 2008;21(4):224-233 [pdf]

 

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