Rev Esp Quimioter 2009;22(1):38-47

Importance of the antimicrobial spectrum and the bacterial resistances in the antibiotic Choice for the treatment of pediatric patients with comunitary infections

F. Baquero ,  J. González ,  D. Martínez ,  V. Olmo ,  A. Orero y J. Prieto (Grupo MUSA) 

  

Objective. This study aimed to know the importance of the antimicrobial spectrum and the bacterial resistances for the antibiotic choice in the extrahospitalary pediatric area, at the same time that establish the relationship with others therapeutics parameters.

Material and methods. Cross-sectional, observational study within the MUSA (Improvement of Use of Antimicrobial Agents in Primary Health Care) Project made by personal interview of 210 pediatrician doctors randomly selected with national represantitivity. This target is included in a bigger universe (855 doctors) representative of the most doctors responsible of the antibiotic prescriptions in the extrahospitalary area (sample error of the 3,3 % for a 95 % confidence interval and maximum response dispersion: p=q=50). The results of the pediatric study were subjected to a comparative analysis with the results of a similar study made ten years ago and with the global results of the general study. The questionnaire used for the interview had two crearly differenced parts: in the first part, the questions were open with the objective to get spontanious answers from the participants; the second part had questions with suggested answers.

Results. Clinical efficacy is the most spontaneously valored issue by the spanish pediatricians when it comes to choosing an antimicrobial agent; efficacy is followed by tolerance/safety and posology. Antimicrobial spectrum is mentioned by one out of 4-5 pediatricians that have participated in the study (21,9%), while the bacterial resistances are only mentioned by a 3,8%. In a suggested level, clinical efficacy is still the most valued parameter, being identified by 7 out of 10 interviewed with the bacterial eradication. In this case, the antimicrobial spectrum is the following parameter on significance, appearing as a synonym of «activity against specific microorganisms» in 2 out of 3 cases. In relation to his own evaluation, 3 out of 4 pediatricians say they take «a lot» the bacterial resistences into consideration, who are mostly understood as «global rate» for 5-6 out of 10 interviewed, whether the resistence showed by the neumococo is what worried the most to 4 out of 10 of them. This importance given to the bacterial resistences at the second part of the study contrasts with the low consideration showed when it is compared eith other parameters and the valoration is treated in a spontaneous way.In relation to a similar study realized on 1997 (Urano Proyect), we observe that clinical efficacy has replaced tolerance/safety as a parameter to bear in mind, probably as a consequence of more experience and confidence with the most important antimicrobial agents in the antibiotic prescriptions in podiatry. On the other hand, the bacterial resistences still being left out on the pediatricians spontaneous consideration, a fact that is shared with the mayority of the collectives participating on the general study. The rest of the parameters stay in a similar way.

Conclusions. Is necessary to emphasize at the importance of bacterial resistences in the antimicrobials rational use on the pediatric patient. As the antimicrobial tolerance profile has been improving in the last ten years, clinical efficacy, understood as «bacterial eradication » has became the most determinating parameter when choosing antimicrobial agents.

  

Key words:Antimicrobials. Pediatry. Bacterial resistences. Antibiotic spectrum. Clinical efficacy.

Rev Esp Quimioter 2009;22(1):38-47   [pdf]

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Rev Esp Quimioter 2009;22(1):34-37

Viral Load in Spanish HIV patients: trends since the introduction of HAART

J. M.ª Eiros ,  E. Sánchez-Padilla ,  F. J. Luquero ,  B. Nogueira ,  S. Rojo ,  J. Atienza-Herrero y R. Ortiz de Lejarazu 

  

The aim of this study is to describe trends in the percentage of samples with undetectable HIV viral load in Spain after the implementation of HAART. A descriptive observational study of HIV-VL measurements carried out in the microbiology department of the Hospital Clínico Universitario de Valladolid (HCUV) was conducted over a 9-year period (1996-2004). Regarding the trend over the study period, the 30-39 years age group accounted for most of the samples, although the percentage decreased from 65.5 % to 59.6% over the study period. In contrast, the 40-49 years group increased from 9.1 % to 14.5 %. The preponderance of men, with percentages above 70 %, was observed during the whole period. Although the purpose of this treatment is to maintain undetectable viral loads, since 1999 more than 60% of nonfirst samples had detectable levels. Based on the results of the VL trend among HIV/AIDS patients observed in this study, a large number of patients maintain elevated detectable VL years after HAART was implemented. Although different factors may be the cause of this and should be delimited in future studies, the phenomenon observed demonstrates the usefulness of monitoring VL and analyzing its time trend to gain further knowledge about the therapeutic results and care of HIV patients as a whole, also serving as the basis for corrective measures.

  

Key words:HIV, Viral Load, HAART.

Rev Esp Quimioter 2009;22(1):34-37  [pdf] 

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Rev Esp Quimioter 2009;22(1):30-33

 

Resistant mutant prevention concentration of fluoroquinolones in clinical isolates of extended spectrum beta-lactamase (ESBL) producing and non-producing strains of Escherichia coli

O. Noguera ,  J. C. Rodríguez ,  J. M. López ,  M. Ruiz y G. Royo 

  

The aim of this job is to study the capacity of ciprofloxacin and levofloxacin in restricting the development of resistant mutants in strains of Escherichia coli by determining the mutant prevention concentration (MPC). Ninety-nine isolates of E. coli with different fluoroquinolone susceptibilities were studied and divided into ESBL-producing (n = 60) and non-ESBL producing (n=36) groups. MPC values were determined using an inoculum of 1010 cfu/ml on Mueller-Hinton plates with serial dilutions of the antibiotics. No significative differences were detected in MIC of ESBL-producing and non-ESBL producing strains of E. coli. Ciprofloxacin susceptible ESBL-producing strains exhibit higher MPC for ciprofloxacin and levofloxacin than non-ESBL producing strains. Our study helps to explain the frequent fluoroquinolone resistance found in ESBL-producing strains. In this context, doubts emerge about the advisability of using fluoroquinolones to treat infections caused by ESBL-producing strains.

 

Key words: Escherichia coli. Extended spectrum beta-lactamase. Fluoroquinolones.

Rev Esp Quimioter 2009;22(1):30-33 [pdf]

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Rev Esp Quimioter 2009;22(1):25-29

In vitro activity of fosfomycin against ESBL-producing enterobacteria of urinary origin

M.ª S. Hernández ,  J. Á. García y J. L. Muñoz 

  

In vitro activity of fosfomycin, compared with other antibiotics used for urinary tract infections (UTI), against extended spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumoniae clinical isolates obtained from UTIs, was determined. The activity of fosfomycin, co-trimoxazole, ciprofloxacin, nitrofurantoin, amoxicillin/ clavulanic acid and gentamicin against 71 ESBL-producing E. coli clinical isolates and 13 ESBL producing K. pneumoniae clinical isolates obtained from UTI was studied by the agar-dilution method or E-test. E. coli isolates produced mainly CTX-M type ESBL (76.1%), especially CTX-M 14 (56.3 %). K. pneumoniae isolates produced most predominantly SHV-type ESBL (92.3%), mainly SHV-2 (76.9 %). Gentamicin (4.4 %), fosfomycin (5.6 %) and nitrofurantoin (5.6 %) showed the lowest resistance proportions against E. coli. Co-trimoxazole and ciprofloxacin (7.7 %) showed the lowest resistance proportions against K. pneumoniae.

 

Key words: Escherichia coli. Klebsiella pneumoniae. Extended spectrum beta-lactamase (ESBL). Fosfomycin.

Rev Esp Quimioter 2009;22(1):25-29  [pdf]

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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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