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One-hundred-and-forty-three patients met the inclusion criteria. The failure rate after a median duration of oral antibiotic treatment of 69 days (IQR 45-95 days) was 11.8%. In 92 cases, PJI was due to Gram-positive microorganisms, in 21 cases PJI was due to Gram-negative microorganisms and in 30 cases PJI was due to a polymicrobial infection with both Gram-positive and Gram-negative microorganisms. In Gram-positive infections, rifampicin administered in combination with linezolid, co-trimoxazole or clindamycin was associated with a higher failure rate (27.8%, P = 0.026) than that in patients receiving a combination of rifampicin with levofloxacin, ciprofloxacin or amoxicillin (8.3%) or monotherapy with linezolid or co-trimoxazole (0%). Among patients with a Gram-negative infection, the use of fluoroquinolones was associated with a lower failure rate (7.1% versus 37.5%, P = 0.044).
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A survey of antibiotic resistance in Australian states was undertaken by the Microbiology Quality Assurance Program of the Royal College of Pathologists of Australasia. Data were obtained from hospitals and private pathology laboratories serving both in-patients and out-patients at community hospitals. The study showed that resistance varied from state to state; it was highest in the Eastern states of New South Wales, Victoria, and Queensland, and lowest in Tasmania and Western Australia. In South Australia, isolates of Escherichia coli demonstrated a high degree of cefoxitin resistance. Western Australia and Tasmania showed high levels of gentamicin resistance for Klebsiella spp., as well as trimethoprim resistance in Proteus mirabilis. The relationship between erythromycin resistance and clindamycin resistance also differed among various states. These studies demonstrated the activity of sulbactam/ampicillin against a wide variety of common pathogenic bacteria in which resistance was mediated by beta-lactamase.
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A case of recurrent methicillin-resistant Staphylococcus aureus (MRSA) neck infection in an HIV-infected patient is presented. HIV infection is a known risk factor for the development of MRSA infections; this report suggests that HIV infection may also increase the risk of recurrent disease. Among HIV-infected persons, risk factors for MRSA infection include injection drug use, low CD4+ cell count, high HIV viral load, sex partners with skin infections, absence of trimethoprim/sulfamethoxazole prophylaxis, and recent receipt of a beta-lactam antibiotic. The diagnosis of MRSA infection should be entertained and the appropriate cultures obtained when HIV-infected persons present with soft tissue infections. Given the rising rates of MRSA infection among HIV-infected persons, empiric antibiotics may be recommended. Since inducible resistance to clindamycin is increasing in MRSA isolates, an erythromycin/clindamycin "D-zone" test should be performed before this antibiotic is used. Educating HIV-infected patients about the risk factors for MRSA infection and hygienic measures to potentially reduce infection is advocated; further studies of preventive strategies in this population are needed.
The occurrence of antibiotic-resistant bacteria in foods of animal origin is a potential health threat because resistance can be transferred among bacteria, and antibiotic-resistant pathogens may not respond to antibiotic treatments. Thirteen brands of ready-to-eat shrimp representing four countries of origin were obtained from local grocery stores. Total heterotrophic plate counts were determined, and antibiotic-resistant bacteria were isolated. Total heterotrophic colony counts ranged from 3.3 to 5.6 log CFU/g, which was within approved quality limits. A total of 1,564 isolates representing 162 bacterial species were recovered during screening of resistance to 10 antibiotics: ampicillin, ceftriaxone, chloramphenicol, clindamycin, erythromycin, nalidixic acid, streptomycin, tetracycline, trimethoprim, and vancomycin. Six hundred fifty-seven (42%) of the isolates and 131 (81%) of the species had acquired resistance to antibiotics. Numerous resistant human pathogens were isolated, including Escherichia coli, Enterococcus spp., Salmonella, Shigella flexneri, Staphylococcus spp., and Vibrio spp. Nonresistant Yersinia spp. also were isolated. Ready-to-eat shrimp is sold with instructions to thaw the product before serving, which may result in consumer exposure to antibiotic-resistant bacteria. Widespread trade of this product provides an avenue for international dissemination of antibiotic-resistant pathogens.
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Spiramycin, a macrolide antibiotic, has been advocated for the treatment of cryptosporidiosis. The disease most commonly occurs in patients with AIDS and can be debilitating, as diarrhea and malnutrition may be contributing factors in the death of these patients. Until recently, treatment for cryptosporidiosis has been largely symptomatic. Response rates with drug therapy such as metronidazole, quinidine-clindamycin, and pentamidine have been extremely poor. Although response to spiramycin has appeared promising, there have been several reported cases of treatment failure. Further investigation with the agent is advocated to determine its role in the treatment of cryptosporidiosis.
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I.v.-to-p.o. switch therapy has become the mainstay of antibiotic therapy for the majority of patients. I.v.-to-p.o. switch therapy is inappropriate for critically ill patients who require i.v. antibiotic therapy and should not be considered in patients who have the inability to absorb drugs. These exceptions constitute a very small percentage of hospitalized patients for which i.v.-to-p.o. switch therapy is ideal. I.v.-to-p.o. switch therapy is best achieved with antibiotics that have high bioavailability that result in the same blood and tissue concentrations of antibiotic as their intravenous counterpart and have few gastrointestinal side effects. Antibiotics ideal for i.v.-to-p.o. switch programs include chloramphenicol, clindamycin, metronidazole, TMP-SMX, fluconazole, itraconazole, voriconazole, doxycycline, minocycline, levofloxacin, gatifloxacin, moxifloxacin and linezolid. Antibiotics that may be used in i.v.-to-p.o. switch programs that have lower bioavailability but are effective include beta-lactams and macrolides. For antibiotics with no oral formulation, e.g., carbapenems, equivalent coverage must be provided with an oral antibiotic from an unrelated class. Excluding gastrointestinal malabsorptive disorders, disease state is not a determinant of suitability for i.v.-to-p.o. switch programs. I.v.-to-p.o. switch programs should be used in patients with any infectious disease disorder for which there is effective oral therapy and is not limited to certain infectious diseases. Oral absorption of antibiotics is near normal in all but the most critically ill patients. Therefore, even in sick, hospitalized individuals, p.o. therapy is appropriate. I.v-to-p.o. switch therapy has several important advantages including decreasing drug cost (i.v. vs. p.o.), decreasing length of stay permitting earlier discharge and optimal reimbursement and decreasing or eliminating i.v. line phlebitis and sepsis with its cost implications. Clinicians should consider all patients, except the most critically ill or those unable to absorb oral medications, as candidates for treatment for most or all of their antibiotic treatment with oral antibiotics. (c) 2001 Prous Science. All rights reserved.
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Antimicrobial efficacy in vivo is not exclusively defined by the activity of an antibiotic as determined in the in vitro susceptibility test where constant inocula of log-phase bacteria are exposed to a steady concentration of drug for short periods of time in a well defined biochemical environment tailored to optimize antimicrobial activity. In vivo, many additional factors come into play which may be decisive for the clinical result of antimicrobial therapy. Clinically, high numbers of bacteria in various states of growth and metabolic activity are to be eliminated in an environment which may be unfavorable for antimicrobial activity. Low pH, low pO2, the presence of proteins, cell debris and biofilms, are all known to interfere with antimicrobial activity in vivo. Moreover, drug concentrations in vivo are fluctuating and vary greatly depending on a variety of pharmacokinetic factors. Finally, clinical treatment usually lasts for days. The impact of the pharmacokinetic profile of an antibiotic on its in vivo activity may be decisive. It is dependent on both, the type of drug in question and its target organisms. The time of supra-MIC concentrations appears to be the main parameter for the activity of macrolides, clindamycin, linezolide and betalactam antibiotics, particularly against gram-negative organisms. In contrast, peak concentrations and the AUC/MIC relationship are key parameters for the activity of aminoglycosides and fluoroquinolones. Regarding upcoming resistant bacterial strains, an as yet ill-defined mutation-prevention concentration has recently been discussed. Thus, in addition to the aim of eliminating target bacteria at the site of infection, in vivo concentrations of antibiotics may be important for both, the suppression of antimicrobial resistance and its epidemic spread. We are looking forward to prospective clinical trials to better understand the clinical relevance of the discussed phenomena.
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Although our data do not establish a causal association, prescriptions of antibiotic prophylaxis have fallen substantially and the incidence of infective endocarditis has increased significantly in England since introduction of the 2008 NICE guidelines.
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To investigate the relationship between parasite prevalence and malaria-related morbidity, we carried out a comparative study among cohorts of school children from two villages, Dienga, Gabon, and Pouma, Cameroon, both located in malaria-endemic areas. Seven to 17 year-old children attending primary schools were similarly followed-up at each site to evaluate the frequency of malaria attacks. Follow-up involved daily temperature recording (and blood smears in the case of fever) and preparation of blood smears every two weeks. In Pouma, 186 children were followed-up for six months. In Dienga, 228 children were followed-up for nine months. The mean prevalence rate of Plasmodium falciparum infections (as assessed by the blood smears) was twice as high in Pouma compared with Dienga (45.2% versus 26.8%; P < 0.0001), whereas the monthly malaria attack rate (as assessed by the daily surveillance) was twice as high in Dienga compared with Pouma (21.5% versus 41.4%; P = 0.003). The possible implication of several parameters that may differ between the two areas, such as the malaria transmission level, the economical and social status of the inhabitants, the characteristics of infecting parasite strains, and the genetic background of the population, is discussed.