Home parenteral antibiotic therapy for patients with cystic fibrosis.

Cystic fibrosis is a genetic disease that affects multiple organ systems. Pulmonary complications associated with it frequently require intense intravenous antibiotic therapy. Home care allows patients to be treated at home, reducing the disruption of family life. New drug administration devices allow the patient increased mobility and independence. With adequate family and nursing support, patients may be able to attend work or school. Reduced hospital stays are good for the patient and cost effective for the hospital. The success of home antibiotic therapy depends on careful selection of the candidate, antibiotic regimen, nursing agency, and home care company. Many patients and families, though motivated, cannot manage the additional stress and time commitment required for home intravenous antibiotic and chest physical therapy. This time commitment may be reduced somewhat by limiting the number of antibiotics and the frequency of their administration

Nosocomial diarrhea outbreak due to Clostridium difficile in a vascular surgery department

INTRODUCTION: Clostridium difficile is considered the most common cause of nosocomial-acquired diarrhea. In Spain this condition is rarely reported. METHODS: Over a five-month period, 35 episodes of C. difficile diarrhea were diagnosed by toxin A detection in stool samples. Case-control studies were designed to assess risk factors for the outbreak. Twelve cases from the vascular surgery department were compared with 24 randomized controls, patients admitted to the same ward during this period, but without diarrhea. Statistical comparisons (SPSS software) were performed with the Student's t and X2 tests (OR with 95% CI). RESULTS: Overall incidence was 3.42 episodes: 48 episodes/1000 admissions to vascular surgery. Among the total, 80% had received antibiotics before admission and the mean number of antibiotics administered was 2.91 per patient. Comparative analyses disclosed that the cases had received a larger number of antibiotics during hospitalization (p 5 0.000) and in the two months before admission (p 5 0.031) than the controls. Clindamycin administered alone (p 5 0.001) or associated with aztreonam (p 0.000) were the most frequently used antibiotic treatments. CONCLUSIONS: C. difficile diarrhea is common in our setting. Diagnosis requires a high index of suspicion. We attribute the nosocomial outbreak in our vascular surgery department to broad-spectrum antibiotic use (clindamycin and aztreonam). Surveillance, together with restriction of antibiotic use was effective for control.

Recurrence of vancomycin-resistant Enterococcus stool colonization during antibiotic therapy.

OBJECTIVE: To test the hypothesis that antibiotic therapy may promote recurrence of vancomycin-resistant Enterococcus (VRE) stool colonization in patients who have previously had three consecutive negative stool cultures obtained at least 1 week apart. DESIGN: One-year prospective cohort study examining the effect of antibiotic therapy on recurrence and density of VRE stool colonization in patients who have cleared colonization. Pulsed-field gel electrophoresis (PFGE) was performed to determine whether recurrent VRE strains were the same clone as the previous colonizing strain. SETTING: A Department of Veterans Affairs medical center including an acute care hospital and nursing home. PATIENTS: All patients with at least one stool culture positive for VRE who subsequently had three consecutive negative stool cultures obtained at least 1 week apart. RESULTS: Of the 16 patients who cleared VRE colonization, 13 received antibiotic therapy during the study period. Eight (62%) of the 13 patients who received antibiotics developed recurrent high-density VRE stool colonization (range, 4.9 to 9.1 log10 colony-forming units per gram) during a course of therapy. Five patients had VRE strains available for PFGE analysis; recurrent strains were unrelated to the prior strain in 3 patients, closely related in 1 patient, and indistinguishable in 1 patient. CONCLUSIONS: Antibiotic therapy may be associated with recurrent high-density VRE stool colonization in many patients who have previously had three consecutive negative stool cultures. These patients should be screened for recurrent stool colonization when antibiotic therapy is administered

Over-the-counter acquisition of antibiotics in the Maltese general population.

Few studies have studied the frequency of over-the-counter acquisition of antibiotics in western countries. In order to provide an insight into these practices in Malta, attitudes towards antibiotic use in the general public were researched through a structured interview. Nineteen percent admitted that they took antibiotics without prescription and 11% of parents replied that they had given antibiotics to their children without prescription. These antibiotics were mainly self-administered for upper respiratory tract symptoms, particularly sore throat, with community pharmacies being the major source in more than 85% of cases. The study indicates the need for an educational campaign on proper antibiotic use amongst the Maltese general public

Community-acquired bacteraemia and antibiotic resistance. Trends during a 17-year period in a Danish county.

INTRODUCTION: The aim was to ascertain the prevalence of antibiotic resistance among blood isolates from patients with community-acquired bacteraemia and to relate it to antibiotic consumption. METHODOLOGY: Cases of community-acquired bacteraemia were identified in a regional bacteraemia register in the County of Northern Jutland. The study included 3974 episodes in 3805 patients during a 17-year period. Total regional consumption of antibiotics was expressed in Defined Daily Doses (DDD). RESULTS: The prevalence of antibiotic resistance was stable with few exceptions. The most notable time trend was noted for Escherichia coli for which the prevalence of resistance to ampicillin increased from 17% (95% confidence limits (CL) 12-23%) to 28% (95% CL 23-33%); for other Enterobacteriaceae the increase was from 73% (95% CL 61-83%) to 86% (95% CL 77-92%). The prevalence of resistance to aminoglycosides, fluoroquinolones and third-generation cephalosporins remained low among all isolates of Enterobacteriaceae. Regional antibiotic consumption ranged from 10.2 to 13.6 DDD/1000 inhabitants/day. Consumption of penicillins with Gram-negative spectrum reached a maximum of 4.6 DDD/1000 inhabitants/day in 1993 and decreased towards the end of the study period. The prevalence of ampicillin-resistant E. coli was positively correlated with consumption of penicillins with Gram-negative spectrum; the correlation was stronger when adjustment was made for co-selection by tetracyclines and sulphonamides. CONCLUSION: Therapeutic options for community-acquired bacteraemia have not yet become seriously limited by prevalence of acquired antibiotic resistance. Still we found some evidence that consumption of penicillins with Gram-negative spectrum, sulphonamides and tetracyclines promotes antibiotic resistance among Enterobacteriaceae

Release of netilmicin and vancomycin from cancellous bone.

First, we studied the effect of the following variables used for netilmicin- and vancomycin-impregnation of cancellous bone: a) antibiotic concentration of the impregnation fluid, b) time used for impregnation, c) pH of the impregnation fluid, d) the degree of bone morselizing and e) antibiotic combination. An increase in the antibiotic concentration of the impregnation fluid increased the amount of antibiotics released from bone. In addition, the amount of vancomycin eluted was also dependent on the time used for impregnation. The fraction of the total amount of netilmicin and vancomycin released after 24 h was 80% and 30%, respectively. More netilmicin and vancomycin were eluted from bone impregnated with antibiotics at pH 7 than the amount eluted from bone impregnated at pH 3. More netilmicin was eluted from fine morselized bone than from coarse morselized bone. By combining netilmicin and vancomycin in the impregnation fluid, the release of vancomycin was reduced. Secondly, we analyzed if the release of antibiotics from bone was complete: 99.9% of the total amount of netilmicin adsorbed to the bone was released by elution during 6 weeks. Finally, after implantation of netilmicin-impregnated bone in rabbit femur condyle, we measured netilmicin and vancomycin in serum: peak serum values of netilmicin were 4.2 (3.7-4.7) mg/L 2-3 h postoperatively.

Endemic nosocomial infections and misuse of antibiotics in a maternity hospital in Saudi Arabia.

Patients admitted during a 6-month period to a maternity hospital in Saudi Arabia were studied for nosocomial infections and misuse of antibiotics. Patient history and diagnosis on admission and subsequent clinical and laboratory data were analysed. Infection developing from 72 h after admission was considered nosocomial. Therapeutic and prophylactic data as recorded on the patients' charts were assessed for possible misuse of antibiotics. Of 3439 patients, 136 (4.0%) developed nosocomial infection: 2.0%, 8.9% and 37.7% in obstetric, gynaecologic and nursery patients, respectively. Infections among adults were mostly found in the urinary (44.4%) and lower genital (33.3%) tracts. Among newborns, over 70% of cases were eye and ear (29.8%), skin (26.2%) and blood (19.0%) infections. Gram-negative bacteria caused 65.7% of the infections. Over 90% of the bacterial isolates were multidrug-resistant. About 24% of patients received single or multiple antibiotics; 57.2% were misused. The minimal hospital cost estimate for both nosocomial infections and misused antibiotics was US $318,705. The findings of this study, the first of its type in this region, should prompt improved infection control measures as well as educational and antibiotic restriction interventions

Epidemiological observations of the judicious use of antibiotics in a pediatric teaching hospital.

OBJECTIVE: This study in a tertiary care teaching center with 361 beds was conducted to assess use, misuse, and abuse of antibiotics. MATERIALS AND METHODS: Every day of the study, a computer program was used to compile a list of patients' bedside records. On a specific day, the bedside charts of selected patients were reviewed to determine whether: (1) a justification for antibiotic prescription was recorded; (2) duration of antibiotic therapy had been defined; (3) suitable cultures had been obtained; and (4) treatment was appropriate for the infection to be treated. For 6 months, charts were evaluated 3 days per week. RESULTS: Of 750 bedside charts 500 (67%) were selected for review. Of the 500 patients, 175 (35%) did not receive antibiotics. The abuses or misuses of antibiotics most frequently observed among the 325 treated patients were no record of justification for the antibiotic prescribed (130/325, 40%); no appropriate blood or fluid samples obtained for culture (45/325, 14%); no subsequent control cultures or cultures obtained before modifying therapy (80/175, 46%); no indication of a planned duration of therapy (180/325, 55%); and improper dosage prescribed in relation to weight (25/325, 8%). Abuse or misuse of antibiotics was more frequently observed among surgical patients than among nonsurgical patients (P<0.05). CONCLUSION: Rational use of antibiotics should be emphasized in every training program as a main strategy to control the increase in drug resistance and to prolong the usefulness of antibiotics

Perioperative antibiotic prophylaxis against vascular graft infection.

This study investigated the efficacy of perioperative antibiotics in preventing bacteremic infection of vascular suture lines, Dacron grafts, and bovine heterografts. One hundred forty-nine dogs had either segmental excision of the abdominal aorta with primary repair, Dacron prosthesis, or bovine heterograft placement. Animals were randomly assigned to a control group, to receive 10(8) S aureus, or to receive this same dose of staphylococci plus cephalothin (15 mg/kg). After six weeks, graft cultures were obtained. All control animals had negative cultures. Often dogs with an aortic suture line subjected to bacteremia, five were infected. Eight dogs with aortic suture lines received bactermia and antibiotics resulting in only one positive culture. Nineteen animals with bovine grafts were given S aureus resulting in 18 infections, and seven of 12 bovine grafts became infected even with antibiotic coverage. Twenty-eight dogs had a Dacron graft and infusion of Staphylococcus, yielding 23 infections. Of the 24 Dacron graft subjects with induced bacteremia and antibiotics, only four were infected. Intraoperative antibiotics are significantly effective in preventing infection of vascular suture lines and Dacron prostheses but afford less protection to bovine heterografts

Prepartum antibiotic treatment of heifers: milk production, milk quality and economic benefit.

Prepartum intramammary antibiotic infusion of heifer mammary glands at 7 or 14 d before expected parturition is an effective procedure for eliminating many infections in heifers during late gestation and for reducing the prevalence of mastitis in heifers during early lactation and throughout lactation. Mastitis pathogens were isolated from 76% of samples obtained from untreated control quarters 7 d before expected calving, from 47% of samples obtained 3 d after calving, and from 29% of samples obtained 10 d postpartum. Mastitis pathogens were isolated from about 30% of control quarters through 240 d of lactation. A similar percentage of samples (70%) was positive for mastitis pathogens at C-7 before antibiotic treatment. However, only 8% of samples obtained at 3 d after calving and 4% of samples obtained at 10 d postpartum from quarters of antibiotic-treated heifers contained mastitis pathogens. Throughout the remainder of lactation, mastitis pathogens were isolated from an average of about 11% of quarters. The percentage of samples with mastitis pathogens was higher in untreated controls than in antibiotic-treated quarters at all sampling intervals during lactation. A similar response was observed in heifers that were treated with antibiotics at 14 d before expected parturition. Prepartum antibiotic-treated heifers produced significantly more milk than control heifers and had significantly lower somatic cell count scores than untreated control heifers. These observations are likely associated with or due to the lower prevalence of mastitis pathogen isolation in prepartum antibiotic-treated heifers throughout lactation. Prepartum antibiotic-treated heifers produced 531 kg more milk than heifers in the untreated control group. Multiplying this increase by a milk price of 0.407 dollars/kg yielded a 216.24 dollars per-heifer increase in gross revenue. The cost of treatment, including the cost of testing for antibiotic residues, was estimated at 15.60 dollars for a net revenue of 200.64 dollars per heifer. Prepartum antibiotic treatment to reduce the rate of mastitis in heifers during lactation was highly effective and economically beneficial