For whom should we use selective decontamination of the digestive tract?
Curr Opin Infect Dis. 2012 Jan 23;
Authors: de Smet AM, Bonten MJ, Kluytmans JA
Abstract
PURPOSE OF REVIEW: This review discusses the relevant studies on selective decontamination of the digestive tract (SDD) published between 2009 and mid-2011. RECENT FINDINGS: In a multicenter cluster-randomized cross-over study in the Netherlands, SDD and selective oropharyngeal decontamination (SOD) were associated with higher survival at day 28, with a lower incidence of ICU-acquired bacteremia and with less acquisition of respiratory tract colonization with antibiotic resistant pathogens, compared to standard care. A post-hoc analysis of this study suggests that SDD might be more effective in surgical patients and SOD in nonsurgical patients. In a randomized study perioperative use of SDD in patients undergoing gastrointestinal surgery was associated with lower incidences of anastomotic leakages. A Cochrane meta-analysis, not including any of the before mentioned studies, reported a reduction of respiratory tract infections in studies by using topical antibiotics only and higher survival rates when topical antibiotics were combined with parenteral antibiotics. SUMMARY: Recent studies show that in ICUs with low levels of antibiotic resistance, SDD and SOD improved patient outcome and reduced infections and carriage with antibiotic-resistant pathogens. The effect in settings with higher levels of antibiotic resistance remains to be determined as well as the efficacy of SDD and SOD in specific patient groups.
PMID: 22274728 [PubMed - as supplied by publisher]
Macrolides for the therapy of nosocomial infections.
Curr Opin Infect Dis. 2012 Jan 13;
Authors: Mouktaroudi M, Giamarellos-Bourboulis EJ
Abstract
PURPOSE OF REVIEW: Nosocomial infections are an emerging threat. Available solutions are limited due to the multidrug-resistance pattern of the pathogens. Macrolides modulate the immune function of the host and may be active in this setting. RECENT FINDINGS: Findings of in-vitro and experimental animal studies are presented. Clinical studies of community-acquired pneumonia (CAP) and ventilator-associated pneumonia (VAP) are described. SUMMARY: Macrolides decrease production of proinflammatory cytokines by circulating monocytes and by alveolar macrophages and decrease apoptosis of circulating lymphocytes in animal models of acute infections. They also inhibit gene expression of proteins participating in quorum sensing of Pseudomonas aeruginosa. Retrospective cohort studies indicate that addition of a macrolide significantly improves outcome in severe CAP. One randomized, double-blind, clinical study is available. This involves patients with VAP allocated to placebo or intravenous clarithromycin 1 g once daily for 3 days. Clarithromycin treatment significantly decreased time to resolution of VAP and time until weaning from mechanical ventilation. The described findings are promising for the use of macrolides in nosocomial infections.
PMID: 22248975 [PubMed - as supplied by publisher]
Authors: Leroy O, Meybeck A, Sarraz-Bournet B, d’Elia P, Legout L
Abstract
PURPOSE OF REVIEW: This review provides a focus on infections of prosthetic vascular grafts used to treat peripheral arterial diseases. RECENT FINDINGS: The incidence of infections varies between 1 and 6%. Risk factors of infection are not well identified. Main causative pathogens are Gram-negative bacilli, Staphylococcus aureus, and coagulase-negative staphylococci, without clear differences according to location of graft and time of onset of infection. There is no consensual diagnostic criterion. The basic principles for management of graft infections have been known for many years. A surgical approach combining graft excision, complete debridement, and maintaining distal vascular flow is required. Antimicrobial therapy is always instituted to reduce sepsis and prevent secondary graft infection, but there are no evidence-based data to recommend any regimen. However, antibiotics should have bactericidal activity whatever the bacteria growth phase, reduce the microbial burden, penetrate within the biofilm, and prevent further biofilm formation. Mortality and morbidity from these infections remain significant. SUMMARY: A multidisciplinary approach with a limited number of reference centres, recruiting sufficient numbers of patients to perform controlled trials, and to provide expert recommendations, could be the best way to answer unresolved questions and improve the prognosis.
PMID: 22248976 [PubMed - as supplied by publisher]
Is healthcare-associated pneumonia a distinct entity needing specific therapy?
Curr Opin Infect Dis. 2012 Jan 13;
Authors: Ewig S, Welte T, Torres A
Abstract
PURPOSE OF REVIEW: Healthcare-associated pneumonia (HCAP) was introduced in 2005 by American Thoracic Society/Infectious Diseases Society of America guidelines as a new entity of pneumonia, resembling nosocomial pneumonia rather than community-acquired pneumonia (CAP) in terms of frequency of multidrug-resistant (MDR) pathogens and outcomes, thus requiring broad spectrum initial antimicrobial coverage in order to prevent inadequate treatment and, as a consequence, excess mortality. This concept continues to be a subject of controversy. Main concerns relate to the definition of HCAP, the true frequency of MDR pathogens, and the impact of MDR pathogens on outcomes. RECENT FINDINGS: Definitions of HCAP and the relative frequencies of HCAP defining subgroups were highly variable. All studies demonstrated an increased severity of pneumonia at presentation and an excess mortality from HCAP as compared to CAP. The incidence of MDR pathogens in different observational studies was slightly increased but generally low in most studies originating from Europe, South Korea, Canada, and Japan. However, the data do not support a causal relationship of MDR incidence and excess mortality. Instead, after adjustment for confounders, mortality might be related to hidden or documented treatment restrictions in elderly and severely disabled patients. Accordingly, HCAP guideline concordant antimicrobial treatment did not improve outcomes. SUMMARY: The HCAP concept is based on varying definitions poorly predictive of MDR pathogens. The incidence of MDR pathogens is far lower than supposed in the original guideline document, and MDR pathogens do not seem to be the main cause of excess mortality. Broad antimicrobial coverage does not alter outcomes. As the HCAP concept results in a tremendous overtreatment without any evidence for improved outcomes, it should not be implemented in clinical practice prior to clear evidence that it is superior to a careful assessment of individual risk factors for MDR pathogens.
PMID: 22248977 [PubMed - as supplied by publisher]
Is a ventilator-associated pneumonia rate of zero really possible?
Curr Opin Infect Dis. 2012 Jan 13;
Authors: Klompas M
Abstract
PURPOSE OF REVIEW: The increasing number of hospitals reporting ventilator-associated pneumonia (VAP) rates at or close to zero begs the question of whether zero should become the national benchmark for VAP. This article explores the significance of very low VAP rates, reviews differences in surveillance and clinical rates, proposes reasons for their discrepancies, and suggests possible objective alternatives for surveillance. RECENT FINDINGS: Surveillance rates of VAP are decreasing, whereas clinical diagnoses and antibiotic prescribing remain prevalent. This growing discrepancy reflects the lack of objective and definitive signs to diagnose VAP. External reporting pressures may be encouraging stricter interpretation of subjective signs and other surveillance initiatives that can artifactually lower rates. It is impossible to disentangle the relative contribution of care improvements versus surveillance effects to currently observed low VAP rates. SUMMARY: The increasing mismatch between surveillance rates and clinical diagnoses limits the utility of official VAP rates to estimate disease burden and guide quality improvement. Advocates are advised to consider objective alternatives such as average duration of mechanical ventilation, length of stay, mortality, and antibiotic prescribing. Emerging surveillance definitions that use more objective criteria may better reflect and inform future clinical practice.
PMID: 22248978 [PubMed - as supplied by publisher]
PURPOSE OF REVIEW: Miltefosine is a new oral treatment against leishmaniasis. The evidence about its use in New and Old World cutaneous leishmaniasis is presented and discussed. RECENT FINDINGS: Miltefosine is being tested with small clinical trials mainly in endemic cutaneous leishmaniasis regions of South America and Iran. Severe cutaneous leishmaniasis forms successfully treated with miltefosine are reported. SUMMARY: The use of miltefosine in cutaneous leishmaniasis has been addressed in a few clinical trials. An important advantage of this drug is its oral administration when compared with the standard parenteral drugs in the context of a large-scale use in the inner regions of the endemic countries. Miltefosine also shows activity in severe or refractory cases. However, this review points out the need for further investment on clinical research into cutaneous leishmaniasis treatment.
PMID: 22248979 [PubMed - as supplied by publisher]
New therapy options for MRSA with respiratory infection/pneumonia.
Curr Opin Infect Dis. 2012 Jan 13;
Authors: Ramirez P, Fernández-Barat L, Torres A
Abstract
PURPOSE OF REVIEW: Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent causative agent of nosocomial pneumonia. Because of important clinical consequences of inappropriate treatment, a current review of the potential modifications undergone by S. aureus and adaptation to new treatment options is necessary. RECENT FINDINGS: Vancomycin has been considered the treatment of choice for pneumonia due to MRSA. However, detection of a progressive increase in the minimum inhibitory concentration for this antibiotic, its limited access to the lung parenchyma, and its considerable adverse effects have called into question its position. Linezolid has been shown to have a better pharmacokinetic and safety profiles. The prior uncertainty regarding the clinical superiority of linezolid appears to have been resolved with the publication of a recent trial. Linezolid achieved a higher clinical and microbiological response rate (the latter was not statistically significant), together with a lower incidence of all types of renal adverse effects in patients with nosocomial pneumonia, compared with vancomycin. Tigecycline, teicoplanin and quinupristin/dalfopristin were inferior to the compared drug in their respective clinical trials. The clinical efficacy of telavancin was similar to that of vancomycin. The renal adverse effects of telavancin have to be clarified. Other drugs are efficacious against MRSA but their profile should be evaluated in nosocomial pneumonia. SUMMARY: Current therapeutic alternatives for nosocomial pneumonia due to MRSA appear to be limited to vancomycin and linezolid. However, vancomycin pitfalls, together with the apparent clinical superiority of linezolid, appear to restrict its indication. Telavancin could be a good alternative in patients without basal renal failure.
PMID: 22248980 [PubMed - as supplied by publisher]
PURPOSE OF REVIEW: Recent advances in the molecular diagnostics of dermatophytosis may improve speed, specificities and sensitivities. This review provides an update on the current available molecular techniques for the diagnosis of dermatophytosis. RECENT FINDINGS: Molecular diagnostics of dermatophytosis relate to the direct detection of dermatophyte DNA in clinical specimens. Important challenges have been associated with the DNA extraction procedures, which despite improvement still lack consensus, and the fact that phenotypic species classification not always translates into distinct molecular taxonomic entities. Molecular methods are divided into conventional PCR, real-time PCR and post-PCR techniques. The former benefits from simplicity and being less expensive to implement, real-time PCR is less laborious, may enable a broader spectrum of simultaneous species detections and the closed system reduces contamination risk, whereas post-PCR strategies may increase the number of species identified but prolong the turnaround time, and the processing of PCR products increases the laboratory contamination risk. SUMMARY: Current molecular methods are on the verge of overcoming most of the early challenges regarding dermatophyte taxonomy, DNA extraction procedures and species specificity, and thus may lead to an increased adoption of such methods. This may point towards a novel consensus in which molecular methods supplement or even replace classical diagnosis of dermatophytosis.
PMID: 22248981 [PubMed - as supplied by publisher]
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