New Therapies Or Therapeutic Strategies

Optimal use of antimicrobials begins by selecting the most potent agent as the first choice for therapy. Pharmacodynamic data from experimental models and clinical studies allow comparisons among members of each antibiotic class to predict the agents that are most likely to effect the greatest bacterial eradication and result in the least selection of resistant mutants (75,76). Sub-optimal exposure to any antimicrobial may occur through inadequate dosing, duration of administration, and failure...

Acute Sinusitis

Acute bacterial rhinosinusitis is a common upper respiratory tract infection, with more than 20 million cases reported annually in the United States (6). Many of these infections are associated with viral illnesses that are occasionally complicated by bacterial superinfection. Data suggest that only about 2 of patients with viral sinusitis develop clinically significant bacterial superinfection. Common presenting signs and symptoms include facial pain, headache, nasal discharge, and fever. It...

Studies of Acute Maxillary Sinusitis in Adults

At least four studies have examined SCAT for the treatment of acute maxillary sinusitis in adults (36). Williams and coworkers carried out a randomized trial of 80 adults with acute maxillary sinusitis treated with 3 versus 10 days of trimetho-prim-sulfamethoxazole (TMP-SMX) and reported 76 cure rates and bacteriologic eradication in both groups. The authors concluded that afebrile, immunocompe-tent adults could receive a 3-day course of TMP-SMX. Nonresponders should be re-evaluated and treated...

Outcomes Of Candidemia Morbidity And Mortality

Candida species are recognized as important causes of healthcare-associated infections and are associated with significant morbidity and mortality. Patients with candidemia have 10 to 30 day excess lengths of hospital stay compared to age-, sex-, and diagnosis-related group-matched controls (32). Candidemia is also associated with significant costs totaling more than 1 billion per year (33). Approximately 85 appear to be attributable to this increased length of stay (32). Candidemia appears to...

Risk Factors For Resistance

Risk factors for the presence of penicillin-resistant isolates in children include daycare attendance, recent antimicrobial treatment (< 90 days), and age younger than 2 years (33). Similarly, in adults, the risk factors for infection with DRSP center on the two factors most important to the spread of DRSP antibiotic selection pressure and exposure to carriers. Not surprisingly, recent beta-lactam therapy (within 3 months) has been identified as a major risk factor for both carriage of and...

Emergence of MDR Pathogens

In the past decade, there has been a notable escalation of infections due to MDR strains in the community and healthcare institutions (2,19). Examples of MDR Gram-negative bacilli include K. pneumoniae and Escherichia coli with ESBL+, P. aeruginosa and Acinetobacter baumannii (4,20). There has also been a rapid increase in infections due to MDR Gram-positive cocci, such as S. pneumoniae, community-acquired (CA) and healthcare-associated (HA) MRSA, and vancomy-cin-resistant strains, such as VRE...

Reduction of Unnecessary Antimicrobials

The Consensus Group identified inappropriate prescribing to be the major influence on developing resistance and increasing costs, and called for antibiotic therapy to be limited to infections in which bacteria are the predominant cause. While this principle certainly seems self-evident, it is one to which adherence seems very difficult. The reasons for over-prescribing antibiotics are multifactorial. Patients may consult clinicians, expecting an antibiotic to be prescribed for an acute...

Risk Factors For Candidemia

Because of the complications associated with candidemia, researchers have investigated potential risk factors, which could be used to develop and implement preventive measures or to identify high-risk patients who might benefit from prophylactic or empiric antifungal treatment. Classic risk factors, including host- and healthcare-related factors, for candidemia are well known (38-41). Host-related factors include malignancy with chemotherapy, solid organ transplantation, hematopoietic stem cell...

Factors Impacting Empiric Antibiotic Selection

To provide an empiric regimen with an adequate spectrum of activity, one must appreciate (i) the likely pathogens causing a variety of nosocomial infections, (ii) local pathogen distribution and resistance patterns, and (iii) patient-specific risk factors for resistance. Ideally, administration of appropriately broad-spectrum empiric antimicrobial therapy is based on consideration of all of these factors and each are examined in the following section. Data from the National Nosocomial...

Catheter Associated UTIs

UTIs account for about 40 of all HAIs (62). Instrumentation, particularly indwelling catheterization, is responsible for the majority of nosocomial UTIs (63). Therefore, using these catheters only when indicated, inserting and maintaining them properly, and removing them when they are no longer needed is important. Urinary catheters are frequently overused and are left in for longer than needed catheters should never be used for convenience (64). Personnel who insert and maintain catheters...

Pharyngitis Strep Throat

The primary use of antibiotics in pharyngitis is to treat infection due to group A Streptococcus (GAS). GAS is the most common bacterial agent causing acute pharyngitis, and accounts for approximately 15 to 30 of cases in children and 5 to 10 of adults (44,45). However, streptococcal pharyngitis is difficult to differentiate from other causes (such as viral etiology) on clinical grounds (45). Definitive diagnosis of streptococcal pharyngitis is based on the identification of GAS in the throat...

Kathleen Steger Craven

Consultant in Infectious Diseases and Public Health, Wellesley, Massachusetts, U.S.A. Clinical medicine seems to consist of a few things we think we know and lots of things we don't know. The population in the United States in the 21st century is at greater risk for infections due to increased longevity coupled with more chronic underlying diseases, aggressive medical and surgical procedures, solid organ transplantation, immunosuppressive therapy, and a highly mobile modern society. The current...

Adaptation of Locally Customized Published Guidelines

National guidelines put forth by the IDSA and SHEA (and other organizations) are available for a variety of infections, providing evidence-based diagnosis and prevention and treatment discussions, and are useful to construct clinical pathways, which can be customized locally. In addition, for some infections (CDI) where significant time has passed since the publication of national guidelines and where the disease process has changed significantly, an institution should have a mechanism to...

Acute Bacterial Rhinosinusitis ABRS

Similar to the CDC's recommendations for AOM, the guidelines issued by the Sinus and Allergy Health Partnership recommends empiric choices for treating ABRS (43). As in AOM, S. pneumoniae and H. influenzae are frequently implicated in ABRS. However, M. catarrhalis is less likely to be the infectious cause of this TABLE 3 Criteria for Initial Antibacterial Treatment or Observation in Children with Acute Otitis Media Age Certain diagnosis Uncertain diagnosis TABLE 3 Criteria for Initial...

Risk Factors For C Glabrata Bloodstream Infections

Despite the emergence of bloodstream infections due to C. glabrata, only a few studies have evaluated the risk factors for this infection. None of these studies performed susceptibility testing to differentiate between fluconazole-susceptible and fluconazole dose-dependent susceptible or resistant isolates. The possible association between fluconazole and the emergence C. glabrata has been mentioned in the literature. As previously mentioned, prior fluconazole use could result in resistance...

Polymyxin Therapy

Given the limited therapeutic options for the most resistant Acinetobacter infections, clinicians have returned to the use of polymyxin B or polymyxin E (colistin) as the best therapeutic option for severe Acinetobacter infections that demonstrate broad antimicrobial resistance to other available classes of agents including carbapenems (71,72). Polymyxins are polypeptide antibiotics originally discovered in 1947 but largely abandoned for clinical use more than 20 years ago due to reports of...

Historical Perspective And Unique Challenges Related To Antimicrobial

Before we discuss ASPs, it is important to address some of the unique attributes of antimicrobials and their use. Antimicrobials have been termed societal drugs (10). Why Because prescribing an antihypertensive to a patient with hypertension, for example, only impacts the patient for whom the drug is prescribed. Conversely, an antimicrobial administered to that same patient has an opportunity to impact not only that person, but countless others. Since antimicrobial resistance has the potential...

References

Risk factors for nosocomial infection in intensive care. Devices vs nature and goals for the next decade. Arch Intern Med 1989 149 30-5. 2. Kollef MH, Fraser VJ. Antibiotic resistance in the intensive care unit. Ann Intern Med 2001 134 298-314. 3. Helfand MS, Bonomo RA. Current challenges in antimicrobial chemotherapy the impact of extended-spectrum beta-lactamases and metallo-beta-lactamases on the treatment of resistant Gram-negative pathogens. Curr Opin Pharmacol 2005 5 452-8. 4....

Nonrecommended Strategies

A variety of management options with theoretical benefits, including probiotics, cholestyramine, and antiperistaltic agents, have gained popularity with some clinicians trying to manage recurrent and severe CDI. Unfortunately, data are insufficient to recommend these modalities or contradict their use. In addition, there is evidence of significant harm associated with their use e.g., bacteremia fungemia associated with probiotics, intraintestinal binding of vancomycin (and other drugs) by...

The Attributable Costs of Resistant Infections in Hospital Settings Economic Theory and Application

Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, U.S.A. Department of Emergency Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois, U.S.A. The emergence of antibiotic resistance in healthcare settings and the community continues to prompt greater policy efforts from public health organizations. In 2001, the World Health Organization issued its global strategy to contain the...

Benchmarking Its Utility in the Fight Against Antibacterial Resistance

Institute for Clinical Pharmacodynamics, Ordway Research Institute, Inc., Albany, New York, U.S.A. Replidyne, Inc., Milford, Connecticut, U.S.A. Antibacterial resistance is a burgeoning and global problem, involving multiple species of bacteria and most antibacterial agents. Although antibacterial resistance rates for both Gram-negative and Gram-positive pathogens continue to rise, increases in the resistance rates of Gram-negative bacilli to many commonly used broad spectrum agents, especially...