Effects of antibiotic treatment on the concentrations of interleukin-6 and interleukin-8 in cervicovaginal fluid.

OBJECTIVE: We investigated to see the effect of antibiotics on interleukin (IL)-6 and IL-8 in cervicovaginal fluid in patients with premature rupture of the membranes. STUDY DESIGN: Cervicovaginal fluid was sampled on admission and before delivery for measurement of IL-6 and IL-8 from 31 patients with less than 35 weeks of gestation. Concentrations of IL-6 and IL-8 were measured by ELISA. RESULTS: The concentrations of IL-6 in cervicovaginal fluid in patients who were delivered because of clinical chorioamnionitis with antibiotics (n = 6) were significantly higher than in patients who were delivered because of active labor with (n = 14, p = 0.0133) and without antibiotics (n = 11, p = 0.0067). A significant change in the concentrations of IL-6 and IL-8 in cervicovaginal fluid was not observed in patients with and without antibiotics who were delivered because of active labor. CONCLUSIONS: The concentrations of IL-6 and IL-8 in cervicovaginal fluid might be influenced by the presence of clinical chorioamnionitis, but not by antibiotic administration.

Exploring the variability in antibiotic prescribing profiles among paediatricians from two different areas of Italy.

We carried out a multicentre community-based study in order to describe the antibiotic therapeutic approach of paediatricians from two different areas of Italy in the treatment of respiratory tract infection (RTIs), and to assess which factors are involved in a possible variability of prescribing habits. Forty paediatricians participated in the study between October 1998 and April 1999. They had to complete a questionnaire for each therapeutic intervention resulting in an antibiotic prescription. A logistic regression model was used to identify possible predictors in choosing parenteral antibiotics for the treatment of RTIs. In 2 975 questionnaires of antibiotic treatment, RTIs represented 90.2% of the total antibiotics used. Upper respiratory tract infections were the most commonly treated diagnostic group (59.6%), followed by lower respiratory tract infections (20.4%), and middle ear infections (19.8%). Statistically significant differences between northern and southern Italy were reported in the antibiotic prescription profile and the duration of the therapy. Another marked difference was reported in the frequency of laboratory analysis requests. The logistic regression model indicated that the use of parenteral antibiotics appears significantly related to the type of infections [lower RTIs: (OR: 3.99; 95% CI: 2.49-6.37)], the geographic location [northern Italy: (OR: 0.20; 95% CI: 0.20-0.39)], and the presence of concurrent diseases (OR: 3.21; 95% CI: 1.46-7.02). The lack of adherence to clinical guidelines and the marked variability of antibiotic prescription rates between different areas of the country appear to be related to factors other than bacterial resistance, and highlight the importance of carrying out educational programmes targeted at the national level for improving the antibiotic prescription habits for the treatment of RTIs

Antibiotic prescribing for children. Too much and too little? Retrospective observational study in primary care.

AIMS: To investigate the extent of dose-related off-label antibiotic paediatric prescribing in primary care and to identify any potential clinical effects, particularly of lower than recommended dose prescribing. METHODS: Assessment of antibiotic prescribing in 168 396 children aged 0-16 years for the year 1999-2000 from data retrieved from 158 general practices using the national Scottish primary care computer system GPASS. The setting was general practices in Scotland. RESULTS: During the study period at least one course of antibiotics was prescribed to 23 911 children (14.2%). A total of 4582 (19.2%) children were prescribed an antibiotic dose of less than that recommended in the Summary of Product Characteristics (SPC). The number of children prescribed an antibiotic at less than recommended dose increased with age from 1154 (11.8%) aged 0-4 years to 1827 (30.0%) in the 12-16 years age group. For each antibiotic, prescribing lower than recommended dose occurred most frequently at those ages at which a dose increase was recommended in the SPC. Antibiotic prescribing at less than the recommended dose was not associated with an increased return rate for further antibiotic prescriptions during the following month, but in 5-11-year-olds was associated with a significant 48% increase in the total number of antibiotic courses prescribed during the study year [mean = 2.09 [95% confidence interval (CI) 1.79, 2.39]vs. 1.41 [95% CI 1.35, 1.47]]. Antibiotic prescribing at doses higher than recommended occurred less frequently (1.6%) and decreased steadily with age. CONCLUSIONS: Off-label prescribing of antibiotics at less than the recommended dose in children is common in primary care and occurs primarily as the result of a failure to increase antibiotic dosage with age in line with SPC recommendations. Adoption of a uniform approach to SPC age banding for antibiotic dose increments would reduce the frequency of dose-related off-label antibiotic prescribing in children and help minimize the potential for the development of antibiotic resistance

Effect of different grades of agar-agar on the nature of the test microbe growth inhibition zones in controlling antibiotic activity by means of agar diffusion

The effect of various agar grades on the size and margin character of the inhibition growth zones in assay of antibiotic activity by the agar diffusion method was studied. It was shown that not all the agar grades could be used in antibiotic activity assay. Depending on the agar type the size of the inhibition growth zones produced by the same antibiotic concentration significantly varied. The variations in the size of the inhibition growth zones depended on the agar ability to bind antibiotics and were mainly defined by the agar purity. The agars with low content of nitrogen admixtures bound the antibiotics to a low extent. The commerical grades of the agars of the South-Sea and Korsakov Plants, the experimental grade of the TINRO agar with additional purification, as well as the agars imported from Argentina and France proved to be most useful for determination of the antibiotic activity by the agar diffusion method

Antimicrobial resistance and enterotoxin production among isolates of Escherichia coli in the Far East.

The frequency of association between transferable extrachromosomal D.N.A. (plasmid) mediated antibiotic resistance and enterotoxin productin is unknown. The antimicrobial susceptibility of 176 enterotoxigenic Escherichia coli from 57 children and adults in the Philippines, Korea, Taiwan, and Indonesia has been examined. 126 isolates (72%) were resistant to one or more antibiotic(s); 77 (44%) were resistant to four or more antibiotics. 43 E. coli which produced both heat-labile and heat-stable toxin, 110 isolates which produced only heat-labile toxin, and 23 which produced only heat-stable toxin were frequently resistant to multiple antibiotics. 25 of 31 resistant isolates tested, 80% transferred antibiotic resistance in bacterial mating experiments. In 35% of the matings transferring antibiotic resistance, the ability to produce enterotoxin was also conferred on the recipients. This in-vitro observation suggests that the widespread use of antibiotics could increase the distribution of enterotoxigenic E. coli, as genes coding for antibiotic resistance and enterotoxin production are frequently transferred together

Hypersensitivity reactions to Beta-lactam antibiotics.

Clinicians commonly encounter patients with a history of allergy to penicillin and other beta-lactarn antibiotics, since about 10% of the population reports such an allergy. At the same time, it is known that about 90% of these patients are not truly allergic and could safely receive beta-lactain antibiotics. Instead, these patients are treated unnecessarily with alternate broadspectrum antibiotics, which increases costs and contributes to the development and spread of multiple drug-resistant bacteria. In the case of penicillin, relevant allergenic determinants that elicit immune responses are known. Hence, validated diagnostic skin testing to detect the presence of drug-specific IgE antibodies is available. For non-penicillin beta-lactams, the immunogenic determinants that are produced by degradation are unknown, and diagnostic skin testing is of more limited value. Ideally, patients with a history of penicillin allergy should be evaluated when they are well and not in immediate need of antibiotic therapy. Patients who are found to be penicillin skin test-negative may be safely treated with all beta-lactam antibiotics. Penicillin skin testpositive patients should only receive a penicillin-class antibiotic via rapid desensitization, and only in cases when an alternative agent cannot be substituted. Penicillin skin test-positive patients may be safely treated with monobactams. The extent of allergic cross-reactivity between penicillin arid cephalosporins/carbapenems is uncertain; therefore penicillin skin test-positive patients should only receive these antibiotics via cautious graded challenge or desensitization. Identification of patients who erroneously carry a label of beta-lactam allergy leads to improved utilization of antibiotics and slows the spread of multiple drug-resistant bacteria

Predictors of an antibiotic prescription by GPs for respiratory tract infections: a pilot.

BACKGROUND: Antibiotics are over-prescribed for respiratory tract infections in Australia. OBJECTIVES: The aim of this study was to describe the clinical predictors of GPs' prescribing of antibiotics. METHODS: We used Clinical Judgment Analysis to study the responses of GPs to hypothetical paper-based vignettes of a 20-year-old with a respiratory tract infection. The nature of four symptoms and signs (colour of nasal mucous discharge; soreness of the throat; presence of fever; and whether any cough was productive of sputum) was varied and their effect on prescribing measured using logistic regression. RESULTS: Twenty GPs participated. The nature of each symptom and sign significantly predicted prescribing of an antibiotic. Cough productive of yellow sputum; presence of sore throat; fever; and coloured nasal mucus increased the probability of an antibiotic being prescribed. CONCLUSIONS: GPs are influenced by clinical signs and symptoms to use antibiotics for respiratory infections for which there is poor evidence of efficacy from the literature

The use of first- and second-line outpatient antibiotics under the Saskatchewan Drug Plan.

The Saskatchewan Drug Plan proposed de-listing several second-line antibiotics from its formulary for reasons of potential overuse and expense. This study evaluated the use of second-line antibiotics as initial and secondary courses of therapy depending on the patient's prior use of other antibiotics and other factors. A total of 637,607 courses of therapy dispensed to Plan members for selected antibiotics between July 1989 and June 1990 were evaluated. Second-line antibiotics were used in 5.0% of all initial courses of therapy. This use was correlated with patient characteristics that may warrant use of second-line antibiotics as initial therapy: age, rural residence, the use of bronchodilators or inhaled steroids, and the number of prior courses of antibiotic therapy. The potential savings from de-listing second-line antibiotics from the formulary are limited because of their use in only 5% of all initial courses of therapy. Savings would be further reduced by administrative costs and physician time required to process prior authorisation requests, and the costs of treating any additional antibiotic treatment failures that may result from reduced access

Early discharge of infected patients through appropriate antibiotic use.

BACKGROUND: Patients with infections are usually discharged from the hospital with antibiotics when afebrile and clinically improved. OBJECTIVES: To compare outcomes of early vs conventionally discharged patients and to examine the role of antibiotic use in the discharge process. METHODS: One hundred eleven patients hospitalized with cellulitis, community-acquired pneumonia, or pyelonephritis (urinary tract infection) discharged from the hospital early in their clinical course before defervescence by an infectious diseases hospitalist (L.J.E.) were compared in a case-controlled study with 112 patients discharged from the hospital according to conventional standards of care by internal medicine (IM) hospitalists. Patients were matched for age, sex, diagnosis, and comorbidities. Outcomes were determined for average lengths of stay, readmission to the hospital within 30 days with the same diagnosis, satisfaction with their discharge program, and time to return to their normal activities of daily living. RESULTS: Patients cared for by the infectious diseases hospitalist had a shorter average length of stay (mean difference, 1.7 days), no readmissions, higher satisfaction scores, and a shorter time to return to their activities of daily living, compared with those cared for by the IM hospitalists. Analysis of the antibiotics that patients were discharged with revealed that the infectious diseases hospitalist used outpatient parenteral antibiotic therapy more frequently than IM hospitalists in the treatment of cellulitis, and switched from intravenous to oral antibiotics sooner than IM hospitalists for patients with community-acquired pneumonia and urinary tract infection. CONCLUSIONS: The infectious diseases hospitalist discharged patients from the hospital earlier than the IM hospitalists by more efficient use of antibiotics. The earlier discharge did not adversely affect outcomes

Multiple antibiotic-resistant Klebsiella and Escherichia coli in nursing homes.

CONTEXT: Infections caused by ceftazidime sodium-resistant gram-negative bacteria that harbor extended-spectrum beta-lactamases (ESBLs) are increasing in frequency in hospitals in the United States. OBJECTIVES: To report a citywide nursing home-centered outbreak of infections caused by ESBL-producing gram-negative bacilli and to describe the clinical and molecular epidemiology of the outbreak. DESIGN: Hospital-based case-control study and a nursing home point-prevalence survey. Molecular epidemiological techniques were applied to resistant strains. SETTINGS: A 400-bed tertiary care hospital and a community nursing home. PATIENTS: Patients who were infected and/or colonized with ceftazidime-resistant Escherichia coli, Klebsiella pneumoniae, or both and controls who were admitted from nursing homes between November 1990 and July 1992. MAIN OUTCOME MEASURES: Clinical and epidemiological factors associated with colonization or infection by ceftazidime-resistant E coli or K pneumoniae; molecular genetic characteristics of plasmid-mediated ceftazidime resistance. RESULTS: Between November 1990 and October 1992, 55 hospital patients infected or colonized with ceftazidime-resistant E coli, K pneumoniae, or both were identified. Of the 35 admitted from 8 nursing homes, 31 harbored the resistant strain on admission. All strains were resistant to ceftazidime, gentamicin, and tobramycin; 96% were resistant to trimethoprim-sulfamethoxazole and 41% to ciprofloxacin hydrochloride. In a case-control study, 24 nursing home patients colonized with resistant strains on hospital admission were compared with 16 nursing home patients who were not colonized on hospital admission; independent risk factors for colonization included poor functional level, presence of a gastrostomy tube or decubitus ulcers, and prior receipt of ciprofloxacin and/or trimethoprim-sulfamethoxazole. In a nursing home point-prevalence survey, 18 of 39 patients were colonized with ceftazidime-resistant E coli; prior receipt of ciprofloxacin or trimethoprim-sulfamethoxazole and presence of a gastrostomy tube were independent predictors of resistance. Plasmid studies on isolates from 20 hospital and nursing home patients revealed that 17 had a common 54-kilobase plasmid, which conferred ceftazidime resistance via the ESBL TEM-10, and mediated resistance to trimethoprim-sulfamethoxazole, gentamicin, and tobramycin; all 20 isolates harbored this ESBL. Molecular fingerprinting showed 7 different strain types of resistant K pneumoniae and E coli distributed among the nursing homes. CONCLUSIONS: Nursing home patients may be an important reservoir of ESBL-containing multiple antibiotic-resistant E coli and K pneumoniae. Widespread dissemination of a predominant antibiotic resistance plasmid has occurred. Use of broad-spectrum oral antibiotics and probably poor infection control practices may facilitate spread of this plasmid-mediated resistance. Nursing homes should monitor and control antibiotic use and regularly survey antibiotic resistance patterns among pathogens