Antimicrobial resistance of gram-negative isolates from intensive care units in Turkey: comparison to previous three years

Resistance rates to selected antibiotics of gram-negative bacteria isolated from intensive care units (ICU) of 16 Turkish hospitals during 1998 were evaluated and compared to data from the previous 3 years. Antibiotic susceptibilities to imipenem, ceftazidime, ceftazidime-clavulanate, cefoperazone-sulbactam, ceftriaxone, cefepime, cefodizime, cefuroxime, piperacillin-tazobactam, ticarcillin-clavulanate, gentamicin, amikacin and ciprofloxacin were determined by Etest. A total of 1,404 isolates from 1,060 patients were collected, mainly from urinary and respiratory tracts. As in the previous 3 years, Pseudomonas spp. was the most frequently isolated gram-negative species (29.7%), followed by Escherichia coli, Acinetobacter and Klebsiella spp. Imipenem was the most active in vitro agent (73.4% susceptible), followed by ciprofloxacin (60.6%), cefoperazone-sulbactam (58.7%), cefepime (56.7%), piperacillin-tazobactam (55.0%) and amikacin (54.7%). In 1996, a decline in susceptibility rates of all antibiotics was evident. With the exception of imipenem, resistance to which remained stable, rates somewhat increased in 1997. In 1998, susceptibility to imipenem and cefepime remained stable, amikacin resistance tended to increase and susceptibility rates to other antibacterials showed a favorable increase. These results may in part be due to the implementation of a surveillance program and increased understanding of the magnitude of the resistance problem.     

Antimicrobial resistance in gram-negative isolates from European intensive care units: data from the Meropenem Yearly Susceptibility Test Information Collection (MYSTIC) programme

Susceptibility data were collected for 6243 gram-negative isolates from 29 European ICUs participating in the Meropenem Yearly Susceptibility Test Information Collection (MYSTIC) Programme (1997-2000). The most commonly isolated bacteria were Pseudomonas aeruginosa (22.5%), Escherichia coli (19.8%), Klebsiella pneumoniae (10.4%), and Enterobacter cloacae (7.7%). The incidence of extended-spectrum beta-lactamase-producers was higher in Turkish, Russian and Italian ICUs (27.9-39.6%) than in other countries (2.5-10.8%). The frequency of AmpC-cephalosporin hyper-producers was 16.8-55.4%. Meropenem was more active against Proteus mirabilis than imipenem (99.0% versus 88.8% susceptibility, respectively). Against Acinetobacter baumannii, meropenem (79.6% susceptible) and imipenem (82.2%) were more active than comparators (34.3-51.6%). Meropenem and imipenem exhibited good activity against P. aeruginosa (76.1% and 68.2%, respectively; but with inter-country variation). Ciprofloxacin resistance in E. coli and K. pneumoniae increased and needs close monitoring. Meropenem (98.2-99.8% susceptibility) and imipenem (88.8-99.4%) remained potent against important species of gram-negative bacteria from European ICUs actively using meropenem.     

Antimicrobial susceptibility patterns of clinical isolates of gram-negative bacteria obtained from intensive care units in a tertiary hospital in Beijing, China

In this study we investigated the prevalence of antimicrobial resistance in clinical isolates of Gram-negative bacteria obtained from intensive care units (ICUs) in the People's Liberation Army (PLA) 309 Hospital located in beijing, China. between 2007 and 2010, a total of 1949 isolates of Gram-negative bacteria were collected and tested using an antibiotic susceptibility assay. A marked decrease was observed in the susceptibility of Acinetobacter baumannii to imipenem and amikacin as compared to that described in a previous report in China. Similar results were obtained for Pseudomonas aeruginosa. However, imipenem and amikacin showed strong activity against Escherichia coli and Klebsiella pneumoniae. Overall, the high rates of antimicrobial resistance against ICU pathogens in our hospital indicated a critical condition in Beijing, China. Development of a national control and monitoring system by the government may be an ideal method to solve the present problem of managing infections due to Gram-negative bacterial pathogens.     

Azole resistance in neonatal intensive care units in Argentina

The aim of this study was to determine the antifungal susceptibility profile and to detect resistant strains of yeast species isolated from neonates in Intensive Care Units. 92 strains isolated from 25 bloodstream cultures, 20 venous catheters, 23 suprapubic aspirations and 24 rectal swabs were studied. A Candida glabrata strain resistant to fluconazole was detected. Candida krusei appeared with its inherent resistance to fluconazole and showed cross-resistance to itraconazole. Two Candida albicans strains were resistant to azoles, one to itraconazole and the other to fluconazole with a high minimum inhibitory concentration (MIC) for itraconazole. All Candida tropicalis strains were susceptible to fluconazole but two of them showed resistance to itraconazole. The detection of resistant strains in neonates whom had not received previous antifungal therapy is noteworthy. The variations in the epidemiology of fungal infections observed and the antifungal resistance detected emphasize the importance of performing a regular surveillance to observe and to assess them.     

Antibiotic use and microbial resistance in intensive care units: impact of computer-assisted decision support

As part of our integrated hospital information system (the HELP system), we developed computer-assisted decision support programs for antimicrobial prescribing that are available at bedside terminals throughout our 520-bed community hospital. Recently, options have been added to allow direct physician order entry of anti-infective agents in the shock-trauma intensive care unit (STRICU). Physicians prescribed the computer-suggested regimens for 46% but followed the suggested dose and interval for 93% of the orders during a 1-year study period. In comparison to a 2-year pre-intervention period, improved drug selection and reductions in adverse drug events and costs were seen. Antimicrobial resistance patterns for nosocomial gram-negative isolates remained stable or improved in the STRICU over an 11-year period of computer-assisted antibiotic management. We conclude that strategies for optimizing antimicrobial prescribing have the potential to stabilize resistance and reduce costs by encouraging heterogeneous prescribing patterns, use of local antimicrobial susceptibility patterns to inform empiric drug selection, and reduced "tonnage" of antibiotic use.     

Antibiotics and antifungals in neonatal intensive care units: a review

The incidence of infections is higher in the neonatal period than at any time of life. The basic treatment of infants with infection has not changed substantially over the last years. Antibiotics (with or without supportive care) are one of the most valuable resources in managing sick newborn babies. Early-onset (ascending or transplacental) or late-onset (hospital acquired) infections present different chronology, epidemiology, physiology and outcome. Some classes of antibiotics are frequently used in the neonatal period: penicillins, cephalosporins, aminoglycosides, glycopeptides, monobactams, carbapenems. Other classes of antibiotics (chloramphenicol, cotrimoxazole, macrolides, clindamycin, rifampicin and metronidazole) are rarely used. Due to emergence of resistant bacterial strains in Neonatal Intensive Care Units (NICU), other classes of antibiotics such as quinolones and linezolid will probably increase their therapeutic role in the future. Although new formulations have been developed for treatment of fungal infections in infants, amphotericin B remains first-line treatment for systemic Candida infection. Prophylactic antibiotic therapy is almost always undesirable. Challenges from pathogens and antibiotic resistance in the NICU may warrant modification of traditional antibiotic regimens. Knowledge of local flora and practical application of different antibiotic characteristics are key to an effective and safe utilization of antibiotics and antifungals in critical newborns admitted to the NICU, and especially in very low birth weight infants.     

Invasive fungal infection in neonatal intensive care units: a multicenter survey

This study assesses the epidemiology of invasive fungal infection (IFI) in Portuguese Neonatal Intensive Care Units (NICUs) and compares the effectiveness and safety of antifungal therapies. A survey concerning the period 2005–2010 was carried out in NICUs of Greater Lisbon. Among 10 473 admitted neonates, 44 cases were identified, 29 among extreme low birth weight neonates (65.9%). Cumulative incidence rate was 0.42% (95%CI 0.309–0.559). A central vascular catheter was present before IFI in all cases. Candida albicans and Candida parapsilosis were the most frequent isolates. The initial antifungic was fluconazole in 22 cases and liposomal amphotericin B (L-AmB) in 18. Therapy was switched in 10 patients on fluconazole and 3 on L-AmB. Case fatality rate was 11.4% (95%CI 4.39–23.91). No serious adverse drugs reactions (SADRs) or clinical side effects were observed. The knowledge of the local epidemiology helps to identify adequate prophylactic and treatment strategies.     

Use of radiation treatment units in breast cancer. Changes in the last 15 years

Introduction Advances in diagnosis and treatment in oncology combined with technical advances in radiotherapy have resulted in qualitative and quantitative changes in the use of radiation to treat breast cancer. Objective The objective was to analyse changes in radiation indications from 1990 to the present time and their consequences in the use of treatments units. Methods and material From January 1990 to December 2005, 4545 radiation treatments for breast cancer were performed, classified as radical after conservative surgery, radical after mastectomy or palliative. Data are presented as relative frequencies and as 3-year period groups. Results An increase in the proportion of treatments for breast cancer and in treatment unit use distribution is observed. Radical treatments have increased over time, ranging from 55% in the first 3-year period group to 82% in the last one. Unit treatment distribution analysis is similar, but with a less important increase, rising from 85% to 95%. A rise in conservative treatment is also observed, from 43% to 75%. Conclusions An increase in breast cancer incidence is observed and there was also an increase in irradiation after conservative treatment. On the contrary, probably due to the rise in the use of systemic treatments, a decrease in post-mastectomy irradiation and palliative treatments is shown.     

Antibiotic resistance among nosocomial isolates in a Croatian intensive care unit--results of a twelve-year focal surveillance of nosocomial infections

Continuous 12-year (1990--2001) focal surveillance of the antibiotic resistance among the most common nosocomial pathogens (Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter sp., and Staphylococcus aureus) in 1325 Intensive Care Unit patients was performed. The surveillance period was divided in three 4-year time intervals (1990--1993, 1994--1997 and 1998--2001) and the prevalence of resistance was compared between intervals. Specimens included blood, urine and respiratory tract specimens. The incidence and trends of resistance to six antibiotics showed inconsistent results. Aminoglycoside resistance decreased among K. pneumoniae_isolates (gentamicin 83%, 72.7% and 49.6%; amikacin 50.9%, 51.5% and 18.2%) and Acinetobacter sp. strains (amikacin 77%, 63.4% and 58.2%) but increased in P. aeruginosa (amikacin 27.5%, 63.3% and 44.1%). Overall, resistance to ceftazidime, ciprofloxacin, and imipenem increased but imipenem resistance is still low, particularly among Acinetobacter sp. isolates (0, 2.1% and 1.5%). However, imipenem resistance increased among P. aeruginosa (10.2%, 31.6%, 22.1%). The prevalence of methicillin resistance was high but did not change during the surveillance period (82.3%, 78.3% and 82.2%). The present study suggests a complex picture of the development of antibiotic resistance in a single ICU. Significant changes occur over time but they are unpredictable and do not show identical tendencies for different species and antibiotics.     

Clinical factors affecting costs in patients receiving systemic antifungal therapy in intensive care units in Greece: Results from the ESTIMATOR study

Invasive fungal infections are common in intensive care units (ICUs) but there is a great variability in factors affecting costs of different antifungal treatment strategies in clinical practice. To determine factors affecting treatment cost in adult ICU patients with or without documented invasive fungal infection receiving systemic antifungal therapy (SAT) we have performed a prospective, multicentre, observational study enrolling patients receiving SAT in participating ICUs in Greece. During the study period, 155 patients received SAT at 14 participating ICUs: 37 (23.9%) for proven fungal infection before treatment began, 10 (6.5%) prophylactically, 77 (49.7%) empirically and 31 (20.0%) pre‐emptively; 66 patients receiving early SAT (55.9%) were subsequently confirmed to have proven infection with Candida spp. (eight while on treatment). The most frequently used antifungal drugs were echinocandins (89/155; 57.4%), fluconazole (31/155; 20%) and itraconazole (20/155; 12.9%). Mean total cost per patient by SAT strategy was €20 458 (proven), €15 054 (prophylaxis), €23 594 (empiric) and €22 184 (pre‐emptive). Factors associated with significantly increased cost were initial treatment failure, length of stay (LOS) in ICU before starting SAT (i.e. from admission until treatment start), fever and proven candidaemia (all P≤.05). Conclusion: Early administration of antifungal drugs was not a substantial component of total hospital costs. However, there was a significant adverse impact on costs with increasing LOS in febrile patients in ICU for whom diagnosis of fungaemia was delayed before starting SAT, and with initial treatment failure. Awareness of potential candidaemia and initiation of pre‐emptive or empirical strategy as early appropriate treatment may improve ICU patient outcomes while reducing direct medical costs.     

Testing new regimens in patients with advanced soft tissue sarcoma: analysis of publications from the last 10 years

BackgroundThe prognosis of advanced soft tissue sarcoma remains poor. Many phase II trials investigating new regimens have been published in the last 10 years.Materials and methodsFull English-language reports of phase II clinical trials from January 1999 to October 2009 have been reviewed. We have defined those that provided 3- and 6-month progression-free survival rates (PFSR) >39% and 14%, respectively, as promising second-line regimens. For studies enrolling both chemonaive and pretreated patients, we have compared the reported PFSR3 to the expected PFSR3 of an active treatment administered in the same proportions of pretreated and nonpretreated patients.ResultsForty-nine trials were identified. Among the trials investigating new regimens in pretreated patients alone, the promising second-line regimens were ifosfamide, brostallicin, pazopanib (except in liposarcoma), temozolomide, trabectedin, dacarbazine–gemcitabine and docetaxel (Taxotere)–gemcitabine combinations (in uterine leiomyosarcoma). Among the trials enrolling both chemonaive and pretreated patients, most regimens reached the level of efficacy; moreover, in three trials, the reported PFSR3 was particularly high: weekly paclitaxel (Taxol) in angiosarcoma, docetaxel–gemcitabine combination (in uterine leiomyosarcoma) and oral perifosine.ConclusionsIn the past 10 years, several drugs or combinations have demonstrated promising activity in exploratory phase II trials and warrant further investigation in appropriate phase III trials.     

Radical treatment of non-small cell lung cancer during the last 5 years

The management of non-small cell lung cancer (NSCLC) has continued to improve over the last 5 years due to advances in surgery, radiological staging, combined modality therapies and advances in radiation technology.We have an updated staging classification (7th Edition American Joint Committee on Cancer staging) and now in 2011, a new histology classification introducing the concepts of adenocarcinoma in situ and minimally invasive adenocarcinoma. This classification has profound surgical implications as the role of limited resection is reconsidered for early stage lesions. Surgery is curative in early stage disease. The role of surgery in locally advanced NSCLC remains controversial. The principal aim is a complete resection as this will determine long-term prognosis. Intraoperative staging of lung cancer is extremely important to determine the extent of resection according to the tumour and nodal status. Systematic nodal dissection is generally advocated to obtain accurate intraoperative staging and to help decide on adjuvant therapy.Radiotherapy currently plays a major role in the management of lung cancer as most patients are not surgical candidates due to disease stage, fitness and co-morbidities. In the last 5 years we have seen continuing optimisation of chemo-radiotherapy combinations and technological advances including the development of image guided radiotherapy (IGRT), stereotactic ablative body radiotherapy (SABR) and intensity modulated radiotherapy (IMRT).Quality of life evaluation is becoming increasingly important and should be considered when deciding on a specific treatment, especially in a multimodality setting.     

Prevalence of obesity among women in Turkey: analysis of KETEM data

Background & Purpose: Determining the prevalence of obesity is a crucial step in combating with obesity and devising national health strategies. It is particularly important to better understand prevalence of obesity among women as women in Turkey also highly impacts the dietary habits of the whole household. This article determines the prevalence of obesity among adult women in the country. Patients & Methods: Each Cancer Early Diagnosis and Screening Center were asked to submit data on BMI indices for women who visited the centers between January and June 2011. The data were collected on January 1 and July 1 first for each respective quarter. Patients ranged between 30-65 years old. World Health Organization guidelines on BMI cutoffs were used to determine the prevalence of obesity and overweight. Results: The prevalence of obesity of adult women aged 35-60 was found to be 35%. The highest prevalence was observed in Western part of Turkey in the Aegean region with 42% of women with BMI over 30. The lowest rate was observed in the Eastern Turkey with 21% obese women, followed by 28% in Southeastern Turkey. Conclusion: The prevalence of obesity among adult women in Turkey is very comparable to some of the other countries with highest rates of obesity in the world. Women specific health strategies against obesity should be devised.