Left-sided endocarditis caused by Pseudomonas aeruginosa: successful treatment with meropenem and tobramycin

Medical treatment alone is rarely successful in left-sided infective endocarditis caused by Pseudomonas aeruginosa. We report the cure of such a case with high-dose meropenem in combination with tobramycin.     

Metronidazole-associated pancreatitis

OBJECTIVE: To report a case of acute reversible pancreatitis associated with metronidazole-treated aspiration pneumonia. CASE SUMMARY: A 61-year-old white woman requiring coronary artery bypass surgery developed acute pancreatitis following treatment with metronidazole for suspected postsurgical aspiration pneumonia. The patient developed moderate to severe bilateral upper quadrant abdominal pain; laboratory studies revealed elevated amylase and lipase concentrations four days following the initiation of metronidazole therapy. After discontinuation of metronidazole, the patient's abdominal pain subsequently improved, and both amylase and lipase concentrations immediately declined and were within normal limits within one week. DISCUSSION: An acute attack of pancreatitis is characterized by moderate to severe abdominal pain that may radiate to the back, accompanied by increased concentrations of pancreatic enzymes and few morphologic changes in the pancreas. Metronidazole is reported as having a probable association with acute pancreatitis, although the mechanism of drug-induced pancreatitis is not known. One speculative mechanism of metronidazole-induced pancreatitis is that, under aerobic conditions, metronidazole may undergo redox cycling and yield hydrogen peroxide, superoxide, and other free radicals. Such redox-active compounds are toxic to pancreatic beta-cells, and oxygen-centered free radicals have been implicated in the induction of pancreatitis. Other suggested mechanisms include immune-mediated inflammatory response, pancreatic duct constriction, and metabolic effects. CONCLUSIONS: Very few cases of metronidazole-associated pancreatitis have been reported, and the long-term sequelae are unknown. However, if metronidazole or any other drug is suspected as the causative agent in pancreatitis, it should be discontinued and rechallenge should be avoided.     

Clinical correlation of the CLSI susceptibility breakpoint for piperacillin- tazobactam against extended-spectrum-beta-lactamase-producing Escherichia coli and Klebsiella species

We assessed infections caused by extended-spectrum-beta-lactamase-producing Escherichia coli or Klebsiella spp. treated with piperacillin-tazobactam to determine if the susceptibility breakpoint predicts outcome. Treatment was successful in 10 of 11 nonurinary infections from susceptible strains and in 2 of 6 infections with MICs of >16/4 mug/ml. All six urinary infections responded to treatment regardless of susceptibility.     

Budgeting based on need: a model to determine sub-national allocation of resources for health services in Indonesia

ABSTRACT: BACKGROUND: Allocating national resources to regions based on need is a key policy issue in most health systems. Many systems utilise proxy measures of need as the basis for allocation formulae. Increasingly these are underpinned by complex statistical methods to separate need from supplier induced utilisation. Assessment of need is then used to allocate existing global budgets to geographic areas. Many low and middle income countries are beginning to use formula methods for funding however these attempts are often hampered by a lack of information on utilisation, relative needs and whether the budgets allocated bear any relationship to cost. An alternative is to develop bottom-up estimates of the cost of providing for local need. This method is viable where public funding is focused on a relatively small number of targeted services. We describe a bottom-up approach to developing a formula for the allocation of resources. The method is illustrated in the context of the state minimum service package mandated to be provided by the Indonesian public health system. METHODS: A standardised costing methodology was developed that is sensitive to the main expected drivers of local cost variation including demographic structure, epidemiology and location. Essential package costing is often undertaken at a country level. It is less usual to utilise the methods across different parts of a country in a way that takes account of variation in population needs and location. Costing was based on best clinical practice in Indonesia and province specific data on distribution and costs of facilities. The resulting model was used to estimate essential package costs in a representative district in each province of the country. FINDINGS: Substantial differences in the costs of providing basic services ranging from USD 15 in urban Yogyakarta to USD 48 in sparsely populated North Maluku. These costs are driven largely by the structure of the population, particularly numbers of births, infants and children and also key diseases with high cost/prevalence and variation, most notably the level of malnutrition. The approach to resource allocation was implemented using existing data sources and permitted the rapid construction of a needs based formula that is highly specific to the package mandated across the country. Refinement could focus more on resources required to finance demand side costs and expansion of the service package to include priority non-communicable services.     

Surviving decentralisation? Impacts of regional autonomy on health service provision in Indonesia

The paper aims to assess the impacts of decentralisation and privatisation reforms on access to and quality of health services in Indonesia. The research draws on qualitative and quantitative data from interviews, focus group discussions, and household surveys in four selected districts. The main conclusions are three-fold; the local administration of health care services is without transparency and accountability, health centres are turned into profit centres, and the increasing roles of private actors tend to reduce concerns over preventive health care and the conditions for poor people. Our policy recommendations include increased government spending to maintain public efforts in environmental and preventive health and in maintaining a minimum health service for the poor.     

Effect of phaleria macrocarpa supplementation on apoptosis and tumor growth of C3H mice with breast cancer under treatment with adriamycin-cyclophosphamide

The objective of this study was to know the response of supplementation of Phaleria macrocarpa (PM) to adriamycin-cyclophosphamide (AC) in the treatment of C3H mice with breast cancer. Twenty-four C3H mice, who were successfully inoculated with breast cancer cells, were randomly allocated into 4 groups: without treatment, treated with AC, treated with AC + PM 0.07 mg/d, and treated with AC + PM 0.14 mg/d. The tumor size was measured using millimeter calipers before and 12 weeks after treatment. The tumor, liver, and kidneys were removed and prepared for pathologic examination using imunohistochemistry staining, and the apoptotic index was counted using the terminal deoxynucleotidyl transferase dUTP nick end labeling method. AC reduce the tumor growth significantly (P < 0.001), whereas supplementation of PM, which significantly reduced the tumor growth compared with AC only, was at the 0.14 mg/d dose (P = 0.007). AC increase the apoptotic index significantly (P < 0.001), and supplementation with PM showed that the higher dose increased the apoptotic index. The correlation between the apoptotic index and the diameter of tumor was significantly negative (r = -0.884; P = 0.020). The apoptotic index of the liver and kidney increased significantly in the AC group (P < 0.001 and P = 0.002, respectively); supplementation with PM decreased significantly the high apoptotic index caused by AC. We conclude that PM supplementation has a synergic effect to AC treatment in reducing the tumor growth, by increasing apoptosis, and protects the liver and kidney from damage caused by AC.     

NO formation by a catalytically self-sufficient bacterial nitric oxide synthase from Sorangium cellulosum

The role of nitric oxide (NO) in the host response to infection and in cellular signaling is well established. Enzymatic synthesis of NO is catalyzed by the nitric oxide synthases (NOSs), which convert Arg into NO and citrulline using co-substrates O₂ and NADPH. Mammalian NOS contains a flavin reductase domain (FAD and FMN) and a catalytic heme oxygenase domain (P450-type heme and tetrahydrobiopterin). Bacterial NOSs, while much less studied, were previously identified as only containing the heme oxygenase domain of the more complex mammalian NOSs. We report here on the characterization of a NOS from Sorangium cellulosum (both full-length, scNOS, and oxygenase domain, scNOSox). scNOS contains a catalytic, oxygenase domain similar to those found in the mammalian NOS and in other bacteria. Unlike the other bacterial NOSs reported to date, however, this protein contains a fused reductase domain. The scNOS reductase domain is unique for the entire NOS family because it utilizes a 2Fe2S cluster for electron transfer. scNOS catalytically produces NO and citrulline in the presence of either tetrahydrobiopterin or tetrahydrofolate. These results establish a bacterial electron transfer pathway used for biological NO synthesis as well as a unique flexibility in using different tetrahydropterin cofactors for this reaction.     

Prediction of methicillin-resistant Staphylococcus aureus involvement in disease sites by concomitant nasal sampling

Nasal colonization with methicillin-resistant Staphylococcus aureus (MRSA) is believed to precede disease. It is therefore reasonable to expect that testing for nasal MRSA colonization could provide guidance in the choice of empirical therapy for infections. We conducted a retrospective review of 5,779 nasal MRSA tests performed within a 24-h period before or after a clinical culture showed the growth of any organism. A positive nasal MRSA test strongly predicted MRSA involvement at a clinical site (relative risk, 12.9 times higher than in the remainder of the population; 95% confidence intervals [CI], 10.4, 16.1). Nasal MRSA colonization also strongly predicted antimicrobial resistance in other organisms. A negative nasal test was less useful; only 217 of 323 patients (67.2%; 95% CI, 61.8, 72.3) with clinical cultures involving MRSA had detectable, concomitant nasal MRSA colonization. Patients with clindamycin-susceptible MRSA infections were less likely (59%) to have nasal colonization than those with clindamycin-resistant MRSA infections (71%; P = 0.042). Patients nasally colonized with MRSA were substantially more likely to have antibiotic-resistant floras in clinical specimens, and this should be considered when initiating therapy. However, nearly a third of MRSA-infected patients were not nasally colonized, suggesting that nasal colonization need not precede disease and that a negative test for nasal colonization would not rule out MRSA disease in settings of moderate or high prevalence.     

Community acceptance and willingness-to-pay for a hypothetical Zika vaccine: A cross-sectional study in Indonesia

Background

Understanding people’s perceptions of the economic benefits of a potential Zika vaccine (ZV) is critical to accelerating its introduction into either public sector programs or private market. The aim of this study was to assess the acceptance and willingness-to-pay (WTP) for a hypothetical ZV and the associated explanatory variables in Indonesia.

Daptomycin for the treatment of vancomycin resistant Enterococcus faecium bacteremia

The best therapeutic options for serious infections due to vancomyci resistant Enterococcus (VRE) remain unclear. We describe the successful treatment of vancomycin resistant Enterococcus faecium bacteremia in 2 patients using daptomycin. We also briefly review the literature on antibiotic options for VRE infection including the use of daptomycin.