Lege Artis Medicinae

[CHANGES IN SENSITIVITY OF NOSOCOMIAL GRAM-NEGATIVE PATHOGENS TO MEROPENEM AND ITS COMPARATIVE AGENTS DURING A FOUR-YEAR PERIOD (2000-2004) - ANALYSIS OF DATA FROM TWO PROSPECTIVE MULTICENTER STUDIES IN HUNGARY]

KONKOLY Thege Marianne, BÁN Éva

NOVEMBER 30, 2004

Lege Artis Medicinae - 2005;15(03 klsz)

[INTRODUCTION - The clinical significance of Gram-negative infections has not diminished in recent years. The number of resistant and multiresistant isolates has increased among Gramnegatives similarly to Gram-positive bacteria. Moreover, panresistant strains (i.e. resistant to all available agents active against Gram-negatives) have emerged. A prospective, multicenter study carried out in 2000 was repeated in 2004 in order to have up to date knowledge of resistance situation of Gram-negative aerobic bacteria and Bacteroides fragilis. In addition, the local data of 2004 were compared to MYSTIC (Meropenem Yearly Susceptibility Test Information) database of year 2004. MATERIALS AND METHODS - The in vitro study protocol-guided was carried out in 20 microbiology laboratories from April 1 to November 15, 2004. Study strains were isolated from relevant samples taken in medical, surgical, haematology, infectious disease wards and intensive care units. The sensitivity of 2099 aerobic Gram-negative and 97 B. fragilis isolates to meropenem and its comparator agents with excellent Gram-negative and/or antianaerob activity was tested according to NCCLS (National Committee for Clinical Laboratory Standards). RESULTS - Meropenem and imipenem have almost retained their 100% activity against Enterobacteriaceae, Acinetobacter and B. fragilis. A very small number of carbapenem nonsusceptible isolates emerged among Enterobacter, Proteus and Acinetobacter strains. Meropenem and especially imipenem sensitivity of Pseudomonas aeruginosa decreased significantly over the 4-year interval (76% vs 67%). The difference between the meropenem and imipenem sensitivity of P. aeruginosa proved significant (<0.001) and a similar difference was found in MYSTIC Programme. The isolation frequency of extended spectrum β-lactamase (ESBL) producing Escherichia coli and Klebsiella strains was relatively low (4.1% and 8.5%, respectively) in Hungary comparing to that in other European countries. Only the carbapenems inhibited consistently the ESBLproducing strains whereas ceftazidime, cefepime and piperacillin/tazobactam were ineffective versus these strains. The rate of cefepime sensitive strains declined significantly in case of Enterobacter (82%), Citrobacter (90%), Acinetobacter (31%) and P. aeruginosa (69%), whereas it did not change among Serratia and Proteus strains. The activity of ceftazidim has decreased, as well: 61% of Enterobacter, 74% of Citrobacter, 15% of Acinetobacter and 78% of P. aeuginosa isolates were sensitive to it. A trend over time toward greater resistance was noted for piperacillin/tazobactam, however, it remained the most active in vitro agent against P. aeruginosa (83%). This rate is better than that was found in MYSTIC. There was not a clear trend in changes of sensitivity to aminoglycosides in Gram-negatives. A significant decrease in gentamicin and tobramycin sensitivity of E. coli and Klebsiella was noted (<90%), and in gentamicin, tobramycin and amikacin sensitivity of P. aeruginosa (57%, 65%, and 79%, respectively). Ciprofloxacin sensitivity also declined over the years: E. coli 85%, Proteus 83%, Acinetobacter 16%, P. aeruginosa 68%. Aztreonam and polymyxin sensitivity were examined only in case of P. aeruginosa because these two agents may be the drugs of choice in infections caused by multior panresistant strains: all isolates were susceptible to polymyxin, and 84% of them to aztreonam. However, panresistant isolates were not sensitive to aztreonam. Ampicillin/sulbactam may be a possible alternative drug in serious infections caused by multiresistant Acinetobacter: 83% of isolates showed sensitivity to it. Carbapenems, piperacillin/tazobactam and metronidazole were active against B. fragilis in 100%, amoxicillin/clavulanic acid resistance occurred scarcely, whereas clindamycin sensitivity was only 79%. CONCLUSIONS - There is no single antibacterial agent which would be effective against >90% of most frequently occurring Gram-negative aerobic bacteria in Hungary. The high increase in resistance rates over a relatively short 4-year period will result in serious challenges in the therapy. At the same time the Hungarian sensitivity rates are better than those reported by MYSTIC Programme.]

COMMENTS

0 comments

Further articles in this publication

Lege Artis Medicinae

[IN VITRO SENSITIVITY OF PSEUDOMONAS AERUGINOSA STRAINS AND ITS CLINICAL CONSEQUENCES IN HUNGARY]

LUDWIG Endre, KONKOLY Thege Marianne

[INTRODUCTION - The antibiotic sensitivity of Pseudomonas aeruginosa isolates in nosocomial infections was determined in a prospective multicenter study in Hungary. METHODS - The sensitivity of 441 nonduplicated Pseudomonas aeruginosa isolates were determined by E-test methodology. Antibiotic sensitivities were determined according to the NCCLS standard. RESULTS - The sensitivity of isolates decreased compared to the results of 2000 surveillance data (meropenem 83 vs 76%, imipenem 82 vs 67%, ceftazidime 80,2 vs 78%, piperacillin/tazobactam 86.3 vs 83%, amikacin 88.2 vs 79%, ciprofloxacin 75,9 vs 68%). The highest resistance rates were detected at the intensive care units and in case of isolates from bloodstream infections. CONCLUSIONS - The antibiotic sensitivity of Pseudomonas aeruginosa isolates decreased in the last three years and the high resistance rates detected in intensive care units and of invasive strains are of special concern. For effective therapy antibiotics should be used in high doses and betalactams given in prolonged infusions might be more efficacious than administered in bolus. In case of probable Pseudomonas infections the use of two effective antipseudomonas agents is recommended. Prudent use of the antibiotics and effective infection control are needed to prevent the further loss of activity of these antimicrobial agents.]

All articles in the issue

Related contents

Clinical Neuroscience

Alexithymia is associated with cognitive impairment in patients with Parkinson’s disease

SENGUL Yildizhan, KOCAK Müge, CORAKCI Zeynep, SENGUL Serdar Hakan, USTUN Ismet

Cognitive dysfunction (CD) is a common non-motor symptom of Parkinson’s disease (PD). Alexithy­mia is a still poorly understood neuropsychiatric feature of PD. Cognitive impairment (especially visuospatial dysfunction and executive dysfunction) and alexithymia share com­mon pathology of neuroanatomical structures. We hypo­thesized that there must be a correlation between CD and alexithymia levels considering this relationship of neuroanatomy. Objective – The aim of this study was to evaluate the association between alexithymia and neurocognitive function in patients with PD. Thirty-five patients with PD were included in this study. The Toronto Alexithymia Scale–20 (TAS-20), Geriatric Depression Inventory (GDI) and a detailed neuropsychological evaluation were performed. Higher TAS-20 scores were negatively correlated with Wechsler Adult Intelligence Scale (WAIS) similarities test score (r =-0.71, p value 0.02), clock drawing test (CDT) scores (r=-0.72, p=0.02) and verbal fluency (VF) (r=-0.77, p<0.01). Difficulty identifying feelings subscale score was negatively correlated with CDT scores (r=-0.74, p=0.02), VF scores (r=-0.66, p=0.04), visual memory immediate recall (r=-0.74, p=0.01). VF scores were also correlated with difficulty describing feelings (DDF) scores (r=-0.66, p=0.04). There was a reverse relationship bet­ween WAIS similarities and DDF scores (r=-0.70, p=0.02), and externally oriented-thinking (r=-0.77,p<0.01). Executive function Z score was correlated with the mean TAS-20 score (r=-62, p=0.03) and DDF subscale score (r=-0.70, p=0.01) Alexithymia was found to be associated with poorer performance on visuospatial and executive function test results. We also found that alexithymia was significantly correlated with depressive symptoms. Presence of alexithymia should therefore warn the clinicians for co-existing CD.

Clinical Neuroscience

Late simultaneous carcinomatous meningitis, temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting with mono-symptomatic vertigo – a clinico-pathological case reporT

JARABIN András János, KLIVÉNYI Péter, TISZLAVICZ László, MOLNÁR Anna Fiona, GION Katalin, FÖLDESI Imre, KISS Geza Jozsef, ROVÓ László, BELLA Zsolt

Although vertigo is one of the most common complaints, intracranial malignant tumors rarely cause sudden asymmetry between the tone of the vestibular peripheries masquerading as a peripheral-like disorder. Here we report a case of simultaneous temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting as acute unilateral vestibular syndrome, due to the reawakening of a primary gastric signet ring cell carcinoma. Purpose – Our objective was to identify those pathophysiological steps that may explain the complex process of tumor reawakening, dissemination. The possible causes of vestibular asymmetry were also traced. A 56-year-old male patient’s interdisciplinary medical data had been retrospectively analyzed. Original clinical and pathological results have been collected and thoroughly reevaluated, then new histological staining and immunohistochemistry methods have been added to the diagnostic pool. During the autopsy the cerebrum and cerebellum was edematous. The apex of the left petrous bone was infiltrated and destructed by a tumor mass of 2x2 cm in size. Histological reexamination of the original gastric resection specimen slides revealed focal submucosal tumorous infiltration with a vascular invasion. By immunohistochemistry mainly single infiltrating tumor cells were observed with Cytokeratin 7 and Vimentin positivity and partial loss of E-cadherin staining. The subsequent histological examination of necropsy tissue specimens confirmed the disseminated, multi-organ microscopic tumorous invasion. Discussion – It has been recently reported that the expression of Vimentin and the loss of E-cadherin is significantly associated with advanced stage, lymph node metastasis, vascular and neural invasion and undifferentiated type with p<0.05 significance. As our patient was middle aged and had no immune-deficiency, the promoting factor of the reawakening of the primary GC malignant disease after a 9-year-long period of dormancy remained undiscovered. The organ-specific tropism explained by the “seed and soil” theory was unexpected, due to rare occurrence of gastric cancer to metastasize in the meninges given that only a minority of these cells would be capable of crossing the blood brain barrier. Patients with past malignancies and new onset of neurological symptoms should alert the physician to central nervous system involvement, and the appropriate, targeted diagnostic and therapeutic work-up should be established immediately. Targeted staining with specific antibodies is recommended. Recent studies on cell lines indicate that metformin strongly inhibits epithelial-mesenchymal transition of gastric cancer cells. Therefore, further studies need to be performed on cases positive for epithelial-mesenchymal transition.

Hypertension and nephrology

[About the care of patients with hyperuricaemia and gout]

[This consensus document is intended to provide guidance for the effective and efficient treatment of asymptomatic individuals with high uric acid levels and gout patients.]

Clinical Neuroscience

[What happens to vertiginous population after emission from the Emergency Department?]

MAIHOUB Stefani, MOLNÁR András, CSIKÓS András, KANIZSAI Péter, TAMÁS László, SZIRMAI Ágnes

[Background – Dizziness is one of the most frequent complaints when a patient is searching for medical care and resolution. This can be a problematic presentation in the emergency department, both from a diagnostic and a management standpoint. Purpose – The aim of our study is to clarify what happens to patients after leaving the emergency department. Methods – 879 patients were examined at the Semmel­weis University Emergency Department with vertigo and dizziness. We sent a questionnaire to these patients and we had 308 completed papers back (110 male, 198 female patients, mean age 61.8 ± 12.31 SD), which we further analyzed. Results – Based on the emergency department diagnosis we had the following results: central vestibular lesion (n = 71), dizziness or giddiness (n = 64) and BPPV (n = 51) were among the most frequent diagnosis. Clarification of the final post-examination diagnosis took several days (28.8%), and weeks (24.2%). It was also noticed that 24.02% of this population never received a proper diagnosis. Among the population only 80 patients (25.8%) got proper diagnosis of their complaints, which was supported by qualitative statistical analysis (Cohen Kappa test) result (κ = 0.560). Discussion – The correlation between our emergency department diagnosis and final diagnosis given to patients is low, a phenomenon that is also observable in other countries. Therefore, patient follow-up is an important issue, including the importance of neurotology and possibly neurological examination. Conclusion – Emergency diagnosis of vertigo is a great challenge, but despite of difficulties the targeted and quick case history and exact examination can evaluate the central or peripheral cause of the balance disorder. Therefore, to prevent declination of the quality of life the importance of further investigation is high.]

Clinical Neuroscience

[The role of sleep in the relational memory processes ]

CSÁBI Eszter, ZÁMBÓ Ágnes, PROKECZ Lídia

[A growing body of evidence suggests that sleep plays an essential role in the consolidation of different memory systems, but less is known about the beneficial effect of sleep on relational memory processes and the recognition of emotional facial expressions, however, it is a fundamental cognitive skill in human everyday life. Thus, the study aims to investigate the effect of timing of learning and the role of sleep in relational memory processes. 84 young adults (average age: 22.36 (SD: 3.22), 21 male/63 female) participated in our study, divided into two groups: evening group and morning group indicating the time of learning. We used the face-name task to measure relational memory and facial expression recognition. There were two sessions for both groups: the immediate testing phase and the delayed retesting phase, separated by 24 hours. 84 young adults (average age: 22.36 (SD: 3.22), 21 male/63 female) participated in our study, divided into two groups: evening group and morning group indicating the time of learning. We used the face-name task to measure relational memory and facial expression recognition. There were two sessions for both groups: the immediate testing phase and the delayed retesting phase, separated by 24 hours. Our results suggest that the timing of learning and sleep plays an important role in the stabilizing process of memory representation to resist against forgetting.]