The optimal strategy for ventilator-associated pneumonia remains controversial. To clarify the tradeoffs involved, we performed a decision analysis. Strategies evaluated included antibiotic therapy with and without diagnostic testing. Tests that were explored included endotracheal aspirates, bronchoscopy with protected brush or bronchoalveolar lavage, and nonbronchoscopic mini-bronchoalveolar lavage (mini-BAL). Outcomes included dollar cost, antibiotic use, survival, cost-effectiveness, antibiotic use per survivor, and the outcome perspective of financial cost-antibiotic use per survivor. Initial coverage with three antibiotics was better than expectant management or one or two antibiotic approaches, leading to both improved survival (54% vs. 66%) and decreased cost (US dollars 55447 vs. US dollars 41483 per survivor). Testing with mini-BAL did not improve survival but did decrease costs (US dollars 41483 vs. US dollars 39967) and antibiotic use (63 vs. 39 antibiotic days per survivor). From the perspective of minimizing cost, minimizing antibiotic use, and maximizing survival, the best strategy was three antibiotics with mini-BAL.
We cared for a patient with methicillin-resistant Staphylococcus aureus bacteremia who experienced clinical failure with daptomycin. The failure was accompanied by progressive elevation of the daptomycin minimum inhibitory concentration during treatment. DNA fingerprinting confirmed that the minimum inhibitory concentration elevation occurred within the same strain of methicillin-resistant Staphylococcus aureus. This observation provides important new information to clinicians who adopt this promising drug for treatment of serious infections caused by methicillin-resistant Staphylococcus aureus.
We evaluated the BD GeneOhm MRSA achromopeptidase (ACP) assay, which incorporates a new specimen preparation approach. A total of 1,216 leftover nasal samples were tested; using culture as the gold standard, the sensitivity and specificity were 92% and 94.6%, respectively. The new lysis method provides good sensitivity and simplifies specimen preparation.Methicillin-resistant Staphylococcus aureus (MRSA) is a leading cause of health care-associated infections and is responsible for increased hospital stays with high financial cost (7,19,24). In fact, by 2005 MRSA had a higher mortality rate than tuberculosis, salmonella infection, influenza, and HIV-AIDS combined within the United States (5). Moreover, Delorme and colleagues recently reported an increase of MRSA infections and disease rate in long-term care facility (LTCF) residents between 2006 and 2007 (6). There has been some success reported in the reduction of invasive infection since 2005, but most of the improvement was related to bloodstream infection and may be related to improved central venous catheter management in acute care hospitals (11). Another recent study has shown that a reduction in the rate of MRSA invasive infection must involve more than a general improvement in basic infection control practice, such as improved hand hygiene, since improved hand hygiene did not lower hospitalacquired MRSA colonization (14).MRSA detection is often followed by either decolonization or isolation to reduce MRSA prevalence within hospitals and in the community (4,8,10). In an elegant crossover study of the impact rapid testing has on MRSA transmission, Hardy and colleagues demonstrated significantly reduced transmission when surveillance testing was done using a real-time PCR assay, as opposed to no significant impact when routine, culture-based testing was utilized by the laboratory (9). Thus, rapid and reliable screening tests for MRSA detection are very important. Real-time PCR assays are fast, reliable, and accurate, which has been useful to reduce the incidence of MRSA disease (19,20).Paule and colleagues developed an achromopeptidase (ACP) lysis procedure for high-volume testing and compared its performance with the original BD GeneOhm MRSA lysis kit method (IDI-MRSA assay). The study results demonstrated that the assay performed equally well using both procedures (18). BD Diagnostics subsequently developed an ACP lysis method for use with the BD GeneOhm MRSA kit. The purpose of this current study was to assess the BD GeneOhm MRSA ACP assay for direct detection of MRSA in nasal specimens as part of an application to the U.S. FDA for clearance as an in vitro diagnostic device.Nasal swabs were collected using double-headed BBL culture swabs with liquid Stuart (Becton Dickinson, Sparks, MD) or liquid Amies (Becton Dickinson) transport medium; singleheaded Amies gel swabs without charcoal (Becton Dickinson) were also included. Excess, deidentified nasal specimens were used for testing after routine laboratory procedures were completed. The subjects enrolled ...
The incidence of aztreonam and cephalosporin susceptibility, determined using the revised CLSI breakpoints, for extendedspectrum--lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumoniae isolates was evaluated. Our analysis showed that results for aztreonam and/or >1 cephalosporin were reported as susceptible or intermediate for 89.2% of ESBLproducing E coli isolates (569/638 isolates) and 67.7% of ESBL-producing K. pneumoniae isolates (155/229 isolates). Extended-spectrum--lactamase (ESBL)-producing Enterobacteriaceae strains represent a challenging problem for health care providers, particularly in acute-care and long-term-care facilities and more recently in community-acquired infections (1-5). ESBL enzymes are capable of inactivating penicillins, aztreonam, cephalosporins, and -lactamase inhibitors, which limits the number of effective antibiotics for treatment (1,2,4,5).The presence of an ESBL is suspected in Escherichia coli and Klebsiella pneumoniae infections when resistance to one or more of the extended-spectrum cephalosporins (ESCs) (cefotaxime, ceftazidime, ceftriaxone, or cefepime) is detected (1, 2, 4). Based on pre-2010 guidelines from the Clinical and Laboratory Standards Institute (CLSI) (Wayne, PA), laboratories then confirmed the presence of an ESBL using labor-intensive manual methods. This supplemental testing often delayed ESBL identification by 24 to 48 h. Confirmatory testing for ESBLs has also been incorporated into automated susceptibility test systems. Since resistance to some ESCs and aztreonam may not always be detected by in vitro methods, strains were reported as resistant to all penicillins, cephalosporins (excluding the cephamycins), and aztreonam based on positive confirmatory test results, independent of the initial susceptibility test results. These guidelines were followed to prevent strains being reported inadvertently as being susceptible to ESCs and aztreonam, leading to potentially inappropriate treatment.In 2010, the CLSI Antibiotic Subcommittee lowered the MIC breakpoints and increased the disk diffusion size criteria for reporting of aztreonam, cefazolin, cefotaxime, ceftizoxime, ceftriaxone, and ceftazidime results. Interpretive criteria for cefuroxime and cefepime were not changed, because the committee determined that the available data did not support any changes in the breakpoints for these two drugs (6). In 2014, the CLSI recommended changing the MIC breakpoints for cefepime to Ͻ2 g/ml for sensitive, 4 to 8 g/ml for sensitive dose dependent (SDD), and Ͼ16 g/ml for resistant (7). The CLSI advises that treatment of ESBL-producing strains can be predicted solely on the basis of MIC values, regardless of the underlying resistance mechanisms. More-stringent interpretive criteria would eliminate the need for confirmatory testing for ESBL, and results could be reported as tested. In theory, this would decrease the time needed to identify ESBL-producing Enterobacteriaceae and the costs associated with additional laboratory work.There were significant conc...
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