Ivor Svetlansky

National and local antibiotic policies in Central and Eastern Europe.

Abstract To assess the antibiotic policies of Central European countries, we performed an overview of antibiotic stewardship, prescription habits and antibiotic prescription regulatory procedures. Since most Central European countries have had centralized health care and drug policies, the situation 10 years after decentralization is surprising. Only 3 of 10 Central European countries have some regulation of prescription of antibiotics, only 4 restrict some antibiotics, only 5 have hospital and only 3 national antibiotic policies. In all but 3 countries physicians can prescribe quinolones and/or 3rd generation oral cephalosporins as first-line antibiotics. Information on local and national antibiotic policies in Central and Eastern European countries is given including prescription guidelines for antibiotic use in community and hospital.

Nosocomial Meningitis Due to Pseudomonas aeruginosa in Children

Although Pseudomonas aeruginosa is a common hospital pathogen, nosocomial meningitis after ventriculoperitoneal shunt insertion (VPS) due to P. aeruginosa is relatively rare and represents about 5% of all foreign-body related nosocomial meningitis cases 1. Here we present 6 cases of nosocomial paediatric meningitis, 3 of them related to VPS insertion and exchange. Table 1 summarizes 6 children from 1 month to 13 years of age who developed nosocomial meningitis during a period of the last 8 years in 3 major pediatric neurosurgery departments in Kosice, Bratislava, and Banska Bystrica teaching hospitals in the Slovak Republic. Two children had hydrocephalus and infected ventriculoperitoneal shunt which was extracted and antibiotics (chloramphenicol plus gentamicin or meropenem) were given; both children survived. Two children had congenital B-cell mediated immunodeficiency and despite antibiotic therapy, both died. Another patient had acute lymphatic leukemia and probably developed meningitis after numerous intrathecal administrations of cytotoxic drugs; this patient was cured. Another patient had perinatal trauma, and after VPS insertion, the foreign device was infected. The VPS was extracted and ceftazidime plus gentamicin were administered for 12 days. This child survived, but neurologic sequellae developed (hydrocephalus)–probably because the treatment was too short. After Journal of Chemotherapy Vol. 12 n. 6 (538-539) 2000

Penicillin Resistance in Viridans Streptococcal Bacteremia is Related with High Mortality

Sir, Viridans streptococci (VS) are a significant cause of bacteremia in neutropenic patients with cancer, in those with endocarditis or in patients after dental surgery or endoscopy. These infections have traditionally been associated with limited morbidity, but serious complications such as septicaemic shock and adult respiratory distress syndrome (ARDS) have been described sporadically in recent years (1, 2). Clinical significance has been demonstrated in penicillin resistant (PEN-R) S. pneumoniae in several studies (3, 4); however, in viridans streptococci only one study in cancer patients (5) revealed in a multivariate fashion that those infected with PEN-R strains had higher mortality in comparison to individuals infected with PEN / susceptible VS. This was not demonstrated with erythromycin resistance (ERY-R) (6). The aim of this short letter is to assess the clinical significance and outcome of PEN and ERY resistance of VSB within a national bacteremia survey in Slovakia. Within 2 y, 127 cases of viridans streptococcal bacteremia (VSB) were observed in national surveillance of streptococcal bacteremia in Slovakia: assessing risk factors and impact of PEN-R on mortality, we compared PEN-R VSB to PEN-S VSB. 111 cases were due to penicillin susceptible (PEN-S) and 16 due to penicillin resistant (PEN-R) VSB (Table I). 13% of VSB cases were caused by PEN-R strains. Risk factors for penicillin resistance (MIC /2 mg/ml) were ventilatory support (p B/0.01), intubation (p B/0.001) and resistance to other antibiotics; 44% of PEN-R VSB were resistant also to erythromycin or cotrimoxazol or tetracycline in comparison to 7% of PEN-R VSB (p B/0.005). Endoscopic procedures in the upper respiratory system were at risk for development of PEN-R VSB. Also, there was difference in outcome, 69% vs 21% (p B/0.0002) of cases infected with PEN-RVSB dying in comparison to PEN-S VSB. Penicillin resistance is therefore clinically significant in viridans streptococcal bacteremia.

Acinetobacter baumanii (AB) bacteremia in cancer patients

© Springer-Verlag 2001 Acinetobacter baumanii (AB) is the third most common, gram-negative, bacteremia-causing bacteria in the cancer patient population [1, 2]. In addition, large surveillance studies on nosocomial infections within the past 2 years show an increasing incidence of AB infections worldwide [3, 4, 5]. A total of 157 episodes of AB bloodstream infections in 157 patients from 8 major teaching hospitals (2650 beds) in 5 cities in Slovakia (5.5 million inhabitants) including the National Cancer Institute, National Institute of Heart Diseases, and National Institute of Lung Diseases within 1 year (1999) were evaluated in a nationwide study in Slovakia, and 162 strains of AB were isolated. Of the 157 patients, 58 had cancer as the underlying disease (20 leukemia, 10 lymphoma, 30 solid tumors). In a univariate analysis (EPI INFO 21 statistical package) and multivariate analysis (STATADV 33 computerised package), significant risk factors for AB bacteremia in cancer patients in comparison to all patients from the nationwide survey were neutropenia (p≤0.0001), prior receipt of antineoplastic (p≤0.001), and prior antimicrobial chemotherapy (p≤0.0006) in univariate, but only prior antimicrobial chemotherapy or prophylaxis in the multivariate logistic regression model (p≤0.01; CI 1.2–6.8; RR 2.06) (Table 1). Vice versa, wound infection, prior surgery, and decubital ulcers (p≤0.004–0.0001) as well as ventilatory support were less frequently observed. However, mortality due to cancer (33.9% and 32.9%) was comparable for all of the patients studied within the survey. Concerning the antimicrobial susceptibility of AB isolates from cancer patients, resistance to meropenem among bloodstream isolates in cancer patients was 16%, 30%to cefepime, 42%to ceftazidime, 27.5% to amikacin, 48% to piperacillintazobactam, 30% to cefoperazonsulbactam, 34% to ciprofloxacin, and 52% to aztreonam. Comparing the resistance rates of AB isolates from cancer vs other patients, resistance to ceftazidime (42% vs 24.5%; p≤0.01), piperacillin-tazobactam (72.8% vs 52%; p≤0.009), and aztreonam (52% vs 27.2%; p≤0.001) was significantly higher in cancer patients, probably because of the extensive use of ceftazidime (since 1985) and piperacillin-tazobactam (since 1992) in the empiric therapy of febrile neutropenia in 8 Slovak cancer centers. Support Care Cancer (2001) 9:558–559 DOI 10.1007/s005200100241 L E T T E R T O T H E E D I T O R

Mortality of Enterococcal Bacteremia: Are Inappropriately Treated Cases Associated with Higher Mortality?

2test was used to determine risk factors for death and comparisons of appropriate therapy versus inappropriate therapy. A multivariate logistic regression model (EPI INFO and STAT ADV computerized package of CDC and Postgraduate Medical School) was also used. Of 101 patients with enterococcal bacteremias, 40 died (39.9%). Predictors for inferior outcome identie ed in univariate analysis were 2 or more positive blood cultures ( pB0.0061), burns or decubital ulcer as underlying diseases ( pB0.004). The latter was the only predictor of death also in multivariate analysis ( pB 0.0006, OR 5.07 Cl (1.4‐ 18 5)). Surprisingly neutropenia and vascular catheters seemed to be protective in univariate analysis (pB0.0475 and pB0.0417, respectively). In multivariate analysis neutropenia was found to be signie cantly ( pB0.007) corrected to a lower mortality probably because of the use of early empirical therapy in neutropenia patients. In this subgroup of patients, death was 3.48 times less likely than in enterococcal bacteremia in non-neutropenic patients. We performed another univariate analysis comparing those who were appropriately treated ( nae81) versus inappropriately treated ( nae20, 19.9%) for enterococcal bacteremia. Both groups were comparable except in 6 of 36 risk factors. Only endocarditis ( pB0.0026) and 2 positive blood cultures (pB0.0267) were more frequently observed in inappropriately treated patients. Appropriate treatment was signie cantly more common in patients with cancer ( pB0.0165) and cytotoxic chemotherapy ( pB0.0147). In summary both analyses showed, that inappropriate therapy (either late therapy of drugs ineffective against enterococci) were associated with higher mortality, in patients with febrile neutropenia, fungaemia and endocarditis (1‐ 3). Vancomycin or other antibiotic resistance in enterococci was however, not associated with higher mortality.