Levofloxacin and pneumonia Nosocomial infections
Nosocomial infections (Latin nosocomium - hospital, from the Greek. Nosokomeo - to care for the sick) are among the most frequent and most severe complications in hospitalized patients. In the U.S., they are the fourth due to mortality after cardiovascular diseases, cancer and cerebrovascular diseases.
The concept of nosocomial infection is suggested by the WHO Regional Office for Europe in 1979 to identify any clinically recognizable infectious disease that developed in a patient as a result of receipt or seeking medical care in hospitals, as well as an employee of the hospital as a result of his work in it regardless of the time of onset of symptoms .
The incidence of nosocomial infections during hospital stay is about 5%, and 90% of them are in bacterial pathogens, and all the other (viral, fungal, protozoan) in the amount of only 10%. In large hospitals nosocomial infections almost two times higher than in the smaller.
With the development of nosocomial infections heavier course of the disease, increases the length of hospital stay, higher costs for his treatment and the risk of adverse outcome.
Resources pathogen nosocomial infections are divided into endogenous and exogenous. To endogenous infections caused by micro-organisms to colonize the patient's admission to the hospital, more than 80% of the total. After hospital admission flora colonizing patients quickly and becomes part of their commensal microflora, under certain conditions, causing the so-called exogenous infection.
About half of nosocomial infections associated with invasive procedures - formulation of catheters connected to an artificial lung ventilation, etc.
The likelihood of developing nosocomial infection significantly increases with a decrease in reactivity of the patient, whose determinants are age, sex, immune status, occurring diseases and their complications. Nosocomial infections are caused not only obligate, but also opportunistic pathogens commonly resistant to environmental factors, but in severe condition of the patient rapidly acquiring resistance to antimicrobial agents.
The structure of nosocomial infections in different hospitals varies and is largely determined by their profile, so the concept of universal design nosocomial infections exists.
Nosocomial urinary tract infections (MVP) in the structure of all hospital-acquired infections occupy approximately 40% and the vast majority of cases involve the use of urinary catheters and drainages.
Nosocomial respiratory infections most often manifest nosocomial pneumonia (25%), and high (70%) mortality. Nosocomial wound (surgery, burns, traumatic wounds) infection occupy up to 25% of all hospital-acquired infections. When the frequency of their wounds clean - no more than 7%, with relatively clean - up to 12%, with contaminated - 17% and dirty - 40%.
Nosocomial bloodstream infections in 75% of cases are associated with intravenous vascular systems (catheter-associated nosocomial bloodstream infections). Most often they occur in patients under the age of 1 year or more than 60 years, neutropenia, immunosuppressive therapy, a history of violations of the integrity of the skin, with severe concomitant diseases (eg, diabetes), and the presence of foci of infection. Nosocomial infections of the gastrointestinal tract (most often gastroenteritis) in most cases are enteric-oral route of infection is often passed through the hands of medical staff from patient to patient, using endoscopic equipment.
Community-acquired infections
Range of community-acquired infections, emerging out of touch with the medical institution (as opposed to hospital-acquired) is much wider - from tuberculosis to AIDS. In outpatient interest are community-acquired non-specific bacterial infections, which also affect the different systems of the body, most commonly the upper and lower respiratory tract (community-acquired pneumonia, acute sinusitis and bronchitis, exacerbation of chronic sinusitis and bronchitis, etc.), urinary tract infection (pyelonephritis, cystitis, urethritis, prostatitis, etc.), complicated and uncomplicated skin and soft tissues. Moreover, almost half of the patients can not detect pathogens.
The general approach to the treatment of nosocomial and community-acquired non-specific bacterial infections
In the treatment of nosocomial and community-acquired non-specific bacterial infections main role belongs to antibiotics. In hospitals, the frequency of administration of antibiotics varies from 20 to 50% (in the intensive care unit). On average, about one-third of these patients are treated with antibiotics, 70% of them - with the purpose of treatment, and 30% - from prevention.
In outpatient antibiotics are usually prescribed more frequently. Almost half of their appointment has not been fully substantiated, and in some cases they are appointed late, which has a well-known consequences.
With that distinguish empirical and causal treatment, in most cases, it starts as an empirical and requires the use of antibiotics (or a combination) with a broad spectrum of action active against the major infectious agents. These antibiotics are fluoroquinolones, carbapenems, cephalosporins past generations, aminoglycosides, protected penicillins and some others. Only after the results of microbiological testing, if conducted, antibiotic treatment may be adjusted.
The favorites of today are the fluoroquinolones antibiotics, which in addition to a broad spectrum of antibacterial activity are favorable pharmacodynamic and pharmacokinetic properties, as well as a high degree of security and compliance of treatment. They are used in clinical practice since the early 80-ies of the last century and today is the number of modern drugs are second only to beta-lactam antibiotics. The four-generation fluoroquinolones have a broad spectrum of bactericidal activity by inhibiting essential enzymes of cells - DNA gyrase and topoisomerase-4 with a disruption of the normal biosynthesis and DNA replication microbial pathogen. This spectrum of bactericidal action of fluoroquinolones was able to expand at the expense of the synthesis and modification of the chemical structure of known compounds by fluorination and the introduction of additional substituents. So there fluoroquinolones III and IV generations.
For activity against respiratory pathogens and the ability to easily penetrate into the respiratory tract and bronchial secretion, they were called respiratory.
Notable among recent generations of fluoroquinolones levofloxacin is.
Levofloxacin - Left-handed
Levofloxacin - the ancestor of respiratory fluoroquinolones. In Japan, it has been registered since 1993 in the United States - in 1997, and therefore has considerable experience in clinical use.
Levofloxacin-resistant coagulase-negative Staphylococci: Inpatient
Coagulase-negative staphylococci (CoNS) are a broad group of species that commensally inhabit the human skin, mucous membranes (S. hominis, S. epidermidis), and the vaginal tract (S. saprophyticus). Although they are less virulent than the coagulase-positive S. aureus and almost never pathogenic in healthy individuals, their persistence on hospital surfaces and devices has made them the most common source of bloodstream infections. Overlooked in the past because of their propensity to contaminate cultures, CoNS have emerged as a clinically relevant pathogen implicated in up to 30%of healthcare-associated sepsis.
This video shows inpatient CoNS resistance to levofloxacin, a newer fluoroquinolone that demonstrates higher antistaphylococcal activity than other drugs of its class (ciprofloxacin and ofloxacin) and is often active against methicillin-resistant strains.
The maps show that levofloxacin resistance was on the rise in the first half of the decade, with a particularly sharp jump from 2004 to 2005, when all divisions simultaneously crossed the 60% mark for the first time. The downward trend that followed was insufficient to compensate for the preceding gains in resistance. The trend was not uniform across regions: in the Mid-Atlantic, where levels were significantly higher, rates peaked from 55% to 82% in 2005. In western regions, rates increased more gradually and peaked later: in West South Central, the peak of 72% came in 2006, and in the Pacific states, 64% resistance was reported between 2005 and 2008. Over the period there was a significant nationwide decrease in the number of isolates CoNS (from nearly 34,000 to 9,000) affecting all divisions except New England.
The observed upward trend is contrary to the declining staphylococcal resistance seen toward other drugs like methicillin, gentamicin, and even ciprofloxacin (not shown). A potential explanation is the changing patterns of antibiotic use: fluoroquinolones have become the most commonly prescribed drug class in the United States since 2002, and levofloxacin use became particularly intensive after it was approved for high-dose treatment of community-acquired pneumonia in 2003. An ophthalmic study (quinolones are heavily used to treat ocular infections) of CoNS resistance to topical fluoroquinolones over a 15-year period suggests that although newer drugs of the class (like levofloxacin) show higher activity than older quinolones (like ciprofloxacin), they rapidly lose their effectiveness as they become common in clinical practice.
The national average resistance level for the sample was 55.5%, rising from 43.5% in 2000 to 58.7% in 2009.
The sample consists of 326,996 inpatient isolates tested for levofloxacin resistance. Data are not available from the following states: : AR (2008--2009), CO (2006--2009), GA (2007--2009), IA (2008--2009), IN (2007--2009), KY (2007--2009), MS (2007--2009), NV (2009), RI (2000--2004), SD (2005--2009), UT (2007--2009), CT, MT, NH, and WY.
