This document discusses the case of a 77-year-old patient (MG) presenting with altered mental status and difficulty breathing who has a history of multidrug-resistant Pseudomonas aeruginosa (MDR PA) infection. MG was initially treated with Zerbaxa for MDR PA but it was discontinued after 4 days. The patient's condition fluctuated with worsening infiltrates seen on imaging and they were ultimately discharged for hospice care due to declining status. The document provides background on MDR PA epidemiology, resistance mechanisms, treatment options including Zerbaxa and Avycaz, and risks of PA colonization.
While MIC is a good measure of antibiotic activity, it is static and reflects in vitro activity. PK and PD of the drug needs to be considered together with MIC if we wish to obtain an in vivo prediction of drug action and success.
DNA Gyrase Inhibitors -Quinolones,Fluoroquinolones Vijay Salvekar
DNA Gyrase Inhibitors -Quinolones,Fluoroquinolones ,its Structure,Antimicrobial activity ,Mechanism of action,classifications ,Mechanisms of Resistance,Pharmacokinetics,Clinical uses,Adverse effects
While MIC is a good measure of antibiotic activity, it is static and reflects in vitro activity. PK and PD of the drug needs to be considered together with MIC if we wish to obtain an in vivo prediction of drug action and success.
DNA Gyrase Inhibitors -Quinolones,Fluoroquinolones Vijay Salvekar
DNA Gyrase Inhibitors -Quinolones,Fluoroquinolones ,its Structure,Antimicrobial activity ,Mechanism of action,classifications ,Mechanisms of Resistance,Pharmacokinetics,Clinical uses,Adverse effects
Montelukast is a selective and orally active leukotriene receptor antagonist that inhibits the Cysteinyl leukotriene CysLT1 receptor. Each 10 mg film-coated Loctril tablet contains 10.4 mg Montelukast sodium, which is equivalent to 10 mg of Montelukast.
ANTIMICROBIAL PEPTIDES & THEIR POTENTIAL TO COMBAT ANTIMICROBIAL RESISTANCE O...Kazimierz Murzyn
Presentation given during Cost AMiCI meeting in Tallinn Nov 2017
by Maria Olivia Pereira, Assistant Professor University of Minho Department of Biological Engineering Braga, Portugal, Professor in Biomedical Engineering Principal Investigator in the Biofilm Group
The presentation include semisynthetic penicillin introduction and classification.
Contents
Semisynthetic penicillins- Introduction
Classification
Acid-resistant alternative to Penicillin G
Penicillinase- resistant penicillins
Extended spectrum penicillins
An Impact of Biofield Treatment: Antimycobacterial Susceptibility Potential U...albertdivis
The aim was to evaluate the impact of biofield treatment modality on mycobacterial strains in relation to antimycobacterials susceptibility. Mycobacterial sensitivity was analysed using 12 B BACTEC vials on the BACTEC 460 TB machine in 39 lab isolates (sputum samples) from stored stock cultures.
Montelukast is a selective and orally active leukotriene receptor antagonist that inhibits the Cysteinyl leukotriene CysLT1 receptor. Each 10 mg film-coated Loctril tablet contains 10.4 mg Montelukast sodium, which is equivalent to 10 mg of Montelukast.
ANTIMICROBIAL PEPTIDES & THEIR POTENTIAL TO COMBAT ANTIMICROBIAL RESISTANCE O...Kazimierz Murzyn
Presentation given during Cost AMiCI meeting in Tallinn Nov 2017
by Maria Olivia Pereira, Assistant Professor University of Minho Department of Biological Engineering Braga, Portugal, Professor in Biomedical Engineering Principal Investigator in the Biofilm Group
The presentation include semisynthetic penicillin introduction and classification.
Contents
Semisynthetic penicillins- Introduction
Classification
Acid-resistant alternative to Penicillin G
Penicillinase- resistant penicillins
Extended spectrum penicillins
An Impact of Biofield Treatment: Antimycobacterial Susceptibility Potential U...albertdivis
The aim was to evaluate the impact of biofield treatment modality on mycobacterial strains in relation to antimycobacterials susceptibility. Mycobacterial sensitivity was analysed using 12 B BACTEC vials on the BACTEC 460 TB machine in 39 lab isolates (sputum samples) from stored stock cultures.
Introduction: Bloodstream infections (BSIs) are associated with a high mortality rate of 20%-50%. Blood culture is paramount to identify causative agents of BSIs to choose an appropriate antimicrobial therapy. Objectives: The present study was undertaken to analyze the various microorganisms causing BSIs and study their antimicrobial resistance patterns in a tertiary care hospital, Eastern India. Materials and Methods: A total of 239 blood specimens from clinically suspected cases of BSIs were studied for 6 months from July 2015 to December 2015. Blood specimens were incubated in BacT/ALERT ® 3D system (bioMerieux, Durham, NC, USA) a fully automated blood culture system for detection of aerobic growth. Identification and antimicrobial susceptibility testing were conducted on VITEK ® 2 (bioMerieux, Durham, NC, USA) as per Clinical Laboratory Standards Institute guidelines. Results: Out of 239 specimens, 41 (17.2%) yielded growth of different microorganisms. From these isolates, 20 (48.8%) were Gram-negative bacilli, 18 (43.9%) were Gram-positive cocci and rest 3 (7.3%) were yeasts. Among Gram-negative bacilli, Klebsiella pneumoniae sub spp. pneumoniae (70%) was most commonly isolated. Coagulase-negative staphylococci (88.9%) were the most common isolate among Gram-positive cocci. All three Candida spp. isolated were nonalbicans Candida (two Candida tropicalis and one Candida krusei). Gram-negative isolates were least resistant to tigecycline and colistin. All Gram-positive cocci were sensitive to linezolid. Conclusion: Monitoring of data regarding the prevalence of microorganisms and its resistance patterns would help in currently prescribing antimicrobial regimens and improving the infection control practices by formulating policies for empirical antimicrobial therapy.
Zyvac TCV - The Indian Typhoid Conjugate VaccineGaurav Gupta
Presented at Ambala in Jan 2020. Is TCV needed, and is it better than Polysaccharide vaccine. Indian data and studies by Dr. Gaurav Gupta, Pediatrician from Charak Clinics, Mohali
An Effect of Biofield Treatment on Multidrug-resistant Burkholderia cepacia: ...Mahendra Kumar Trivedi
Aim of the present study was to analyze the impact of biofield treatment on multidrug resistant B. cepacia. Clinicalsample of B. cepacia was divided into two groups i.e. control and biofield treated.
An Evaluation of Biofield Treatment on Susceptibility Pattern of Multidrug Re...Mahendra Kumar Trivedi
Stenotrophomonas maltophilia (S. maltophilia) is a Gram-negative bacillus, an opportunistic pathogen, particularly among nosocomial infections. Multi-drug resistant strains are associated with very high rate of morbidity and mortality in severely immunocompromised patients. Present study was designed to evaluate the effect of biofield treatment against multidrug resistant S. maltophilia. Clinical sample of S. maltophilia was collected and divided into two groups i.e. control and biofield treated which were analyzed after 10 days with respect to control. The following parameters viz. susceptibility pattern, minimum inhibitory concentration (MIC), biochemical studies and biotype number of both control and treated samples were measured by MicroScan Walk-Away® system. The results showed an overall change of 37.5% in susceptibility pattern and 39.4% in biochemical study while 33.3% changes in MIC values of tested antimicrobials after biofield treatment. Further, the treated group of S. maltophilia has also shown a significant change in biochemical reactions followed by its biotype number as compared to control group. Biochemical reactions of treated group showed negative reaction to acetamide and positive reactions to colistin, glucose, adonitol, melibiose, arabinose, nitrate, oxidation-fermentation, raffinose, rhaminose, sorbitol, sucrose, and Voges-Proskauer as compared with control. The biofield treatment showed an alteration in MIC values of amikacin, amoxicillin/K-clavulanate, chloramphenicol, gatifloxacin, levofloxacin, moxifloxacin, ceftazidime, cefotetan, ticarcillin/K-clavulanate, trimethoprim/sulfamethoxazole. Altogether, data suggest that biofield treatment has significant effect to alter the sensitivity pattern of antimicrobials and biotype number against multidrug resistant strain of S. maltophilia.
An Evaluation of Biofield Treatment on Susceptibility Pattern of Multidrug Re...albertdivis
Stenotrophomonas maltophilia ( S. maltophilia ) is a Gram-negative bacillus, an opportunistic pathogen, particularly among nosocomial infections. Multi-drug resistant strains are associated with very high rate of morbidity and mortality in severely immunocompromised patients. Present study was designed to evaluate the effect of biofield treatment against multidrug resistant S. maltophilia.
An Evaluation of Biofield Treatment on Susceptibility Pattern of Multidrug Re...Mahendra Kumar Trivedi
Present study was designed to evaluate the effect of biofield treatment against multidrug resistant S. maltophilia. Clinical sample of S. maltophilia was collected and divided into two groups i.e. control and biofield treated which were analyzed after 10 days with respect to control.
Biofield Treatment: An Alternative Approach to Combat Multidrug-Resistant Sus...Mahendra Kumar Trivedi
As biofield therapy is increasingly popular in biomedical heath care, so present study aimed to evaluate the impact of Mr. Trivedi’s biofield treatment on antimicrobial sensitivity, minimum inhibitory concentration (MIC), biochemical study, and biotype number of multidrug resistant strain of R. ornithinolytica.
Biofield Treatment: An Alternative Approach to Combat Multidrug-Resistant Sus...albertdivis
As biofield therapy is increasingly popular in biomedical heath care, so present study aimed to evaluate the impact of Mr. Trivedi’s biofield treatment on antimicrobial sensitivity, minimum inhibitory concentration (MIC), biochemical study, and biotype number of multidrug resistant strain of R. ornithinolytica.
Dr. Cady deconstructs some the medical literature about the use of nutrients - and the evidence of what happens in the presence of their insufficiency. Everything for decreased viral replication to decrease brain shrinkage is covered. The role of antioxidant and carotenoids, measured by the Pharmanex Biophotonic Scanner, is reviewed.
Please note - there is no representation that any nutrient or supplement can treat, prevent, mitigate, or cure any medical condition. It does seem, however, upon reflecting on the medical literature, that there seems to be a lot of evidence for therapeutic effect in the presence of good levels of nutrient, and harm to patients if they have insufficient levels.
Evaluation of Prescribing Patterns of Antibiotics in General Medicine Ward in...ijtsrd
Knowledge about antibiotic utilization and resistance patterns of most common microorganisms are unavailable in tertiary care hospitals. To assess the pattern of antibiotic utilization and outcome of patients in a General Medical Ward, all positive blood cultures BC over a 4 month period from July 2019 to October 2019 were retrospectively reviewed. Sixty five positive BC were recorded in which patients 43 males and 22 females . 72 of the patients received antibiotics before or soon after obtaining the BC, and ceftriaxone was the most frequently prescribed antibiotic 41.93 , either alone or in combination with other antibiotics. The bacteraemia was due to gram positive cocci in 60.46 of cases, gram negative rods in 30.23 , and gram positive rods in 9.30 . Positive BC due to contamination was not included. The most common gram positive cocci were Staphylococcus epidermidis, followed by S. aureus, while the most common gram negative bacilli were Brucella species, Proteus mirabilis, and Klebsiella sp. The suspected sources of the bacteraemia were respiratory 21.2 , urinary 19.2 , or skin 19.2 . A subsequent change in the antibiotics regimen was done in 69.76 cases after BC results became available with no apparent effect on the outcome. Adding Cefotaxime, Amoxicillin clavulonic acid, piperacillintazobactum, vancomycin and clindamycin was the most frequent change done 19.4 for each equally . Complications developed in 69.76 of patients, with 88.66 of them suffering from sepsis shock. 69.23 of the patients improved and 30.77 expired death was related to infection in 87.5 of cases. In conclusion, most bacteremia in the medical ward of the hospital were due to gram positive cocci, which should be considered in antibiotic selection prior to BC. Vageeshwari Devuni | Debabrata Chaudhary "Evaluation of Prescribing Patterns of Antibiotics in General Medicine Ward in a Tertiary Care Hospital" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-4 | Issue-1 , December 2019, URL: https://www.ijtsrd.com/papers/ijtsrd29618.pdf Paper URL: https://www.ijtsrd.com/pharmacy/pharmacology-/29618/evaluation-of-prescribing-patterns-of-antibiotics-in-general-medicine-ward-in-a-tertiary-care-hospital/vageeshwari-devuni
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdf
Antimicrobial presentation
1. TO TREAT OR NOT TO
TREAT?
MDR P. AERUGINOSA: A
PATIENT CASE
ERIK CHIEUW PHARMD CANDIDATE 2018
HCA-CENTRAL FLORIDA REGIONAL HOSPITAL
APPE-ANTIMICROBIAL STEWARDSHIP
PRECEPTOR: KATRINA BABILONIA, PHARMD
Image from: http://www.news.com.au/lifestyle/health/health-problems/how-geneticallyaltered-ecoli-strain-can-kill-dangerous-boneeating-superbug-pseudomonas-aeruginosa/news-
3. PATIENT CASE MG
• 77 YO F PRESENTS TO ED FROM SNF WITH CC: AMS X 2 DAYS (SLEEPY AND CONFUSED) AND
DIFFICULTY BREATHING
• PMH: HTN, DYSLIPIDEMIA, CHF, C DIFF, STAGE 3 B CKD, DM, DEMENTIA, ANEMIA; HAS TRACH,
PEG, AND PICC
• ALLERGIES: PCN (HIVES), CEFEPIME (HALLUCINATIONS), BACITRACIN, POLYMYXIN B, NEOMYCIN
(HIVES), TAPE
• WEIGHT: 61 KG; BASELINE SCR: 1.4
• HOME MEDS: ATORVASTATIN 10 MG PEG QHS, METOPROLOL TARTRATE 25 MG PEG Q12H,
FAMOTIDINE 20 MG PEG QD
• RECENTLY ADMITTED FOR HCAP 3 MONTHS AGO WITH MDR P. AERUGINOSA TREATED WITH
ZERBAXA
4. PATIENT CASE MG CONT.
• ED LABS/VITALS:
• ED U/A:
• CXR DAY 1: PERSISTENT DIFFUSE INTERSTITIAL OPACITIES
(INFECTION/INFLAMMATORY/EDEMA)
• CXR 1 MONTH AGO: STABLE MODERATE BILATERAL INTERSTITIAL
O2
Sat
(%)
BP
(mm
HG)
Temp
(C)
Puls
e
RR SCr
(mg/dL
)
CrCl
(mL/min)
WBC
(k/m
m3)
Plt
(k/m
m3)
Lactat
e
99 163/7
0
38.1 114 32 2.3 19.7 16.2 260 1.25
Nitrite Leukocyte
Esterase
WBC Epithelial
Cells
Bacteria
Negative Large 15-25 Moderate Moderate
5. PATIENT CASE MG CONT.
• DIAGNOSIS: HCAP SEPSIS, AKI ON CKD
• CONSULTS: NEPHRO, ID, PULMONARY
• INITIAL ABX TX: AZTREONAM 2GM IV X 1, TOBRAMYCIN 425 MG IV X 1,
VANCOMYCIN 1.25 GM X 1, LEVOFLOXACIN X 1
• ID D/C’D AZTREONAM AND STARTED ZERBAXA DAY 1 WITH PROJECTED 7 DAY
DURATION
6. EPIDEMIOLOGY OF P. AERUGINOSA
• P. AERUGINOSA IS THE CAUSE OF 10% OF HOSPITAL ACQUIRED INFECTIONS IN
THE WORLD
• MDR P. AERUGINOSA IN US: 15.4% (7452 ISOLATES FROM 2012-2015)
• MDR: RESISTANCE TO AT LEAST 1 ANTIBIOTIC IN 3 OR MORE ANTIMICROBIAL
CATEGORIES
• 2013 CDC REPORT ON P. AERUGINOSA
• CAUSE OF 51,000 HEALTHCARE ASSOCIATED INFECTIONS
• ASSOCIATED WITH ABOUT 400 DEATHS PER YEAR
• 13% OF THOSE BEING MULTI DRUG RESISTANT
References:
1) Chatterjee, Maitrayee, et al. "Antibiotic resistance in Pseudomonas aeruginosa and alternative therapeutic options." International Journal of Medical Microbiology 306.1 (2016): 48-58.
2) Sader HS, Huband MD, Castanheira M, Flamm RK. Pseudomonas aeruginosa Antimicrobial Susceptibility Results from Four Years (2012 to 2015) of the International Network for Optimal Resistance Monitoring Program in the United States.
Antimicrobial Agents and Chemotherapy. 2017;61(3):e02252-16. doi:10.1128/AAC.02252-16.
3) Magiorakos, A-P., et al. "Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance." Clinical microbiology and infection 18.3
7. MICROBIOLOGY OF MDR P. AERUGINOSA
• P. AERUGINOSA IS A GRAM NEGATIVE ROD
• PSEUDOMONAS CAN COLONIZE THE NORMAL FLORA AND FORM BIOFILMS
• VIRULENCE FACTORS:
• ADHERENCE FACTORS (PILI)
• PSEUDOCAPSULE (PROTECTION)
• EXOTOXINS AND PROTEASES WHICH DAMAGES THE HOST TISSUE->(INVASION, SPREADING AND
INFECTION)
• TOXIN EFFECTS:
• PROTEIN SYNTHESIS INHIBITION
• PROTEASE ACTIVITY
• INHIBITION OF COMPLEMENT ACTIVATION AND NEUTROPHIL PHAGOCYTOSIS
• DEGRADATION OF PLASMINOGEN AND FIBRINOGEN, ETC.
References: Chatterjee, Maitrayee, et al. "Antibiotic resistance in Pseudomonas aeruginosa and alternative therapeutic options." International Journal of Medical Microbiology 306.1 (2016): 48-58.
8. RESISTANCE MECHANISMS OF MDR P.
AERUGINOSA
• ANTIBIOTIC MODIFYING ENZYMES: AMINOGLYCOSIDES, BETA LACTAMASES (ESBL
+METALLO BETA LACTAMASES)
• METALLO BETA LACTAMSES HYDROLYZE CARBAPENEMS AND OTHER BETA LACTAMS
EXCEPT AZTREONAM
• TAZOBACTAM DOES NOT INHIBIT
• EFFLUX PUMPS
• REMOVE OF PORINS (REDUCED PERMEABILITY FOR ABX)
References:
1) Hong DJ, Bae IK, Jang I-H, Jeong SH, Kang H-K, Lee K. Epidemiology and Characteristics of Metallo-β-Lactamase-Producing Pseudomonas aeruginosa. Infection & Chemotherapy. 2015;47(2):81-97. doi:10.3947/ic.2015.47.2.81.
2) Chatterjee, Maitrayee, et al. "Antibiotic resistance in Pseudomonas aeruginosa and alternative therapeutic options." International Journal of Medical Microbiology 306.1 (2016): 48-58.
9. Reference: Chatterjee, Maitrayee, et al. "Antibiotic resistance in Pseudomonas aeruginosa and alternative therapeutic options." International Journal of Medical Microbiology 306.1 (2016): 48-58.
10. ANTIBIOTICS FOR MDR P. AERUGINOSA
• ZERBAXA (CEFTOLOZANE-TAZOBACTAM): DOSE 1.5 GM IV Q8H
• AVYCAZ (CEFTAZIDIME-AVIBACTAM): DOSE 2.5 GM IV Q8H
• COLISTIN: NEPHROTOXIC AND OTOTOXIC (SALVAGE)
• COMBINATION THERAPY FOR SYNERGY
• RIFAMPIN + COLISTIN
• FOSFOMYCIN + CARBAPENEM
• FQ + CEFEPIME
Reference: "Principles of antimicrobial therapy of Pseudomonas aeruginosa infections". June 22, 2017. Retrieved from: https://www.uptodate.com/contents/principles-of-antimicrobial-therapy-of-pseudomonas-aeruginosa-
infections#H6675731
11. ZERBAXA VS AVYCAZ
• 2016 IN VITRO MEROPENEM RESISTANT P. AERUGINOSA (38 ISOLATES)
• AVYCAZ: 47% ISOLATES MIC AT OR ABOVE BREAKPOINT
• ZERBAXA: 13% ISOLATES MIC AT OR ABOVE BREAKPOINT
• RATES OF RESISTANCE FOR BOTH AGENTS: 8%
• 2017 IN VITRO P. AERUGINOSA ACTIVITY (31 ISOLATES)
• ZERBAXA MIC50: 0.75 MCG/ML VS AVYCAZ 1.5 MCG/ML
• MDR P. AERUGINOSA ACTIVITY: ZERBAXA 89% VS AVYCAZ 78%
References:
1) Alatoom, Adnan, et al. "Comparison of antimicrobial activity between ceftolozane–tazobactam and ceftazidime–avibactam against multidrug-resistant isolates of Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa."
International Journal of Infectious Diseases 62 (2017): 39-43.
2) Buehrle, Deanna J., et al. "Evaluation of the in vitro activity of ceftazidime-avibactam and ceftolozane-tazobactam against meropenem-resistant Pseudomonas aeruginosa isolates." Antimicrobial agents and chemotherapy 60.5 (2016):
3227-3231.
12. ZERBAXA VS AVYCAZ CONT.
• ZERBAXA
• NO ACTIVITY AGAINST KPC
• BETTER MDR PSEUDOMONAL COVERAGE THAN AVYCAZ
• AVYCAZ
• KPC ACTIVITY
• BETTER FOR CRE
• NEITHER ACTIVE AGAINST METALLO BETA LACTAMASE (RARE IN US)
Reference: Liscio, Jordan L., Monica V. Mahoney, and Elizabeth B. Hirsch. "Ceftolozane/tazobactam and ceftazidime/avibactam: two novel β-lactam/β-lactamase inhibitor combination agents for the treatment of resistant Gram-negative
bacterial infections." International journal of antimicrobial agents 46.3 (2015): 266-271.
13. ZERBAXA (CEFTOLOZANE-TAZOBACTAM)
• MOA: CEFTOLOZANE (INHIBIT CELL WALL SYNTHESIS), TAZOBACTAM (BETA LACTAMASE
INHIBITOR)
• USUAL DOSING (CUTI/AP/CIAI): 1.5 GRAMS (CEFTOLOZANE 1 GRAM + TAZOBACTAM 500 MG) IV
Q8H
• INFUSION TIME: 60 MINUTES
• LOW TOXICITY PROFILE
• WARNINGS: CURE RATES LOWER IN PATIENTS WITH CRCL < 50 ML/MIN
• NO TRIALS COMPLETED FOR ZERBAXA FOR PNEUMONIA YET, BUT ONE IN PROGRESS (NO
RESULTS)
• COMPARING ZERBAXA 3 GRAMS (CEFTOLOZANE 2 GM + TAZOBACTAM 1 GM) Q8H VS MEROPENEM 1
GM Q8H
• WHY ZERBAXA 3 GM?
• ZERBAXA LEVELS ARE 50% IN LUNG COMPARED TO PLASMA
Reference: Xiao AJ, Miller BW, Huntington JA, Nicolau DP. Ceftolozane/tazobactam pharmacokinetic/pharmacodynamic‐derived dose justification for phase 3 studies in patients with nosocomial pneumonia. Journal of Clinical Pharmacology.
2016;56(1):56-66. doi:10.1002/jcph.566.
14. P. AERUGINOSA COLONIZATION
• P. AERUGINOSA COLONIZATION ASSOCIATED WITH 3 FOLD INCREASE IN MORTALITY IN
ADULTS WITH BRONCHIECTASIS
• 5 YEARS: 30-50% MORTALITY (COLONIZED) VS 5 YEARS: 9-15% MORTALITY (NOT-COLONIZED)
• CYSTIC FIBROSIS PATIENTS: FASTER LUNG DETERIORATION AND EARLIER MORTALITY
• RECOMMEND TO TREAT COLONIZED PATIENTS FOR ERADICATION (EUROPEAN RESP SOCIETY)
• “CONDITIONAL, VERY LOW QUALITY OF EVIDENCE”
• CHRONIC INFECTION: 2 OR MORE ISOLATES OF THE SAME ORGANISM AT LEAST 3 MONTHS APART IN
1 YEAR
• ONE THERAPY REGIMEN: IV ABX X 2 WEEKS THEN INHALED COLISTIN/TOBRAMYCIN/GENTAMICIN FOR
2.5 MONTHS
References:
1) Finch, Simon, et al. "A comprehensive analysis of the impact of Pseudomonas aeruginosa colonization on prognosis in adult bronchiectasis." Annals of the American Thoracic Society 12.11 (2015): 1602-1611.
2) Polverino, Eva, et al. "European Respiratory Society guidelines for the management of adult bronchiectasis." European respiratory journal 50.3 (2017): 1700629.
15. BACK TO PATIENT MG
Day 2
•Aerating well,
arousable, non-
communicative
•BP 125/58
•RR 25
•HR 82
•Tmax: 36.5
Day 3
•AMS
•BP: 127/61
•RR 32
•HR 81
•Tmax: 36.7
•UTI: P. Mirabilis grew
•Started Ceftriaxone IV
and azithromycin x 1
empiric for sputum gm
+ cocci per ID
•Zerbaxa D/C’d by ID
Day 4
•No productive phlegm;
no change in mental
•BP: 161/78
•RR: 23
•HR: 88
•Tmax: 36.7
•CXR: Interstitial and
airspace infiltrates
improving in left and
worsening in right lung
Day 5
•No productive phlegm
•BP 159/72
•RR 32
•HR 88
•Tmax 36.7
•Pulmonary switched
rocephin for aztreonam
d/t p. aeruginosa
growth
•C. diff + start PO
vanco; Abdomen: non-
tender, soft; no reports
of loose stools
Day 6
•No productive phlegm
•BP 168/70
•RR 16
•HR 98
•Tmax 37
•Pt alert to questions
and responsive to
questions, denies SOB
and pain
•Discharged for hospice
care
•Not discharged on PO
Vanco
•CXR: Near complete
opacification of left
hemithorax
18. BACK TO PATIENT MG-LABS
Day 1 Day 2 Day 3 Day 5 Day 6
WBC 16.2 10.6 12.3 12.3 10.1
Tmax 38.1 36.5 36.7 36.7 37
SCr 2.3 2.1 1.9 1.9 1.7
Procalcito
nin
<0.05
Lactate 1.1
C Diff
Toxin
Negative
C Diff Ag Positive
C Diff PCR Positive
19. BACK TO PATIENT MG-ABX
• ZERBAXA 1.5 GM IV Q8H: DAY 1->DAY 4 (4 DOSES) THEN D/CED BY ID
• FOR MDR P. AERUGINOSA HX HCAP
• AZITHROMYCIN 500 MG IV X 1 BY ID
• EMPIRIC
• CEFTRIAXONE 1 GM IV Q24H: DAY 2 (2 DOSES) THEN SWITCHED TO AZTREONAM BY
PULMONARY
• FOR P. MIRABILIS IN URINE
• AZTREONAM 1 GM IV Q12H (2 DOSES) DAY 5
• FOR + P. AERUGINOSA IN SPUTUM
• VANCOMYCIN 125 MG PO (4 DOSES) BY ID
• FOR + C. DIFF
20. CASE ASSESSMENT
• PT HAD S/SX OF INFECTION: AMS, SIRS (HR, RR, WBC, FEBRILE) WITH P. MIRABILIS
IN URINE (NOSOCOMIAL?) AND PROVIDENCIA STUARTII (NOT ADDRESSED BY ID)
• RECOMMEND A FULL TREATMENT COURSE FOR UTI AND PNEUMONIA FOR 7 TOTAL
DAYS
• CHANGE AZTREONAM TO CEFTRIAXONE 1 GM IV Q12H (BOTH SUSCEPTIBLE) FOR 3
MORE DAYS EVEN THOUGH PT TRANSFER TO HOSPICE
• AGREE WITH NOT RECOMMENDING TO TREAT COLONIZED MDR P. AERUGINOSA DUE
TO HOSPICE TRANSFER
21. CASE ASSESSMENT CONT.
• AGREE NOT TO TREAT RECURRENT C DIFF INFECTION
• TOXIN (-), AG +->PCR +->TREATMENT NOT INDICATED SINCE ASYMPTOMATIC
(CARRIER)
• ABX RENALLY DOSED APPROPRIATELY EXCEPT ZERBAXA 1.5 GM Q8H
• PT CRCL RANGE: 19.27-26.7 ML/MIN
• ZERBAXA RENAL DOSING: CRCL 15-29 ML/MIN: 375 MG Q8H
22. TO TREAT OR NOT TO
TREAT?
MDR P. AERUGINOSA: A
PATIENT CASE
QUESTIONS?
