1/4. Treatment of life-threatening multiresistant staphylococcal and enterococcal infections in patients with end-stage renal failure with quinupristin/dalfopristin: preliminary report.BACKGROUND: life-threatening infections with multiresistant gram-positive bacteria are increasing. Treatment with quinupristin/dalfopristin (Q-D) has turned out to be effective against such resistant pathogens. patients AND methods: We report on treatment of six patients on dialysis (four with additional liver injury) and of one renal graft recipient with normal renal function who had severe infections caused by multiresistant Staphylococus epidermidis (1/7), methicillin-resistant staphylococcus aureus (4/7) and vancomycin-resistant enterococcus faecium (2/7). RESULTS: Six out of seven patients were cured by therapy with Q-D in adjusted doses lasting for 10 to 34 days. pharmacokinetics of Q-D and its metabolites were determined and remained within the therapeutic range, despite a modest increase of all compounds at the presumed steady state. The concentrations of the metabolites of Q-D were clearly lower than the parent drugs, including those of quinupristin-conjugated derivatives, which has not been reported previously. CONCLUSION: These preliminary results suggest that: a) neither quinupristin nor dalfopristin or its metabolites accumulated despite the long duration of treatment; b) no adjustment of the standard dosage regimen (three times 7.5 mg/kg/day) is necessary in end-stage renal disease.- - - - - - - - - - ranking = 1keywords = aureus (Clic here for more details about this article) |
2/4. mars therapy in critically ill patients with advanced malignancy: a clinical and technical report.BACKGROUND/methods: Molecular Adsorbent Recirculating System (mars) was used in three consecutive critically ill patients at the singapore General Hospital with advanced malignancy and acute liver failure (ALF). Case 1 was a male patient with hepatocellular carcinoma (HCC) for which initial right hepatectomy was followed by left hepatectomy 5 months later for recurrent HCC. The postoperative course following second surgery was complicated by severe methicillin-resistant staphylococcus aureus (MRSA) sepsis, mild azotaemia and subacute cholestatic liver failure. mars was used thrice in this patient. Case 2 was a female patient with advanced acute lymphoblastic leukaemia (ALL) with post bone marrow transplantation (BMT) acute haemolytic-uraemic syndrome (HUS) secondary to cyclosporin A (Cy A), cytomegalovirus (CMV) infection, severe nosocomial pneumonia, acute renal failure (ARF) treated with continuous haemofiltration and acute veno-occlusive disease resulting in budd-chiari syndrome. The latter precipitated ALF. mars was instituted twice. Case 3 was a male patient with advanced, refractory Hodgkin's disease previously treated with multiple courses of chemotherapy. ALF developed secondary to acute viral hepatitis b flare. He was given a trial of mars once in the ICU. All the three patients eventually died. RESULTS: Mean mars intradialytic systemic pressures were as follows: systolic pressure range was 95 /- 17 to 128 /- 17 mmHg and diastolic pressure range was 51 /- 5 to 67 /- 7 mmHg. pressure at albumin dialysate exit point from dialyser 1 (Ae) ranged from 253 /- 11 to 339 /- 15 mmHg and that at albumin dialysate entry point into dialyser 1 (Aa) ranged from 142 /- 11 to 210 /- 6 mmHg. ultrafiltration (UF) was 633 /- 622 mL over mean treatment duration of 6.3 /- 0.9 h with a total heparin dose of 1583 /- 817 IU. Coagulation status pre- and 6-h post-mars was similar: aPTT (P=0.116) and platelet count (P=0.753). There were no bleeding complications or circuit thromboses. mars had a significant de-uraemization effect (pre- and post-mars serum creatinine and urea: P=0.046 and 0.028, respectively) but did not significantly attenuate blood lactate, ammonia or total bilirubin levels. Albumin dialysate (Ae - Aa) urea and creatinine concentrations appeared to be sharply attenuated after 6 h of mars. In contrast, the removal of total bilirubin by albumin dialysate from the blood compartment appeared to plateau after 4 h of continuous mars operation. CONCLUSIONS: mars was well-tolerated in critically ill patients with advanced and complicated cancer. Low-dose heparin was safe and did not compromise mars circuit integrity. Although mars had a significant de-uraemization effect, this appeared to be limited by the duration of mars operation. Our data suggested that such a limit was reached earlier for total bilirubin. More data are needed to confirm the present findings and further delineate the saturation limit of mars for different toxins that accumulate in ALF. This would affect the optimal duration of mars therapy.- - - - - - - - - - ranking = 1keywords = aureus (Clic here for more details about this article) |
3/4. Use of quinupristin/dalfopristin in a critical patient with a methicillin-resistant Staphilococcus aureus infection.The growing incidence of infections due to Gram-positive multiresistant germs has stimulated research into new drugs endowed with broader activity, that are useful in case of infections unresponsive to common antibiotics. The case of a 28-year-old man infected with a methicillin resistant Staphylococcus aureus non responder to therapy with glycopeptide antibiotics is reported. At admission the patient presented a septic condition and required mechanical ventilation. Antibiotic therapy was immediately started with teicoplanin meropenem. Blood culture and bronchial aspirate evidenced a methicillin resistant Staphylococcus aureus with high sensibility to glycopeptide antibiotics. Although this therapy produced a slight improvement in clinical condition and the patient was extubated, fever and leucocytosis associated with a BAL positive to methicillin resistant Staphylococcus aureus, in vitro susceptible to glycopeptides, persisted. Considering the possibility of a non-responder condition of the patient to glycopeptide antibiotics, quinupristin/dalfopristin was added. The streptogramin produced a quick improvement in clinical condition with resolution of sepsis and culture sterilization. The patient improved progressively and was discharged. In conclusion, in our experience the association quinupristin/dalfopristin was effective in the resolution of a critical methicillin resistant Staphylococcus aureus infection non responder to classical treatment with glycopeptide antibiotics that showed a high sensibility in vitro.- - - - - - - - - - ranking = 8keywords = aureus (Clic here for more details about this article) |
4/4. Endovascular management of ruptured, mycotic abdominal aortic aneurysm.patients with mycotic aneurysms have a high mortality rate. The standard surgical approach can be exceptionally difficult and fraught with complications. There has been reluctance to insert an endograft into an infected field. We believe that this thought should be challenged and present a case of a successful endovascular repair of a ruptured, mycotic abdominal aortic aneurysm. The patient is a 63-year-old man with severe medical comorbidities and methicillin-sensitive Staphylococcus aureus. He required 6 units of red blood cells on admission. magnetic resonance angiography (MRA) showed a contained rupture of his distal abdominal aorta, and he underwent emergent endovascular repair. An aortomono-iliac device (12 mm x 10 cm iliac extension limb) was inserted along with coil embolization of his right common iliac artery and a femoral-femoral bypass. He did not require additional transfusions after the procedure and was discharged in good condition. He is on antibiotics and doing well 1 year post-op. Endovascular management of ruptured, mycotic aneurysms is feasible. In fact, it is an attractive approach for a medically compromised patient subset that would carry an exceptionally high mortality rate with traditional surgical repair. Further follow-up is necessary to determine its long-term efficacy.- - - - - - - - - - ranking = 1keywords = aureus (Clic here for more details about this article) |