RATIONAL USE OF ANTIMICROBIAL DRUGS IN CLINICAL PRACTICE BY IMPLEMENTING ANTIMICROBIAL STEWARDSHIP PROGRAMS

Prema dosadašnjim istraživanjima neracionalna primjena antimikrobne terapije značajan je problem u bolničkim i vanbolničkim ustanovama. Studije su pokazale da se približno 50 % antimikrobnih lijekova koristi nepotrebno i suboptimalno s obzirom na indikaciju, vrstu antimikrobnog lijeka, te duljinu primjene. Dosadašnja istraživanja su pokazala uzlazni trend prevalencije Clostridium diffi cile pseudomembranoznog kolitisa, bakterijskih patogena rezistentnih na fl uorokinolone i vankomicin rezistentnih enterokoka. Porast multirezistencije gram negativnih bakterija i na karbapeneme opasnost je za sigurnost bolesnika te ostavlja ograničene terapijske mogućnosti zadnje linije obrane poput primjene toksičnog polimiksinskog ntibiotika kolistina. U skladu s time mogućnosti optimalnog infektivnog liječenja već sada postaju ograničavajuće. Prema dosadašnjim radovima uvođenje bolničkog programa praćenja i rukovođenja antimikrobnom terapijom pokazalo se dobrim sredstvom optimalizacije antimikrobne terapije u 81 % studija. Primjena ovoga programa dovela je do značajnog poboljšanja mikrobiološkog ishoda, smanjenja stope antimikrobne rezistencije i nuspojava te kliničkog ishoda poput smanjenja stope mortaliteta i duljine boravka u bolnici. Stoga su Centres for Disease Control and Prevention, Atlanta, USA (CDC) i European Centre for Disease Prevention and Control (ECDC) suglasne da bi zdravstvene ustanove trebale implementirati multidisciplinarni Bolnički program praćenja i rukovođenja antimikrobnom terapijom (engl. Antimicrobic Stewardship Programs - ASP) u svakodnevnu kliničku praksu. Primjena navedenog programa započeta je 1. 12. 2016. g. u Klinici za kardiovaskularne bolesti Magdalena u sklopu Internacionalne kanadske akreditacije (Accreditation Canada International).According to studies, about 50% of antimicrobial drugs are prescribed unnecessarily and inappropriately in hospitals and other healthcare institutions. Besides the high prevalence of Clostridium diffi cile infection, of particular concern is the increase in bacterial pathogen resistance to fl uoroquinolones and vancomycin-resistant enterococci. Additionally, infections due to bacterial pathogens completely resistant to carbapenems are currently emerging in Europe. In this case, therapeutic options are limited to the use of the polymyxin antibiotic colistin, which is old and has many adverse and toxic events. Growing evidence demonstrates that hospital programs dedicated to improving the use of antimicrobial therapy, referred to as Antimicrobial Stewardship Programs (ASP), can optimize treatment of infections, reduce adverse events of antimicrobial therapy, improve patient safety and quality of care, and at the same time signifi cantly reduce hospital costs, mortality rate and length of hospital stay. Therefore, the US Centers for Disease Control and Prevention and European Centre for Disease Prevention and Control recommend that every acute care hospital implement the multidisciplinary ASP in daily clinical practice

Restauracija fotografija

Restauriranje uključuje radove na stabiliziranju i povratu oštećenog gradiva što je moguće bliže izvornom stanju, ali to je složeno područje koje zahtijeva posebnu izvježbanost i znanje. Da bi se fotografija mogla na pravi način zaštititi i restaurirati, potrebno je dobro poznavanje tehnologije proizvodnje fotografskog materijala, njegove fizičke i kemijske osobine te ponašanje tijekom fotografskog postupka. Također je potrebno razmotriti utjecaj kemijskih, fizikalnih i bioloških čimbenika koji mogu utjecati na stabilnost fotografskog materijala. Svrha ovog rada je istražiti čimbenike koji mogu utjecati na trajnost fotografija te postupke njihove identifikacije sa ciljem upoznavanja svojstava neophodnih za razumijevanje restauracije i zaštite fotografija

Infekcija krvotoka uzrokovana Corynebacterium striatum kod COVID-19 pacijenta: prikaz bolesnika i pregled literature

Objectives: Recent research recognized coryneform bacteria as emerging opportunistic pathogens. Corynebacterium striatum appears as a significant pathogen in immunocompromised and immunocompetent patients. Methods: In this paper, we report a case of an adult COVID-19 patient with C. striatum bloodstream infection. In addition, we reviewed clinical cases of bloodstream infection caused by Corynebacterium spp, mainly C. striatum. Results: We present a 43-year-old patient hospitalized due to bilateral pneumonia caused by a SARS-CoV-2 infection. During hospitalization, the patient was connected to a veno-venous extracorporeal membrane oxygenation (ECMO) circuit. C. striatum was isolated in seven sets of blood cultures sampled over seven consecutive days. Based on identification done by MALDI- ToF, empirical therapy with vancomycin was initiated. Identification was confirmed by 16S ribosomal RNA gene sequencing. Although central venous catheter was replaced, C. striatum was persistently isolated in blood cultures in the following days. Although replacement of the ECMO cannula would be recommended, the procedure was not performed due to the severe patient\u27s condition. Fosfomycin was added to vancomycin as salvage therapy in order to reorganize the structure of the biofilm and enable better penetration and efficacy of vancomycin which resulted in sterile blood cultures in the following days. Conclusion: During the last decades, there have been many examples of bloodstream infections caused by skin contaminants. Although the central venous catheter is most commonly described as a route of entry of the skin microbiota in the bloodstream, other catheters such as pleural catheter and ECMO system, should not be neglected. It is well known that bacterial cells often form a biofilm on the surface of different medical devices such as central venous catheters, endoscopes, and urinary catheters. Fosfomycin has the potential to penetrate the biofilm, transform the biofilm structure and potentially increase the concentration of other antimicrobial agents in the biofilm.Cilj: Nedavna istraživanja prezentirala su korinebakterije kao uzročnike oportunističkih infekcija. Corynebacterium striatum pojavljuje se kao značajan uzročnik kod imunokompromitiranih i imunokompetentnih bolesnika. Metode: U ovom radu je prikazan slučaj odraslog pacijenta oboljelog od COVID-19 bolesti s infekcijom krvotoka uzrokovanom C. striatum. Uz to, predstavljeni su klinički slučajevi infekcija krvotoka uzrokovanih Corynebacterium spp., uglavnom C. striatum. Rezultati: Prikazujemo 43-godišnjeg pacijenta hospitaliziranog zbog bilateralne pneumonije uzrokovane virusom SARS-CoV-2. Tijekom liječenja primijenjen je postupak izvantjelesne membranske oksigenacije (engl. extracorporeal membrane oxygenation, ECMO). C. striatum izoliran je u sedam setova hemokultura uzorkovanih tijekom sedam uzastopnih dana. Na temelju identifikacije pomoću MALDI-ToF-a, započeta je empirijska terapija vankomicinom. Identifikacija je potvrđena sekvenciranjem gena 16S ribosomske RNA. Centralni venski kateter je zamijenjen, ali je C. striatum kontinuirano izoliran u hemokulturama sljedećih dana. Iako je preporučena zamjena ECMO kanile, postupak nije izveden zbog teškog stanja pacijenta. Vankomicinu je dodan fosfomicin kao „terapija spasa” kako bi se reorganizirala struktura biofilma te omogućila bolja penetracija i učinkovitost vankomicina što je rezultiralo sterilnim hemokulturama u narednim danima. Zaključak: Tijekom posljednjih desetljeća u literaturi je opisano mnogo primjera infekcija krvotoka uzrokovanih kontaminantima kože. Iako se centralni venski kateter najčešće opisuje kao put ulaska mikrobiote kože u krvotok, ne smiju se zanemariti ni drugi kateteri, poput pleuralnog katetera i ECMO sustava. Poznato je kako bakterijske stanice često stvaraju biofilm na površini različitih medicinskih uređaja, kao što su središnji venski kateteri, endoskopi i urinarni kateteri. Fosfomicin ima potencijal prodrijeti u biofilm, transformirati strukturu biofilma i potencijalno povećati koncentraciju drugih antimikrobnih sredstava u biofilmu

Tricuspid Valve Endocarditis Due to Methicillin-Resistant <i>Staphylococcus aureus</i> in a Previously Healthy Young Patient without a Drug Abuse History: A Case Report and a Review of the Literature

Right-sided infective endocarditis due to methicillin-resistant Staphylococcus aureus (MRSA) is strongly associated with intravenous drug abuse, congenital heart disease, or previous medical treatment and is rare in healthy patients without a history of drug abuse. Here, we present a case of an 18-year-old male with no drug abuse history and no medical burden who was diagnosed with MRSA tricuspid valve endocarditis. Due to initial symptoms which indicated community-acquired pneumonia and radiological finding of interstitial lesions, empiric therapy with ceftriaxone and azithromycin was started. After the detection of Gram-positive cocci in clusters in several blood culture sets, endocarditis was suspected, and flucloxacillin was added to the initial therapy. As soon as methicillin resistance was detected, the treatment was switched to vancomycin. Transesophageal echocardiography established the diagnosis of right-sided infective endocarditis. A toxicological analysis of hair was carried out, and no presence of narcotic drugs was found. After six weeks of therapy, the patient was fully recovered. Exceptionally, tricuspid valve endocarditis can be diagnosed in previously healthy people who are not drug addicts. As the clinical presentation commonly resembles a respiratory infection, a misdiagnosis is possible. Although MRSA rarely causes community-acquired infections in Europe, clinicians should be aware of this possibility

Outbreak of healthcare-associated bacteremia caused by Burkholderia gladioli due to contaminated multidose vials with saline solutions in three Croatian hospitals

Objectives: Burkholderia gladioli has been associated with infections in patients with cystic fibrosis, chronic granulomatous disease, and other immunocompromising conditions. The aim of this study was to better depict the outbreak of healthcare-associated bacteremia caused by B. gladioli due to exposure to contaminated multidose vials with saline solutions. ----- Methods: An environmental and epidemiologic investigation was conducted by the Infection Prevention and Control Team (IPCT) to identify the source of the outbreak in three Croatian hospitals. ----- Results: During a 3-month period, 13 B. gladioli bacteremia episodes were identified in 10 patients in three Croatian hospitals. At the time of the outbreak, all three hospitals used saline products from the same manufacturer. Two 100-ml multidose vials with saline solutions and needleless dispensing pins were positive for B. gladioli. All 13 bacteremia isolates and two isolates from the saline showed the same antimicrobial susceptibility patterns and pulsed-field gel electrophoresis profile, demonstrating clonal relatedness. ----- Conclusion: When an environmental pathogen causes an outbreak, contamination of intravenous products must be considered. Close communication between the local IPCT and the National Hospital Infection Control Advisory Committee is essential to conduct a prompt and thorough investigation and find the source of the outbreak