COLISTIN-CARBAPENEM COMBINATION THERAPY AGAINST CARBAPENEM RESISTANT GRAM NEGATIVE BACILLI INFECTIONS: CLINICAL AND AN IN VITRO SYNERGY STUDY

Objective: Combination therapy is recommended for carbapenem resistant Gram negative bacilli (CR GNB) infections. However, limited data exists on the clinical effectiveness of antibiotic combinations. The purpose of this study was to evaluate the efficacy of colistin-carbapenem combination against CR GNB infection in a clinical study and an in vitro synergy study using Etest. Methods: A study was conducted in a tertiary care hospital to evaluate the clinical outcome of patients with CR GNB infections who were treated with colistin-carbapenemcombination between January to April, 2013. It was comprised of 33 patients with CR GNB infection. Detection of in vitro synergy was performed by Etest for colistin-meropenem combination on five isolates. These isolates were also screened for the resistant genes blaOXA-23, blaVIMand blaNDM using single target PCR. Results: 33 CR GNB included Acinetobacterspp. (19), Pseudomonas aeruginosa (7) and Enterobacteriaceae spp. (7). Overall clinical success of 60.6% was observed in patients receiving colistin-carbapenem combination therapy. In respiratory infection, the clinical success rate was only 25%, whereas in soft tissue infection it was 57.1%. In bloodstream infection 100%  clinical success was observed. All five isolates screened using PCR was carrying bla NDM gene, whereas isolate of Acinetobacter baumannii also carried blaOXA-23 and blaVIM gene. Indifferent interactions were observed between colistin and meropenem against all five isolates. Conclusion: We observed low clinical success rate for colistin-carbapenem combination therapy, probably due to indifferent interactions between colistin and meropenem against NDM producing strain. In addition, probable pharmacokinetic concern of colistin may have a role to play

CHARACTERIZATION OF CARBAPENEM RESISTANT ACINETOBACTER BAUMANNII ISOLATED IN A TERTIARY CARE HOSPITAL: EPIDEMIOLOGY AND TREATMENT OUTCOME

Objective: Carbapenem resistant Acinetobacter baumannii (CR-Ab) has emerged as a major nosocomial pathogen, but optimal treatment regimens are unknown. Our objectives were to determine the epidemiology and outcome of CR-Ab infections at a tertiary care hospital.Methods: CR-Ab isolates were collected from January to April 2013. MICs were determined and isolates were subjected to screening for carbapenemase production by Modified Hodge test (MHT), metallo-β-lactamase (MBLs) by EDTA disk synergy test and AmpC β-lactamase by AmpC disk test. 15 isolates were subjected to PCR for detection of resistant genes, blaOXA-23, blaVIM and blaNDM. Treatment outcomes of infections were evaluated.Results: 51 CR-Ab isolates from tracheal aspirate (21), blood (15); tissue/wound/drainage (13) and urine samples (2) were collected. Colistin appeared to be the most effective agent with 98% in vitro activity. MHT showed 98% positivity, MBLs production was detected in 94.1% isolates and 64.7% were positive for AmpC β-lactamase production. All 15 isolates carried blaOXA-23 and blaVIM, of these 3 also carried blaNDM gene. Colistin containing combinations were more commonly used (68.3%). Colistin-noncarbapenem combination showed improved clinical response compared to colistin-carbapenem combination against Acinetobacter isolates carrying blaOXA-23 and blaVIM.Conclusion: A stringent infection control practice along with antimicrobial stewardship is needed to prevent emergence of Acinetobacter carrying multiple carbapenemase genes along with blaNDM. Various colistin combinations are preferentially used to treat CR-Ab infections. Identification of antimicrobial combinations with proven in vitro activity that encompass local susceptibility patterns as well as molecular mechanisms of resistance is needed to provide better outcome.Keywords: Acinetobacter baumannii, Carbapenem resistance, Carbapenemases, Colistin combination, metallo-β-lactamase, NDMÂ

Stigmatizing attitudes and low levels of knowledge but high willingness to participate in HIV management: A community-based survey of pharmacies in Pune, India

<p>Abstract</p> <p>Background</p> <p>The World Health Organization (WHO) recommends that the role of pharmacists in low-income settings be expanded to address the increasing complexity of HIV antiretroviral (ARV) and co-infection drug regimens. However, in many such settings including in India, many pharmacists and pharmacy workers are often neither well trained nor aware of the intricacies of HIV treatment. The aims of our study were; to determine the availability of ARVs, provision of ARVs, knowledge about ARVs, attitudes towards HIV-infected persons and self-perceived need for training among community-based pharmacies in an urban area of India.</p> <p>Methods</p> <p>We performed a survey of randomly selected, community-based pharmacies located in Pune, India, in 2004-2005 to determine the availability of ARVs at these pharmacies, how they were providing ARVs and their self-perceived need for training. We also assessed knowledge, attitudes and perceptions on HIV and ARVs and factors associated with stocking ARVs.</p> <p>Results</p> <p>Of 207 pharmacies included in the survey, 200 (96.6%) were single, private establishments. Seventy-three (35.3%) pharmacies stocked ARVs and 38 (18.4%) ordered ARVs upon request. The reported median number of ARV pills that patients bought at one time was 30, a two week supply of ARVs (range: 3-240 pills). Six (2.9%) pharmacy respondents reported selling non-allopathic medicines (i.e. Ayurvedic, homeopathy) for HIV. Ninety (44.2%) pharmacy respondents knew that ARVs cannot cure HIV, with those stocking ARVs being more likely to respond correctly (60.3% vs. 34.8%, p = 0.001). Respondents of pharmacies which stocked ARVs were also more likely to believe it was a professional obligation to provide medications to HIV-infected persons (91.8% vs. 78.8%, p = 0.007) but they were also more likely to believe that HIV-infected persons are unable to adhere to their medicines (79.5% vs. 40.9%, p < 0.01). Knowledge of the most common side effects of nevirapine, abnormal liver enzyme profile and skin rash, was reported correctly by 8 (3.9%) and 23 (11.1%) respondents, respectively. Seven (3.4%) respondents reported that they had received special training on HIV, 3 (1.5%) reported receipt of special training on ART and 167 (80.7%) reported that they believed that pharmacy staff should get special training on ART.</p> <p>Conclusion</p> <p>There is a high willingness to participate in HIV management among community-based pharmacies but there is a tremendous need for training on HIV therapies. Furthermore, stigmatizing attitudes towards HIV-infected persons persist and interventions to reduce stigma are needed, particularly among those that stock ARVs.</p