Aerosolized colistin for the treatment of nosocomial pneumonia

Aerosolized colistin for the treatment of nosocomial pneumonia tài liệu, giáo án, bài giảng , luận văn, luận án, đồ án,...

Int. J. Med. Sci. 2010, 7 http://www.medsci.org 120IInntteerrnnaattiioonnaall JJoouurrnnaall ooff MMeeddiiccaall SScciieenncceess 2010; 7(3):120-123 © Ivyspring International Publisher. All rights reserved Research Paper Endoscopic Facet Debridement for the treatment of facet arthritic pain – a novel new technique Scott M.W. Haufe 1,3  and Anthony R. Mork 2,3 1. Chief of Pain Medicine and Anesthesiology 2. Chief of Spine Surgery 3. MicroSpine, DeFuniak Springs, FL 32435, USA  Corresponding author: Scott M.W. Haufe, M.D., 101 MicroSpine Way, DeFuniak Springs, FL 32435. Phone: 888-642-7677; Fax: 850-892-4212; Email: Haufe@MicroSpine.com Received: 2010.03.29; Accepted: 2010.05.24; Published: 2010.05.25 Abstract Study design: Retrospective, observational, open label. Objective: We investigated the efficacy of facet debridement for the treatment of facet joint pain. Summary of background data: Facet joint disease, often due to degenerative arthritis, is common cause of chronic back pain. In patients that don’t respond to conservative measures, nerve ablation may provide significant improvement. Due to the ability of peripheral nerves to regenerate, ablative techniques of the dorsal nerve roots often provide only temporary relief. In theory, ablation of the nerve end plates in the facet joint capsule should prevent reinner-vation. Methods: All patients treated with endoscopic facet debridement at our clinic from 2003-2007 with at least 3 years follow-up were included in the analysis. Primary outcome measure was percent change in facet-related pain as measured by Visual Analog Scale (VAS) score at final follow-up visit. Results: A total of 174 people (77 women, 97 men; mean age 64, range 22-89) were included. Location of facet pain was cervical in 45, thoracic in 15, and lumbar in 114 patients. At final follow-up, 77%, 73%, and 68% of patients with cervical, thoracic, or lumbar disease, respec-tively, showed at least 50% improvement in pain. Mean operating time per joint was 17 mi-nutes (range, 10-42). Mean blood loss was 40 ml (range, 10-100). Complications included suture failure in two patients, requiring reclosure of the incision. No infection or nerve damage beyond what was intended occurred. Conclusions: Our results demonstrate a comparable efficacy of endoscopic facet debridement compared to radiofrequency ablation of the dorsal nerve branch, with durable results. Large scale, randomized trials are warranted to further evaluate the relative efficacy of this surgical treatment in patients with facet joint disease. Key words: vertebral arthritis, facet syndrome, back pain, minimally invasive, nerve ablation INTRODUCTION Facet joint disease, often due to degenerative arthritis, is common cause of chronic back pain. Among low back pain patients, facet joint disease is present in an estimated 7 to 75% 6. In epidemiological surveys, 40-45% of patients had evidence of facet joint pain based on anesthetic nerve blocks 9 10. Conservative therapy for facet joint pain consists of rest, physical therapy, and short-term use of non- Int. J. Med. Sci. 2010, 7 http://www.medsci.org 121steroidal anti-inflammatory drugs or oral steroids 18. Local steroid injections and trigger point injects may provide rapid relief that continues to improve over 5-7 days, but lacks evidence in the form of well de-signed clinical trials 6 18 14 16 4. With steroid injection, pain relief can last anywhere from 2 months to 2 Aerosolized colistin for the treatment of nosocomial pneumonia due to multidrug-resistant Gram-negative bacteria Khoa Hô Hấp BS: Lê Thị Kiến Trúc Contents Overview of nosocomial pneumonia Advantages and disadvantages of IV- Colistin Evidences of aerosolized colistin in MDR nosocomial Recommendations for the use of AS-Colistin Conclusions The major HAIs CDC 2015: • Catheter-associated urinary tract infections (CAUTI; 40%) • Ventilator-associated and healthcare-associated pneumonia (25%), • Catheter-associated bloodstream infections (CABSI; 10%), • And surgical site infections (SSI) Agents of nosocomial pneumonia • Ps aeruginosa • MRSA • Acinetobacter baumanii • Stenotrophomonas maltophila Agents of nosocomial pneumonia CDC 2015 Pseudomonas Acinetobacter Stenotrophomonas Pathogen P.aerug or Acinetobacter Other organisms Mortality 71% 41% Consequence ? • 0.5 – 2% of hospitalized patients • #1 cause of death due to nosocomial infections • Mortality 25 – 50% • Antimicrobial resistance increasing 10 Conclusion: Colistin is a reasonable safe lastline therapeutic alternative for pneumonia due to MDR G-ve pathogens Aerosolized colistin may be considered as a useful adjunctive to i.v colistin 2013 Production and hosting by Elsevier B.V on behalf of The Egyptian Society of Chest Diseases and Tuberculosis 22 23 24 25 26 Clinical cure rate IV Colistin AS-IV Colistin p 54.8% 69.2% 0.03 days 0.001 Days of MV after 12 days pneumonia onset, median Eradication of the causative organism 50% 63.4% 0.08 Septic shock at VAP onset 70.9% 27.9% 0.001 AKI during Colistin therapy 25% 22% 0.62  No different ICU mortality No different 27 28 29 30 31 Forest plot depicting clinical cure 32 Forest plot depicting nephrotoxicity 33 Forest plot depicting intensive care unit mortality 34 Recommendations for the use of AS-Colistin The dosage recommended is: • 40 mg (500,000 IU) every 12 h for patients with bodyweights of ≤40 kg • 80 mg (1 million IU) every 12 h for patients with bodyweights of >40 kg 35 Thank you for your attention ! Int. J. Med. Sci. 2009, 6 http://www.medsci.org 224IInntteerrnnaattiioonnaall JJoouurrnnaall ooff MMeeddiiccaall SScciieenncceess 2009; 6(4):224-226 © Ivyspring International Publisher. All rights reserved Research Paper Endoscopic thoracic laminoforaminoplasty for the treatment of thoracic radiculopathy: report of 12 cases Scott M.W. Haufe 1,2 , Ryan A. Baker 3 and Morgan L. Pyne 3 1. Chief of Pain Medicine and Anesthesiology 2. MicroSpine and Healthmark Regional Medical Center, Florida, USA 3. University of South Florida, Florida, USA  Correspondence to: Scott M.W. Haufe, M.D., 101 MicroSpine Way, DeFuniak Springs, FL 32435. Phone: 888-642-7677; Fax: 850-892-4212; Email: Haufe@MicroSpine.com Received: 2009.06.03; Accepted: 2009.08.10; Published: 2009.08.12 Abstract Background: Spinal stenosis of the thoracic spine is less common than that of the cervical and lumbar regions. Due to the close proximity to thoracic and abdominal organs, surgical operations can be difficult and carry a greater risk of complications. The most efficacious intervention for thoracic stenosis, whether central or foraminal, refractory to conservative management is uncertain. We aimed to evaluate the efficacy of endoscopic laminoforamino-plasty (ELFP) in the treatment of thoracic radiculopathy. Methods: Twelve patients with radicular pain involving the lower thoracic levels (at or be-low T6) were treated with ELFP. Results: Seven of twelve patients showed marked improvement in pain scores. Average follow-up scores were 2.9 and 12.08 on the Visual Analog Scale (VAS) and Oswestry Dis-ability Index, respectively. The significance was 0.005 between the pre and post surgical data. One patient with moderate symptoms, two with severe symptoms, and two with crippling symptoms did not report significant improvement on VAS or Oswestry. No complications were encountered. Conclusions: Endoscopic laminoforaminoplasty offers an alternative to fusion or conven-tional laminotomy with similar success rates. Patients additionally benefit from a decrease risk of complications, short hospital stay, and faster recovery. Key words: thoracic, radiculopathy, laminoforaminoplasty, minimally invasive, endoscopic, spi-nal stenosis Introduction Radicular back pain is an important public health issue that can result in long term disability and poor quality of life. Conservative therapy is the initial treatment of choice, but fails to provide relief in a substantial number of patients. Central and foraminal stenosis with entrapment of descending and/or exit-ing nerve roots is a common cause of radicular pain, with an estimated incidence of 8 to 11% [1] [2] [3]. Spinal stenosis of the thoracic vertebrae is less common than that of the cervical and lumbar regions. In our experience, patients tend to be older and are more commonly male. Due to the close proximity to thoracic and abdominal organs, open surgical opera-tions can be difficult and carry a greater risk of com-plications due to the requirement of a transthoracic approach. The most efficacious intervention for tho-racic stenosis refractory to conservative management is uncertain at this time. Here we report on our experience with 12 pa-tients diagnosed with thoracic radiculopathy due to Int. J. Med. Sci. 2009, 6 http://www.medsci.org 225central or foraminal stenosis treated with endoscopic laminoforaminoplasty via a small incision, of less than one inch. Materials and Methods Twelve patients were treated with endoscopic laminoforaminoplasty Open Access Available online http://ccforum.com/content/9/1/R53 R53 February 2005 Vol 9 No 1 Research Aerosolized colistin for the treatment of nosocomial pneumonia due to multidrug-resistant Gram-negative bacteria in patients without cystic fibrosis Argyris Michalopoulos 1 , Sofia K Kasiakou 2 , Zefi Mastora 3 , Kostas Rellos 4 , Anastasios M Kapaskelis 5 and Matthew E Falagas 6 1 Director, Intensive Care Unit, 'Henry Dunant' Hospital, Athens, Greece 2 Research Fellow, Alfa HealthCare, Athens, Greece 3 Attending Physician, Intensive Care Unit, 'Henry Dunant' Hospital, Athens, Greece 4 Associate Director, Intensive Care Unit, 'Henry Dunant' Hospital, Athens, Greece 5 Attending Physician, Alfa HealthCare and Department of Medicine, 'Henry Dunant' Hospital, Athens, Greece 6 Adjunct Assistant Professor of Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA and Director, Infectious Diseases Clinic, Department of Medicine 'Henry Dunant Hospital', Athens, Greece Corresponding author: Matthew E Falagas, matthew.falagas@tufts.edu Abstract Introduction The clinical and economic consequences of the emergence of multidrug-resistant Gram- negative bacteria in the intensive care unit (ICU) setting, combined with the high mortality rate among patients with nosocomial pneumonia, have stimulated a search for alternative therapeutic options to treat such infections. The use of adjunctive therapy with aerosolized colistin represents one of these. There is extensive experience with use of aerosolized colistin by patients with cystic fibrosis, but there is a lack of data regarding the use of aerosolized colistin in patients without cystic fibrosis. Methods We conducted the present study to assess the safety and effectiveness of aerosolized colistin as an adjunct to intravenous antimicrobial therapy for treatment of Gram-negative nosocomial pneumonia. We retrospectively reviewed the medical records of patients hospitalized in a 450-bed tertiary care hospital during the period from October 2000 to January 2004, and who received aerosolized colistin as adjunctive therapy for multidrug-resistant pneumonia. Results Eight patients received aerosolized colistin. All patients had been admitted to the ICU, with mean Acute Physiological and Chronic Health Evaluation II scores on the day of ICU admission and on day 1 of aerosolized colistin administration of 14.6 and 17.1, respectively. Six of the eight patients had ventilator-associated pneumonia. The responsible pathogens were Acinetobacter baumannii (in seven out of eight cases) and Pseudomonas aeruginosa (in one out of eight cases) strains. Half of the isolated pathogens were sensitive only to colistin. The daily dose of aerosolized colistin ranged from 1.5 to 6 million IU (divided into three or four doses), and the mean duration of administration was 10.5 days. Seven out of eight patients received concomitant intravenous treatment with colistin or other antimicrobial agents. The pneumonia was observed to respond to treatment in seven out of eight patients (four were cured and three improved [they were transferred to another facility]). One patient deteriorated and died from septic shock and multiple organ failure. Aerosolized colistin was well tolerated by all patients; no bronchoconstriction or chest tightness was reported. Conclusion Aerosolized colistin may be a beneficial adjunctive treatment in the management of nosocomial pneumonia (ventilator associated or not) due to multidrug-resistant Gram-negative bacteria. Keywords: apnea, bronchoconstriction, colistin, inhaled, nosocomial pneumonia Received: 6 August 2004 Revisions requested: 17 September 2004 Revisions received: 24 September 2004 Accepted: 18 November 2004 Published: 6 January 2005 Critical Care 2005, 9:R53-R59 (DOI 10.1186/cc3020) This article is online at: http://ccforum.com/content/9/1/R53 © 2004 Michalopoulos et al., licensee BioMed Central Ltd. This is an 29 Available online http://ccforum.com/content/9/1/29 Gram-negative rod pneumonia, particularly if nosocomial, carries a high morbidity and mortality rate that has been accentuated in the era of antibiotic resistance [1–3]. New therapies are desperately needed, particularly against organisms that carry carbapenemases, cephalosporinases and aminoglycoside-modifying enzymes, and that are resistant to fluoroquinolone. Among these organisms, Acinetobacter baumanii and Pseudomonas aeruginosa are particularly common, but Burkholderia cepacia and other non-fermenters also count. Considering the patterns of drug non-susceptibility among organisms such as Acinetobacter spp., the necessity to explore other therapeutic avenues has led investigators to consider older agents, including the tetracyclines and polymixins. The polymixins are a class of cationic polypeptide antimicrobials derived from Bacillus polymyxa. Concerns about toxicity and limited efficacy, in the context of safer available effective alternatives such as the expanded- spectrum β-lactams, led to the abandonment of colistin in clinical practice. As a consequence there is only a paucity of physicians with clinical experience in the use of this class of antimicrobials. The spectrum of activity of the polymixins is limited to some, but not all, Gram-negative organisms. Use of the intravenous formulation for inhalation results in incomplete nebulization, so a micronized powder formulation has been developed [4]. In addition to bactericidal activity at higher concentrations, polymixins have anti-endotoxin activity through inhibiting the elaboration of cytokines by lipopolysaccharide-induced macrophages; in addition, this class of agents binds chemically to lipopolysaccharide – the major constituent of endotoxin – and neutralizes its activity [5]. Toxicities associated with the intravenous administration of colistin include mainly nephrotoxicity and neurotoxicity, specifically neuromuscular blockade. The latter is particularly noted in the context of renal dysfunction, with concomitant anaesthesia posing a particular risk. In patients receiving nebulized colistin sulphate, chest tightness, throat irritation Commentary Aerosolized colistin for the treatment of nosocomial pneumonia due to multidrug-resistant Gram-negative bacteria in patients without cystic fibrosis Samira Mubareka and Ethan Rubinstein Section of Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada Corresponding author: Ethan Rubinstein, erubins@yahoo.com Published online: 11 January 2005 Critical Care 2005, 9:29-30 (DOI 10.1186/cc3036) This article is online at http://ccforum.com/content/9/1/29 © 2005 BioMed Central Ltd See Research by Michalopoulos et al., page 119 Abstract The management challenges of patients with nosocomial pneumonia are great because of resistance among the responsible pathogens. In this issue of Critical Care, Argyris Michalopoulos and colleagues describe the use of inhaled colistin in the treatment of multidrug-resistant Gram-negative nosocomial pneumonia in a small group of patients. Although seven of eight patients who received nebulized colistin showed clinical improvement, some patients also received other active antibiotics. Microbiological eradication was demonstrated in only four of the eight patients. Serum levels of colistin were not measured. In addition, although adverse events were not documented in patients receiving colistin, formal assessments for bronchoconstriction and neurological toxicity were not completed in this retrospective study. Although resistance to colistin in Gram-negative organisms has not evolved, the risk of breakthrough infection with Gram-positive and inherently resistant Gram- negative bacteria remains a concern. The Open Access Available online http://ccforum.com/content/12/2/R44 Page 1 of 9 (page number not for citation purposes) Vol 12 No 2 Research Risk factors for the development of nosocomial pneumonia and mortality on intensive care units: application of competing risks models Martin Wolkewitz 1 , Ralf Peter Vonberg 2 , Hajo Grundmann 3 , Jan Beyersmann 1 , Petra Gastmeier 2 , Sina Bärwolff 4 , Christine Geffers 4 , Michael Behnke 4 , Henning Rüden 4 and Martin Schumacher 1 1 Institute of Medical Biometry and Medical Informatics, University Medical Center Freiburg, Freiburg, Germany 2 Institute for Medical Microbiology and Hospital Epidemiology, Medical School Hannover, Hannover, Germany 3 European Antimicrobial Resistance Surveillance System, National Institute for Public Health and the Environment, Bilthoven, The Netherlands 4 Institute of Hygiene and Environmental Medicine, Charité – University Medicine, Berlin, Germany Corresponding author: Martin Wolkewitz, wolke@fdm.uni-freiburg.de Received: 9 Nov 2007 Revisions requested: 19 Dec 2007 Revisions received: 7 Feb 2008 Accepted: 2 Apr 2008 Published: 2 Apr 2008 Critical Care 2008, 12:R44 (doi:10.1186/cc6852) This article is online at: http://ccforum.com/content/12/2/R44 © 2008 Wolkewitz et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Introduction Pneumonia is a very common nosocomial infection in intensive care units (ICUs). Many studies have investigated risk factors for the development of infection and its consequences. However, the evaluation in most of theses studies disregards the fact that there are additional competing events, such as discharge or death. Methods A prospective cohort study was conducted over 18 months in five intensive care units at one university hospital. All patients that were admitted for at least 2 days were included, and surveillance of nosocomial pneumonia was conducted. Various potential risk factors (baseline- and time-dependent) were evaluated in two competing risks models: the acquisition of nosocomial pneumonia and discharge (dead or alive; model 1) and for the risk of death in the ICU and discharge alive (model 2). Results Patients from 1,876 admissions were included. A total of 158 patients developed nosocomial pneumonia. The main risk factors for nosocomial pneumonia in the multivariate analysis in model 1 were: elective surgery (cause-specific hazard ratio = 1.95; 95% CI 1.33 to 2.85) or emergency surgery (1.59; 95% CI 1.10 to 2.28) prior to ICU admission, usage of a nasogastric tube (3.04; 95% CI 1.25 to 7.37) and mechanical ventilation (5.90; 95% CI 2.47 to 14.09). Nosocomial pneumonia prolonged the length of ICU stay but was not directly associated with a fatal outcome (p = 0.55). Conclusion More studies using competing risk models, which provide more accurate data compared to naive survival curves or logistic models, should be carried out to verify the impact of risk factors and patient characteristics for the acquisition of nosocomial infections and infection-associated mortality. Introduction Nosocomial pneumonia (NP) is the most commonly reported infection in intensive care units (ICUs), especially in mechani- cally ventilated patients with an incidence of about 15 infec- tions per 1,000 ventilation days [1]. ... Overview of nosocomial pneumonia Advantages and disadvantages of IV- Colistin Evidences of aerosolized colistin in MDR nosocomial Recommendations for the use of AS -Colistin Conclusions The major... Evidence of aerosolized colistin in MDR nosocomial 19 20 21 Conclusion: Colistin is a reasonable safe lastline therapeutic alternative for pneumonia due to MDR G-ve pathogens Aerosolized colistin. .. pneumonia 16 Advantages of IV Colistin 17 Disadvantages of IV Colistin • After parenteral administration, colistin achieves low protein binding, approximately 50% • About two thirds of CMS is eliminated