- Email: [email protected]
Antimicrobial resistance of Pseudomonas aeruginosa in pediatric infections
84 of SIADH by lopinavir was probably responsible for the severe hyponatraemia in our patient. Conflict of interest: No conflict of interest to declare.
References 1. Jugulete G, Mardarescu M, Petrea S, Dragan MI, Luminos ML. Kaletra (lopinavir/ritonavir) on treatment of HIV infected children. Abstract no. TuPeB4441. 15th International AIDS Conference. July 11—16, 2004. Bangkok, Thailand. 2. Martinez E, Domingo P, Galindo MJ, Milinkovic A, Arroyo JA, Baldovi F, et al. Risk of metabolic abnormalities in patients infected with HIV receiving antiretroviral therapy that contains lopinavir—ritonavir. Clin Infect Dis 2004;38:1017—23. 3. Capparelli EV, Letendre SL, Ellis RJ, Patel P, Holland D, McCutchan JA. Population pharmacokinetics of abacavir in plasma and cerebrospinal fluid. Antimicrob Agents Chemother 2005;49: 2504—6. 4. Lanier ER, Sturge G, McClernon D, Brown S, Halman M, Sacktor N, et al. HIV-1 reverse transcriptase sequence in plasma and cerebrospinal fluid of patients with AIDS dementia complex treated with abacavir. AIDS 2001;15:747—51. 5. Bonfanti P, Martinelli C, Ricci E, Carradori S, Parruti G, Armignacco O, et al. CISAI Group (Italian Coordinators for the Study of Allergies HIV Infection). An Italian approach to postmarketing monitoring: preliminary results from the SCOLTA (Surveillance Cohort Long-
Antimicrobial resistance of Pseudomonas aeruginosa in pediatric infections Problems encountered in the management of pediatric infections include treatment failure, which often occurs as a result of antimicrobial-resistant bacterial strains; especially among Pseudomonas aeruginosa.1,2 For this reason antimicrobial drug activity surveillance is necessary, especially for opportunistic and nosocomial P. aeruginosa.2 In Latin America, resistant bacteria are emerging as a real threat in the community as well as in hospital-acquired infections, including pediatric infections.2 We reviewed susceptibility data of isolates cultured from hospitalized pediatric patients with suspected community-acquired infections in the West General Hospital (WGH) Caracas, Venezuela between 1997 and 2003. The WGH is a 300-bed general community hospital serving people from west Caracas. Samples were taken before antimicrobial drug therapy was commenced. Samples were processed and organisms identified by traditional methods. In vitro antimicrobial susceptibility of the isolates was assessed by an agar disk diffusion method using Mueller—Hinton agar as recommended by the Clinical and Laboratory Standards Institute (formerly NCCLS). Antipseudomonal third generation cephalosporins and carbapenems are freely prescribed in hospitalized patients but previous antimicrobial drug exposure in this patient series was not measured; there were no chronic conditions reported. During this seven-year period, P. aeruginosa accounted for 137 (4%) of 3425 bacterial isolates from children: 49% from otorrhinolaryngological (ORL) infections, 18% urinary tract infections, 7% skin, and 7% gastrointestinal tract, among others. Overall susceptibility rates are shown in Figure 1. Better antimicrobial activity was observed with
Letters to the Editor Term Toxicity Antiretrovirals) project on the safety of lopinavir/ ritonavir. J Acquir Immune Defic Syndr 2005;39:317—20. 6. Vogel M, Rockstroh JK. Safety of lopinavir/ritonavir for the treatment of HIV-infection. Expert Opin Drug Saf 2005;4:403—20. 7. Akalin E, Chandrakantan A, Keane J, Hamburger RJ. Normouricemia in the syndrome of inappropriate antidiuretic hormone secretion. Am J Kidney Dis 2001;37:E8. 8. Bevilacqua M. Hyponatraemia in AIDS. Baillieres Clin Endocrinol Metab 1994;8:837—48.
M.T.M. Roberts* S.H. Aliyu Department of Infectious Diseases, Box 25, Addenbrooke’s Hospital, Cambridge, CB2 2QQ, UK *Corresponding author. Tel.: +44 1223 245151; fax: +44 1223 586874 E-mail address: [email protected] (M.T.M. Roberts) Corresponding Editor: Salim S. Abdool Karim, Durban, South Africa 26 September 2005 doi:10.1016/j.ijid.2005.11.002
ciprofloxacin, meropenem, and imipenem (<5% resistant) than for gentamycin, piperacillin and piperacillin/tazobactam (>10% resistant). For urinary isolates, we found strains resistant to norfloxacin (13%) and gentamycin (8%), but only intermediate resistance to aztreonam, ceftazidime, and ciprofloxacin (8% for each). Susceptibility to imipenem, piperacillin/tazobactam, and tobramycin was 100%. In ORL infections, we found significant resistance to carbenicillin (18%) and some resistance to meropenem (5%) and imipenem (3%) but 100% susceptibility to ciprofloxacin, ofloxacin, and piperacillin/tazobactam.
Figure 1 Overall antimicrobial drug susceptibility (%) of Pseudomonas aeruginosa isolated from pediatric infections against tested antibiotics (WGH, Venezuela, 1997—2003).
85
Letters to the Editor Although multidrug resistance has commonly been reported in nosocomial P. aeruginosa, community-acquired data are less frequently reported. For this reason, epidemiological studies on the prevalence and antimicrobial susceptibility patterns of resistant isolates in different geographical settings, would provide useful information for both empirical treatment of suspected infections and better management of patients. Our results show that in our setting imipenem is still very active against strains of P. aeruginosa in pediatric infections, although other studies have reported higher resistance rates.3,4 Recent studies have reduced safety concerns over the use of quinolones in pediatric patients. Combined with the good antimicrobial activity shown in this and other studies,5 this makes them a good empirical choice for community-acquired infections. Local surveillance of antimicrobial activity should be done periodically to guide antimicrobial therapy, especially as carbapenem-resistant P. aeruginosa has been reported as an emerging problem in Latin America.6
Acknowledgments This work was presented in part at the 24th International Congress of Chemotherapy, Manila, Philippines, June 4—6, 2005. Abstract No. PP1-035. A.J. Rodrı´guez-Morales was the recipient of an Inter-American Society for Chemotherapy Travel Award (IASC) to attend this meeting. Conflict of interest: No conflicting interest declared.
References 1. Chang MR, Carvalho NC, Oliveira AL, Moncada PM, Moraes BA, Asensi MD. Surveillance of pediatric infections in a teaching hospital in Mato Grosso do Sul, Brazil. Braz J Infect Dis 2003; 7:149—60. 2. Guzman-Blanco M, Casellas JM, Sader HS. Bacterial resistance to antimicrobial agents in Latin America. The giant is awakening. Infect Dis Clin North Am 2000;14:67—81. 3. Rodrı´guez AJ, Samaniego DR, Soskin A, Rodrı´guez CN, Canese J, Ortellado de Canese J, et al. Comparative study of antimicrobial
Unrecognized near-fatal hyperlactatemia in an HIV-infected infant exposed to nucleoside reverse transcriptase inhibitors Nucleoside analogue reverse transcriptase inhibitors (NRTIs) inhibit mitochondrial DNA (mtDNA) polymerase gamma thereby interfering with mtDNA replication.1—3 The relative potency of the NRTIs in causing mitochondrial dysfunction is highest for zalcitabine, followed by didanosine, stavudine, and zidovudine. Lamivudine, abacavir, and tenofovir have lower affinity for mtDNA polymerase.4 In utero and perinatal exposure to NRTIs are known to cause hyperlactatemia (HLA) from mitochondrial toxicity.5,6 An HIV-infected mother detected at 30 weeks of pregnancy was treated with lamivudine, stavudine, and nevirapine. A live male baby weighing 2135 g was delivered by elective cesarean section at 38 weeks of gestation with intrapartum intravenous zidovudine cover as per PACTG
resistance of Pseudomonas aeruginosa strains isolated from patients of Caracas and Asuncio ´n in a 4-year-period. Chemotherapy 2002;48:164—7. 4. Rodrı´guez CN, Rodrı´guez AJ, Nin ˜o RA, Meijomil P, Molina N, Garcı´a A, et al. Comparative study of antimicrobial resistance of Pseudomonas aeruginosa strains isolated from urinary tract infection in patients from Caracas and Lima. Int J Antimicrob Agents 2002;20:476—7. 5. Rodriguez AJ, Rodriguez CN, Meijomil P, Garcia A, Duque C, Molina N, et al. In vitro activity of quinolones against isolates from paediatric urinary tract infections from three Venezuelan centres. Int J Antimicrob Agents 2001;17:531—2. 6. Gales AC, Sader HS, Jones RN, SENTRY Participants Group (Latin America). Urinary tract infection trends in Latin American hospitals: report from the SENTRY antimicrobial surveillance program (1997—2000). Diagn Microbiol Infect Dis 2002;44:289—99.
Alfonso J. Rodrı´guez-Morales ´ Witremundo Torrealba, Instituto Experimental Jose Universidad de Los Andes, Trujillo, Venezuela Cruz N. Rodrı´guez* Ada Garcia Bileida Pastran Ivette Jime ´nez Pilar Meijomil Laboratory of Microbiology, ´ Gregorio Hernandez West General Hospital (WGH), Jose Caracas, DC, Venezuela *Corresponding author. Tel.: +58 212 963 4053 fax: +58 212 442 9790 E-mail address: [email protected] (C.N. Rodriguez) Corresponding Editor: Timothy Barkham, Singapore 5 July 2005 doi:10.1016/j.ijid.2005.10.010
076 protocol.7 He was discharged well with oral zidovudine on the third day. At three weeks old he developed fever, abdominal distension, diarrhea, and vomiting, which required treatment with intravenous fluids and antibiotics, and was discharged well after 12 days. At five weeks old he returned with diarrhea, poor feeding, dehydration, and acidotic breathing. Arterial blood pH was 7.13, pO2 128 mmHg, pCO2 18.7 mmHg, base excess 21.9 mmol/L, and anion gap 24 mmol/L. Serum lactate and ammonia levels were 4.07 mmol/L and 203.6 mmol/L, respectively. Serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), and gamma glutamyltransferase (GGT) levels were 89, 189, and 166 IU/L, respectively. Serum albumin was 28 g/L with prolonged activated partial thromboplastin time (APTT) and increased prothrombin time (PT) ratio. Repeated hemoculture and stool cultures did not yield any pathogen. His urine was screened for inborn errors of metabolism but proved normal. On the second hospital day he developed jerking movements
References 1. Jugulete G, Mardarescu M, Petrea S, Dragan MI, Luminos ML. Kaletra (lopinavir/ritonavir) on treatment of HIV infected children. Abstract no. TuPeB4441. 15th International AIDS Conference. July 11—16, 2004. Bangkok, Thailand. 2. Martinez E, Domingo P, Galindo MJ, Milinkovic A, Arroyo JA, Baldovi F, et al. Risk of metabolic abnormalities in patients infected with HIV receiving antiretroviral therapy that contains lopinavir—ritonavir. Clin Infect Dis 2004;38:1017—23. 3. Capparelli EV, Letendre SL, Ellis RJ, Patel P, Holland D, McCutchan JA. Population pharmacokinetics of abacavir in plasma and cerebrospinal fluid. Antimicrob Agents Chemother 2005;49: 2504—6. 4. Lanier ER, Sturge G, McClernon D, Brown S, Halman M, Sacktor N, et al. HIV-1 reverse transcriptase sequence in plasma and cerebrospinal fluid of patients with AIDS dementia complex treated with abacavir. AIDS 2001;15:747—51. 5. Bonfanti P, Martinelli C, Ricci E, Carradori S, Parruti G, Armignacco O, et al. CISAI Group (Italian Coordinators for the Study of Allergies HIV Infection). An Italian approach to postmarketing monitoring: preliminary results from the SCOLTA (Surveillance Cohort Long-
Antimicrobial resistance of Pseudomonas aeruginosa in pediatric infections Problems encountered in the management of pediatric infections include treatment failure, which often occurs as a result of antimicrobial-resistant bacterial strains; especially among Pseudomonas aeruginosa.1,2 For this reason antimicrobial drug activity surveillance is necessary, especially for opportunistic and nosocomial P. aeruginosa.2 In Latin America, resistant bacteria are emerging as a real threat in the community as well as in hospital-acquired infections, including pediatric infections.2 We reviewed susceptibility data of isolates cultured from hospitalized pediatric patients with suspected community-acquired infections in the West General Hospital (WGH) Caracas, Venezuela between 1997 and 2003. The WGH is a 300-bed general community hospital serving people from west Caracas. Samples were taken before antimicrobial drug therapy was commenced. Samples were processed and organisms identified by traditional methods. In vitro antimicrobial susceptibility of the isolates was assessed by an agar disk diffusion method using Mueller—Hinton agar as recommended by the Clinical and Laboratory Standards Institute (formerly NCCLS). Antipseudomonal third generation cephalosporins and carbapenems are freely prescribed in hospitalized patients but previous antimicrobial drug exposure in this patient series was not measured; there were no chronic conditions reported. During this seven-year period, P. aeruginosa accounted for 137 (4%) of 3425 bacterial isolates from children: 49% from otorrhinolaryngological (ORL) infections, 18% urinary tract infections, 7% skin, and 7% gastrointestinal tract, among others. Overall susceptibility rates are shown in Figure 1. Better antimicrobial activity was observed with
Letters to the Editor Term Toxicity Antiretrovirals) project on the safety of lopinavir/ ritonavir. J Acquir Immune Defic Syndr 2005;39:317—20. 6. Vogel M, Rockstroh JK. Safety of lopinavir/ritonavir for the treatment of HIV-infection. Expert Opin Drug Saf 2005;4:403—20. 7. Akalin E, Chandrakantan A, Keane J, Hamburger RJ. Normouricemia in the syndrome of inappropriate antidiuretic hormone secretion. Am J Kidney Dis 2001;37:E8. 8. Bevilacqua M. Hyponatraemia in AIDS. Baillieres Clin Endocrinol Metab 1994;8:837—48.
M.T.M. Roberts* S.H. Aliyu Department of Infectious Diseases, Box 25, Addenbrooke’s Hospital, Cambridge, CB2 2QQ, UK *Corresponding author. Tel.: +44 1223 245151; fax: +44 1223 586874 E-mail address: [email protected] (M.T.M. Roberts) Corresponding Editor: Salim S. Abdool Karim, Durban, South Africa 26 September 2005 doi:10.1016/j.ijid.2005.11.002
ciprofloxacin, meropenem, and imipenem (<5% resistant) than for gentamycin, piperacillin and piperacillin/tazobactam (>10% resistant). For urinary isolates, we found strains resistant to norfloxacin (13%) and gentamycin (8%), but only intermediate resistance to aztreonam, ceftazidime, and ciprofloxacin (8% for each). Susceptibility to imipenem, piperacillin/tazobactam, and tobramycin was 100%. In ORL infections, we found significant resistance to carbenicillin (18%) and some resistance to meropenem (5%) and imipenem (3%) but 100% susceptibility to ciprofloxacin, ofloxacin, and piperacillin/tazobactam.
Figure 1 Overall antimicrobial drug susceptibility (%) of Pseudomonas aeruginosa isolated from pediatric infections against tested antibiotics (WGH, Venezuela, 1997—2003).
85
Letters to the Editor Although multidrug resistance has commonly been reported in nosocomial P. aeruginosa, community-acquired data are less frequently reported. For this reason, epidemiological studies on the prevalence and antimicrobial susceptibility patterns of resistant isolates in different geographical settings, would provide useful information for both empirical treatment of suspected infections and better management of patients. Our results show that in our setting imipenem is still very active against strains of P. aeruginosa in pediatric infections, although other studies have reported higher resistance rates.3,4 Recent studies have reduced safety concerns over the use of quinolones in pediatric patients. Combined with the good antimicrobial activity shown in this and other studies,5 this makes them a good empirical choice for community-acquired infections. Local surveillance of antimicrobial activity should be done periodically to guide antimicrobial therapy, especially as carbapenem-resistant P. aeruginosa has been reported as an emerging problem in Latin America.6
Acknowledgments This work was presented in part at the 24th International Congress of Chemotherapy, Manila, Philippines, June 4—6, 2005. Abstract No. PP1-035. A.J. Rodrı´guez-Morales was the recipient of an Inter-American Society for Chemotherapy Travel Award (IASC) to attend this meeting. Conflict of interest: No conflicting interest declared.
References 1. Chang MR, Carvalho NC, Oliveira AL, Moncada PM, Moraes BA, Asensi MD. Surveillance of pediatric infections in a teaching hospital in Mato Grosso do Sul, Brazil. Braz J Infect Dis 2003; 7:149—60. 2. Guzman-Blanco M, Casellas JM, Sader HS. Bacterial resistance to antimicrobial agents in Latin America. The giant is awakening. Infect Dis Clin North Am 2000;14:67—81. 3. Rodrı´guez AJ, Samaniego DR, Soskin A, Rodrı´guez CN, Canese J, Ortellado de Canese J, et al. Comparative study of antimicrobial
Unrecognized near-fatal hyperlactatemia in an HIV-infected infant exposed to nucleoside reverse transcriptase inhibitors Nucleoside analogue reverse transcriptase inhibitors (NRTIs) inhibit mitochondrial DNA (mtDNA) polymerase gamma thereby interfering with mtDNA replication.1—3 The relative potency of the NRTIs in causing mitochondrial dysfunction is highest for zalcitabine, followed by didanosine, stavudine, and zidovudine. Lamivudine, abacavir, and tenofovir have lower affinity for mtDNA polymerase.4 In utero and perinatal exposure to NRTIs are known to cause hyperlactatemia (HLA) from mitochondrial toxicity.5,6 An HIV-infected mother detected at 30 weeks of pregnancy was treated with lamivudine, stavudine, and nevirapine. A live male baby weighing 2135 g was delivered by elective cesarean section at 38 weeks of gestation with intrapartum intravenous zidovudine cover as per PACTG
resistance of Pseudomonas aeruginosa strains isolated from patients of Caracas and Asuncio ´n in a 4-year-period. Chemotherapy 2002;48:164—7. 4. Rodrı´guez CN, Rodrı´guez AJ, Nin ˜o RA, Meijomil P, Molina N, Garcı´a A, et al. Comparative study of antimicrobial resistance of Pseudomonas aeruginosa strains isolated from urinary tract infection in patients from Caracas and Lima. Int J Antimicrob Agents 2002;20:476—7. 5. Rodriguez AJ, Rodriguez CN, Meijomil P, Garcia A, Duque C, Molina N, et al. In vitro activity of quinolones against isolates from paediatric urinary tract infections from three Venezuelan centres. Int J Antimicrob Agents 2001;17:531—2. 6. Gales AC, Sader HS, Jones RN, SENTRY Participants Group (Latin America). Urinary tract infection trends in Latin American hospitals: report from the SENTRY antimicrobial surveillance program (1997—2000). Diagn Microbiol Infect Dis 2002;44:289—99.
Alfonso J. Rodrı´guez-Morales ´ Witremundo Torrealba, Instituto Experimental Jose Universidad de Los Andes, Trujillo, Venezuela Cruz N. Rodrı´guez* Ada Garcia Bileida Pastran Ivette Jime ´nez Pilar Meijomil Laboratory of Microbiology, ´ Gregorio Hernandez West General Hospital (WGH), Jose Caracas, DC, Venezuela *Corresponding author. Tel.: +58 212 963 4053 fax: +58 212 442 9790 E-mail address: [email protected] (C.N. Rodriguez) Corresponding Editor: Timothy Barkham, Singapore 5 July 2005 doi:10.1016/j.ijid.2005.10.010
076 protocol.7 He was discharged well with oral zidovudine on the third day. At three weeks old he developed fever, abdominal distension, diarrhea, and vomiting, which required treatment with intravenous fluids and antibiotics, and was discharged well after 12 days. At five weeks old he returned with diarrhea, poor feeding, dehydration, and acidotic breathing. Arterial blood pH was 7.13, pO2 128 mmHg, pCO2 18.7 mmHg, base excess 21.9 mmol/L, and anion gap 24 mmol/L. Serum lactate and ammonia levels were 4.07 mmol/L and 203.6 mmol/L, respectively. Serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), and gamma glutamyltransferase (GGT) levels were 89, 189, and 166 IU/L, respectively. Serum albumin was 28 g/L with prolonged activated partial thromboplastin time (APTT) and increased prothrombin time (PT) ratio. Repeated hemoculture and stool cultures did not yield any pathogen. His urine was screened for inborn errors of metabolism but proved normal. On the second hospital day he developed jerking movements