Updates
Updates
Syncercid Approved by the FDA
Source: ProMED-mail post, Oct. 17, 1999. www.healthnet.org.
Syncercid, or quinupristin/dalfopristin (Q/D), has now been approved by the FDA for use in the United States. Q/D is a combination streptogramin antimicrobial used for more than 15 years in Europe for the treatment of gram-positive infections. Its value to us, for the moment, is in multi-drug-resistant gram-positive in-fections, such as those due to resistant Staphylococcus aureus, Streptococcus pneumonia, and vancomycin-resistant Enterococcus (VRE). However, clinicians must keep in mind that Q/D is bacteriostatic, and cases of recurrent bacteremia or even resurgent bacteremia during therapy have been reported (Kemper CA. Infect Dis Alert 1997;16:72; Chow JW, et al. Clin Infect Dis 1997;24:90-92). Q/D is, therefore, not adequate as sole therapy for more severe infections due to VRE, such as endocarditis or osteomyelitis. In addition, Q/D has limited activity against Enterococcus with VanA and VanB resistance; it has intermediate activity against vancomycin resistant E. faecium isolates with MICs 2-32 mg/L and poor activity against those with MICs of 64 mg/L (2 mg/L is generally considered the breakpoint for resistance to Q/D).
Q/D resistance may, unfortunately, already be well established in the human and animal population in the United States and other countries. Another streptogramin antimicrobial, virginiamycin, has been used as a growth promotor in chickens since 1974, with the resultant emergence of Q/D-resistant isolates throughout Europe, the United Kingdom, and the United States. In a recent study, 12% of E. faecium isolates from human stool specimens in the United States were found to be Q/D resistant (Angulo F, et al. 39th ICAAC, San Francisco, CA: September 26-29, 1999: Abstract # 726:103). In addition, 35 of 36 E. faecium strains (97%) isolated from chickens purchased from grocery stores in the United States also proved to be Q/D resistant! The mechanisms of resistance appear multiple and widespread, at least in E. faecium isolates from animals, raw meat, and sewage, as well as patients in the United Kingdom (Soltani M, et al. 39th ICAAC, San Francisco, CA: September 26-29, 1999;Abstract #725:103). The European Union recently prohibited the use of virginiamycin in food animals, but the United States has yet to follow suit. Newer agents, such as linezolid (a new oxazolidinone), presently under investigation may provide activity against some of these remarkably resistant isolates.
Why Patients in Isolation Feel More Isolated
Source: Kirkland KB, Weinstein JM. Lancet 1999;354:1177-1178.
Kirkland and weinstein as-sessed the handwashing compliance of and the frequency of contact between the physician and nursing staff at Duke University and 14 patients in contact isolation (e.g., gowns and gloves) compared with 21 patients who were not in isolation. Data were as-sessed over a one-hour period per patient. While the staff compliance with gowns and gloves was remarkably good (90%) for patients in isolation, the rate of physician and nursing staff contact with these patients was only half that for nonisolation patients (2.1 vs 4.2 contacts/hr; P = 0.03). In addition, fewer health care workers entered the room if a patient was in isolation.
On a positive note, health care workers were more than twice as likely to wash their hands when encountering a patient in isolation compared with nonisolation subjects (90% vs 40%). Most of the staff were observed washing their hands following contact with a patient in isolation and only 7% washed their hands before contact. Because of this, Kirkland and Weinstein questioned whether the staff were possibly more concerned about their own health or that of their patients. I suspect that staff, while making rounds, wash their hands between patients, an observation which may not have been captured by this study. Whether restricting pa-tients to isolation affects the quality of the care is not clear, but the significant reduction in staff contact in this study supports the findings of other investigators that patients in isolation feel—more isolated.
Shortage of Penicillin G in the United States
Source: Reader notice. October 29, 1999. www.cdc.gov/nchstp.
Because of fda concerns at one of its manufacturing facilities, a major United States supplier of intravenous penicillin G (sodium and potassium [PCN G]) is recalling all of its penicillin products. This has resulted in an immediate shortage of PCN G in certain parts of the United States. Supplies of benzathine and procaine penicillin for intramuscular use have not been affected. Physicians are urged to limit their use of PCN G to those conditions where reasonable alternatives are not available (e.g., congenital and neurosyphilis). Information was not available as to when this problem would be resolved.
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