La somministrazione perioperatoria di agenti antibatterici allo scopo di prevenire eventuali infezioni post-chirurgiche rappresenta uno dei cardini della medicina moderna. Nonostante che i principi fondamentali della profilassi chirurgica siano stati sufficientemente chiariti negli ultimi decenni, i progressi delle tecniche chirurgiche (interventi protesici, interventi “a cuore aperto”, chirurgia vascolare, trapianti, etc), i cambiamenti dell’ecologia batterica ospedaliera, i fenomeni delle resistenze microbiche e le sensibili modificazioni della popolazione chirurgica (aumento degli anziani, degli immunodepressi e dei soggetti a rischio), hanno fatto sì che molti aspetti della profilassi chirurgica debbano essere nuovamente discussi ed eventualmente verificati in studi controllati in proposito. Le revisioni effettuate nel corso degli anni delle linee guida americane (CDC) di profilassi in chirurgia non hanno nella sostanza modificato quelle elaborate alcuni decenni or sono ed hanno fortemente influenzato l’elaborazione di protocolli d’impiego e comportamenti prescrittivi in altri paesi, compresa l’Italia. Esistono elementi per ritenere che le linee guida del CDC siano oggi poco adeguate alla situazione reale non tenendo in considerazione che: • numerose evidenze allargano le indicazioni della profilassi ad altri interventi di chirurgia pulita • gli attuali criteri classificativi degli interventi chirurgici non includono le caratteristiche cliniche della “popolazione chirurgica “ attuale • la durata della profilassi ed il suo eventuale ruolo sulle infezioni a distanza non è stato definito con attenzione • l’evoluzione della epidemiologia batterica e delle resistenze batteriche ed una contemporanea disponibilità di antibiotici innovativi hanno allontanato lo spettro di un’era post-antibiotica Nella pratica clinica sulla base di tali considerazioni ed in attesa dei risultati di ampi studi in proposito, in talune circostanze e per taluni pazienti sembra giustificato per la profilassi chirurgica l’impiego delle cefalosporine di terza generazione ed in particolare del ceftriaxone che, per le sue proprietà farmacocinetiche mostra con una singola somministrazione perioperatoria, una efficace sovrapponibile a quella di tre dosi /die di altre cefalosporine.

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Till now there is not a gold standard therapy for Mediterranean spotted fever (MSF) in children. Standard treatment for MSF is the administration of tetracycline or chloramphenicol, however both these drugs can cause significant adverse effects in children (tetracyclines can cause staining of teeth, chloramphenicol severe hematological adverse events such as aplastic anemia, gray baby syndrome and hemolytic anemia in patients with the Mediterranean form of G6PD deficiency). We conducted two randomized clinical trials; the first compared clarithromycin versus chloramphenicol: mean time to defervescence was 36.7 +/- 18.1 h in the clarithromycin group and 47.1+/- 21.9 h in the chloramphenicol group (P= 0.047). The second trial compared clarithromycin versus azithromycin and did not show any statistically significant difference: mean time to defervescence was 46.2 +/- 36.4 h in the clarithromycin group and 39.3 +/- 31.3 h in the azithromycin group (P= 0.34). On the basis of these studies we think that clarithromycin and azithromycin could constitute an acceptable alternative to chloramphenicol and to tetracyclines for the treatment of MSF in children.

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In a survey of 247 HIV-infected patients which received at least six months of combined antiretroviral therapy including the protease inhibitor nelfinavir during the last two years (2000-2001), the specific primary genotypic mutation D30N (with or without the minor mutation N88D), was detected in only four of the 149 (2.7%) subjects who received genotypization after virological failure. Three of these cases of primary nelfinavir resistance occurred among the 84 patients who were protease inhibitor- and/or non-nucleoside reverse transcriptase inhibitor-naïve, while the last episode was registered in a female patient treated since five years, who received an indinavir-based therapy of nearly 12-month duration (interrupted because of untoward kidney effects). During the subsequent follow-up, the substitution of nelfinavir had a favourable laboratory and clinical outcome in all reported patients who continued a different highly active anti-HIV treatment, while a significantly less positive virological and immunological response was seen in all the remaining subjects, and especially in those who experienced virological failure after undergoing at least two prior changes of combined antiretroviral therapy, and were borne by a broad spectrum of protease gene mutations (save those regarding codons 30 and 88). Due to its exclusive resistance pattern, nelfinavir may represent a favorable first-line choice among protease inhibitor-based regimens, since it may spare further treatment options even in the same pharmacological class. In fact, cross-resistance with other protease inhibitors may be limited also in patients experiencing prior long-term antiretroviral therapy, from second-line to rescue regimens, provided that they were pre-treated with drugs other than nelfinavir.

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Aim of the study was to evaluate the prevalence and characteristics of non operative spondylodiskitis (SD) in our geographic area. Methods. We evaluated retrospectively epidemiological, clinical, laboratory and radiological features of patients with non operative SD observed between 1990 and 2001 in our department of the "D. Cotugno" hospital - Naples. Results. Eighteen patients with diagnosis of SD were evaluated. Etiologic agent was identified in 17 patients: M. tuberculosis in 5, brucella spp. in 4 and pyogenic bacteria in 8. Ten patients had underlying diseases or risk factors (4 diabetes mellitus, 3 arthrosis, 1 CRF, 1 IVDA and 2 previous back trauma). Symptoms preceded observation between 2 days and 12 months (median value 15 days). Seventeen patients presented fever, 13 back pain, 6 meningitis, 3 were comatous and 2 had severe sepsis. Ten patients showed high white blood cells count with granulocyte prevalence. Eritrosedimentation rate or C reactive protein were elevated in all patients. Diagnosis was confirmed in 8 patients only with radiographs of the spine, while 3 needed a CT and 11 a RMN imaging. Antimicrobial therapy was perfomed for at least 6 months in patients with brucellosis, 12 months in patients with tuberculosis and 2 months in patients with pyogenic SD. Persistent neurological deficit were observed in 2 patients. Conclusions. Neurological deficit may be avoid in patients affected by SD only with a carefull diagnosis and an accurate antibiotic therapy.

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Aim: To determine drop-out causes and EFV efficacy in ARVT. Materials: We examined a case-study of 106 patients (74% males, 26% females) followed for up to 23 months. 14% of the patients were naive for ARVT, 21% had already been treated with other drugs (non effective therapy), 28% were administered EFV as a supporting drug, 37% were administered EFV as a replacement drug (side-effects). The parameters used to assess efficacy are: CD4+ lymphocyte count and HIV viral load. The statistical tests used are: Student t, Fischer F, Kruskal Wallis H. Results: 33 (31.1%) patients are D.O. because of: non efficacy (11%), rash (5%), psychological disorders (8%), impotence (1%), psychosis (2%), acute hepatitis (1%), abdominal pain (2%), self-suspended ARVT (2%). After the EFV introduction, in few months it has been observed a sudden fall of the viral load while the CD4+ course increases up to the 18° month of follow up, and later on it has been observed a small decrease. Conclusion: This study proves the efficacy of EFV in ARVT. The D.O. patients because of side-effects are only a small number.

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In the early eighties, in the US the advantages (reduced costs, no hospitalisation trauma in children, no immobilization syndrome in elderly, reduction of nosocomial and acquired infections by multi-resistant organisms) of OPAT were identified and suitable therapeutic programs were established. Following the US experience, other countries set up their own OPAT programs which vary considerably from country to country because of different ways in which infections are managed in different parts of the world and because of different reimbursement systems. In order to understand the ways of managing OPAT and its results, a National OPAT Registry was set up in 1999 in Italy belonging to a wider International OPAT database, which collects data also from USA, Canada, Spain, Uruguay and Argentina. Up to now 396 patients and as many antibiotic courses have been included in the National Registry by eight different centres. The analysis of data permits to get information about the criteria of patient’s selection, treatment (route of administration, site of care, choice of antibiotic, dosage and duration), outcomes and possible side-effects. Italian results offer a quite peculiar picture of OPAT in this country when comparing data with those of other countries. In contrast with other countries where soft tissue infections and osteomyelitis are the most frequent diagnoses for including patients in OPAT programmes, in Italy pneumonia and bronchitis are the top two amenable infections. Ceftriaxone, Teicoplanin and Amikacin are absolutely the top three antibiotics selected for OPAT in Italy which confirm that a single daily dose regimen represents a great advantage in terms of compliance. Finally, a large percentage of antibiotic courses (50%) are carried out by using the i.m. administration route, which is very unusual in other countries. OPAT Registry is still ongoing and it will give us more detailed information in the future about the management of infections in the outpatient setting, but it already permits to define an actual picture of OPAT in our country and/or to compare and correlate data and information from different countries.

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Two cases of visceral leishmaniasis (VL) in immunocompetent patients have been described. Both patients lived in endemicic areas for leishmaniasis in the south of Italy, tested positive for anti-Leishmania antibodies. A definitive diagnosis of VL was delayed by false negative microscopic examinations. Both patients were treated successfully with liposomal amphotericin B. Conclusions: Immuno Fluorescent Assay (IFA) performed as an available test. It helped to pursue the correct diagnosis and therapy. Microscopy is reported to be highly sensitive and specific in the diagnosis of VL, nevertheless it may yield false negative results when examined in laboratories without good expertness.

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