Programmation linéaire, Jeux, Complexité mdr Professeur Michel de Rougemont [email protected] mdr.
Pseudomonas ed Acinetobacter MDR · 2018. 6. 27. · Pseudo: ceppi MDR ceftolozano/tzb o...
Transcript of Pseudomonas ed Acinetobacter MDR · 2018. 6. 27. · Pseudo: ceppi MDR ceftolozano/tzb o...
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Pseudomonas ed
Acinetobacter MDR
Valerio Del Bono SC Malattie Infettive e Tropicali
ASO Santa Croce e Carle
Cuneo
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“……The treatment of metallo-β-lactamase producers or non-fermenters such as Acinetobacter spp. remains more problematic…..”
H. Wright, R.A. Bonomo, D.L. Paterson. New agents for the treatment of infections with Gram-negative bacteria: restoring the miracle or false dawn? Clinical Microbiology and Infection 23 (2017) 704e712
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30.7%
23.5%
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74.7%
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Open Forum Infectious Diseases, 2017
2009-2013: 13.262/292.742 (4.5%)
carba-RA.baumannii (22%)
P. aeruginosa (60.3%)
K. pneumoniae + E. coli (17.7%)
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● ASO Santa Croce e Carle
● 700 letti
● 35.000 ricoveri/anno
● Ospedale di alta specializzazione
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Isolamenti 2017 Pseudomonas
molecola n. resistenti %
chinoloni 4/19 21
carbapenemi 3/18 16.7
Pipera/tazo 1/19 5.2
19 da emocoltura
62 da urinocoltura
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2070 ceppi, 529 R
a doripenem, 106
(5%) classe
molecolare B (IMP
o VIM)
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Pseudomonas aeruginosa
• Fibrosi Cistica 75%
• Bronchiectasie non FC 43%
• IPF 4-12%
• BPCO (FR: ospedalizzazione nei 3 mm
prec, steroide, ATB, FEV-1 <30%)5-10%
Report Registro CFF 2015Yamazaki R et al. PLoS ONE, 2016, 11(12)Sethi S, et al. N Engl J Med 2008;359:2355-65Dimakou K, et al. Respiratory Medicine 116, 2016; 1-7Woodhead M, et al. Clin Microbiol Infect. 2011; suppl 6: E1-59
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Cosa abbiamo a
disposizione:
ceftolozano-tazobactam
ceftazidime-avibactam
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AAC, 2012; 56: 544-49
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Caso Clinico
Uomo, 76 anni, sindrome
bronchiectasica, nota
colonizzazione da PA R a FQ
+cefalo III e IV
Inizia meropenem 2 g x 3 +
genta 5 mg/kg
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Pseudomonas aeruginosa
Amikacina S
Ciprofloxacina R
Cefepime R
Piperacillina/tazobactam R
Meropenem R
Gentamicina S
Colistina S
Ceftolozane/tazobactam S (1 mg/L)
Ceppo mucoide 10.000 CFU
Fallimento terapia con mem +
genta ceftolozane/tazobactam 3g
x 3/die + amicacina, risposta clinica
completa
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E in prospettiva?
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In vitro activity of cefiderocol (S-649266), a siderophorecephalosporin, against carbapenem-susceptible and resistant non-fermenting Gram-negative bacteriaP0187 Bonomo et al. ECCMID 2018
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AAC, 2017
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PLOS Biology | https://doi.org/10.1371/journal.pbio.2004356 April 30, 2018
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«Acinetobacter is a gram-negative coccobacillus that during the past threedecades has emerged from an organismof questionable pathogenicity to an infectious agent of importance to hospitals worldwide»
VAP-BSI
>lenght of hospital stay
A.baumannii
Emergent: A.pittii, A.ursingii
NEJM, 2008
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Isolamenti 2017 Acinetobacter
molecola n. resistenti %
carbapenemi 11/18 61.1
19 (vs 58 nel 2016)
4 da emo
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30 pazienti con precedente, remoto
(≥ 6 mesi prima) isolato clinico di A. baumannii e nuovamente ricoverati
nello stesso ospedale (TASMC)
5 pazienti positivi
Intervallo medio da isolato clinico
20 mm (range 8-42)
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34 pazienti con isolati clinici di
A.baumanniiVerifica di colonizzazione
Controllo ambientale
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CRAB in TAIWAN 6° causa di tutte le infezioni e 3° di polmonite in ICU
238 casi di Polmonite da CRAB
FR per mortalità
BMI più elevato
Degenza pre CRAB più lunga
APACHE score più elevato
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118 casi di CRAB BSI
76 coli in mono
42 combo con tige a dosaggio
standard
76 casi VAP origine di BSI
Mortalità complessiva 71/118 (60%)
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Antimicrobial Agents and Chemotherapy 2017; 61 e01268-16
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A statistically significant difference was
observed in favor of the IVCC when high
dose (>6 MIU) colistin was employed
(0.80, 0.69-0.93), in studies conducted in
Asia (0.82, 0.71-0.95), in patients with
bacteremia (0.75, 0.57-0.98), and in patients with Acinetobacter infections(0.88,0.78-1.00).
Intravenous colistin combination antimicrobial treatment versus monotherapy: a systematic review and meta-analysis
Vardakas K, et al. IJAA, 2018
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406 pts in 6 ospedali (3 Israele, 2 Grecia, 1
Italia)con infezione (BSI, VAP, HAP) da gram
neg carba-R. Studio randomizzato 1:1 in aperto
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Considerazioni conclusive
Mancanza di RCTs
Pseudo: ceppi MDR ceftolozano/tzb o
ceftazidime/AVB, in prospettiva cefiderocol
MBL colistina HD, in prospettiva
aztreonam/AVB
Acineto MDR: colistina HD, non necessaria
Tige, meglio AMP/SULB
In prospettica cefiderocol, eravaciclina
Prevenire colonizzazioni: sorveglianza!
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Grazie per l’attenzione!