Quasiexperimental Study of the Effects of Antibiotic Use, Gastric Acid-Suppressive Agents, and Infection Control Practices on the Incidence of Clostridium difficile-Associated Diarrhea in Hospitalized Patients

The objective of this study was to evaluate the effects of antimicrobial drug use, gastric acid-suppressive agent use, and infection control practices on the incidence of Clostridium difficile-associated diarrhea (CDAD) in a 426-bed general teaching hospital in Northern Ireland. The study was retrospective and ecological in design. A multivariate autoregressive integrated moving average (time-series analysis) model was built to relate CDAD incidence with antibiotic use, gastric acid-suppressive agent use, and infection control practices within the hospital over a 5-year period (February 2002 to March 2007). The findings of this study showed that temporal variation in CDAD incidence followed temporal variations in expanded-spectrum cephalosporin use (average delay = 2 months; variation of CDAD incidence = 0.01/100 bed-days), broad-spectrum cephalosporin use (average delay = 2 months; variation of CDAD incidence = 0.02/100 bed-days), fluoroquinolone use (average delay = 3 months; variation of CDAD incidence = 0.004/100 bed-days), amoxicillin-clavulanic acid use (average delay = 1 month; variation of CDAD incidence = 0.002/100 bed-days), and macrolide use (average delay = 5 months; variation of CDAD incidence = 0.002/100 bed-days). Temporal relationships were also observed between CDAD incidence and use of histamine-2 receptor antagonists (H2RAs; average delay = 1 month; variation of CDAD incidence = 0.001/100 bed-days). The model explained 78% of the variance in the monthly incidence of CDAD. The findings of this study highlight a temporal relationship between certain classes of antibiotics, H2RAs, and CDAD incidence. The results of this research can help hospitals to set priorities for restricting the use of specific antibiotic classes, based on the size-effect of each class and the delay necessary to observe an effect.

Degradation products of clavulanic acid promote clavulanic acid production in cultures of Streptomyces clavuligerus

The role of clavulanic acid, an unstable antibiotic produced by Streptomyces clavuligerus, in biomass accumulation and production of clavulanic acid in batch cultures of the organism was examined. The organism was grown in a medium containing either 20 g/l lysine, 1 g/l lysine or 1 g/l lysine supplemented with degraded clavulanic acid as nitrogen sources. Biomass accumulation was highest in cultures grown with supplemented degraded clavulanic acid and reached a maximum of 2.2 g/l, compared with 1.5 g/l when lysine only was used. The yield coefficient for clavulanic acid production was again highest in cultures grown with supplemented degraded clavulanic acid, with a Y-p/x, value of 2 mg/g compared with Y-p/x value of 1.5 mg/g in 20 g/l lysine. No clavulanic acid was produced in cultures containing non-supplemented 1 g/l lysine. Non-degraded clavulanic, acid was added at 60 h to non-producing cultures of the organism containing 1 g/l lysine only. Clavulanic acid concentration immediately decreased on addition from 0.04 g/l over a period of 20 h, then remained constant at 0.02 g/l for a further 30 h until the end of the cultivation. This suggests that the rate of degradation was equivalent to the rate of production of clavulanic acid following a period of initial additive degradation. These results indicate that clavulanic acid is both produced and degraded in cultures of S. clavuligerus and that the products of degradation are used by the organism, resulting in further production of the antibiotic. (C) 2003 Elsevier Inc. All rights reserved.

Production of clavulanic acid and cephamycin C by Streptomyces clavuligerus under different fed-batch conditions

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

INFLUENCE of GLYCEROL and ORNITHINE FEEDING on CLAVULANIC ACID PRODUCTION BY Streptomyces clavuligerus

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Clavulanic acid production processes in a tower bioreactor with immobilised cells

The feasibility of using Streptomyces clavuligerus ATCC 27064 bioparticles supported on alginate gel containing alumina to produce clavulanic acid (CA) was investigated. To this end, effectiveness factors for spherical bioparticles, relating respiration rates of immobilised and free cells, were experimentally determined for various dissolved oxygen (DO) levels and bioparticle radii. Monod kinetics was assumed as representative of the oxygen consuming reaction, while internal oxygen diffusion was considered the limiting step. A comparison was made of the results from a tower bioreactor operating under batch, repeated-batch and continuous conditions with immobilised bioparticles. The theoretical curve of the effectiveness factor for the zero-order reaction model, considering an inert nucleus - the dead core model - was very well fitted to the experimental data. The results of the bioprocess indicated that the batch operation was the most efficient and productive, requiring a do concentration in the reactor above 60% of the saturation value. (C) 2007 Elsevier B.V. All rights reserved.

Optimisation of the glycerol-to-ornithine molar ratio in the feed medium for the continuous production of clavulanic acid by Streptomyces clavuligerus

Amino acids are well metabolized by Streptomyces clavuligerus during the production of clavulanic acid using glycerol as main carbon and energy source. However, only a few amino acids such as arginine and ornithine are favorable for CA biosynthesis. The aim of this work was to optimize the glycerol:ornithine molar ratio in the feed medium containing only these compounds to maximize CA production in continuous cultivation. A minimum number of experiments were performed by means of a simple two-level full-factorial central composite design to investigate the combined effect of glycerol and ornithine feeding on the CA concentration during the intermittent and continuous process in shake-flasks. Statistical analysis of the experimental data using the response surface methodology showed that a glycerol-to-ornithine molar ratio of approximately 40:1 in the feed medium resulted in the highest CA concentration when fermentation was stopped. Under these optimized conditions, in bench-scale fermentor runs, the CA concentration reached more than double the concentration obtained in shake-flasks runs. (C) 2009 Elsevier B.V. All rights reserved.

Clavulanic acid production by immobilized cells if Streptomyces clavuligerus

A clavulanic acid production process with immobilized Streptomyces clavuligerus cells was investigated. Cells were immobilized in diatomaceous earth, calcium alginate gel as well as in the form of natural pellets and cultivated in shake flasks in a medium containing glycerol and soytone as the carbon and nitrogen sources, respectively. In all experiments growth occurred in the first 48 h and glycerol consumption after 72 h, while clavulanic acid production was observed between 48 and 60h, with gradual degradation after this period. The natural pellets presented higher product concentration as compared with the cells immobilized in supports. However, calcium alginate was found to be the best support in relation to cell retention capacity.

Influence of free amino acids on clavulanic acid production by Streptomyces clavuligerus in synthetic medium

The effect of nitrogen source on clavulanic acid production was investigated in shake flasks. Media containing asparagine plus one of several different amino acids or a combination of two amino acids was tested. The best result, ca. 180 mg/L clavulanic acid, CA, in 60 h, was obtained with the lysine-tyrosine pair In an aerated and agitated fermentor this medium led to CA concentrations of ca. 210 mg/L, a remarkable production for synthetic medium utilization. Amino acids analysis during cultivation indicated that, while asparagine was consumed rapidly, lysine and tyrosine were metabolized slowly, promoting CA production.

Kinetic studies on clavulanic acid degradation

Clavulanic acid (CA), a potent beta-lactamase inhibitor, is very sensitive to pH and temperature. It is produced by Streptomyces clavuligerus and to optimize both the fermentation step and the downstream process, the expression of the hydrolysis kinetics has to be determined. In the present work the CA degradation rate from various sources was investigated at temperatures of 10, 20, 25, 30 and 40degreesC and PH values of 6.2 and 7.0. The results showed that first-order kinetics explained very well the hydrolysis kinetics and the Arrhenius equation could be applied to establish a relationship between the degradation rate constant and temperature, at both pHs. It has been observed that CA from fermentation medium was much more unstable than that from standard solution and from a commercially available medicine. Also, it was observed that CA was more stable at PH 6.2 than at pH 7.0, irrespective of the CA source. (C) 2004 Elsevier B.V. All rights reserved.

Screening of wild type Streptomyces isolates able to overproduce clavulanic acid

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Dextran sulfate/Triton X two-phase micellar systems as an alternative first purification step for clavulanic acid

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

A stable liquid-liquid extraction system for clavulanic acid using polymer-based aqueous two-phase systems

The partitioning of Clavulanic Acid (CA) in a novel inexpensive and stable aqueous two-phase system (ATPS) composed by poly(ethylene glycol) (PEG) and sodium polyacrylate (NaPA) has been studied. The aqueous two-phase systems are formed by mixing both polymers with a salt (NaCl or Na2SO4) and an aqueous solution of CA. The stability of CA on the presence of both polymers was investigated and it was observed that these polymers do not degrade the biomolecule. The effect of PEG-molecular size, polymer concentrations on the commercial CA partitioning has been studied, at 25 degrees C. The data showed that commercial CA was preferentially partitioned for the PEG-rich phase with a partition coefficient (K-CA) between 1 and 12 in the PEG/NaPA aqueous two phase systems supplemented with NaCl and Na2SO4. The partition to the PEG phase was increased in the systems with high polymer concentrations. Furthermore, Na2SO4 caused higher CA preference for the PEG-phase than NaCl. The systems having a composition with 10 wt.% of PEG4000, 20 wt.% of NaPA8000 and 6 wt.% of Na2SO4 were selected as the optimal ones in terms of recovery of CA from fermented broth of Streptomyces clavuligerus. The partitioning results (K-CA = 9.15 +/- 1.06) are competitive with commercial extraction methods of CA (K-CA = 11.91 +/- 2.08) which emphasizes that the system PEG/NaPA/Na2SO4 can be used as a new process to CA purification/concentration from fermented broth. (C) 2012 Elsevier B.V. All rights reserved.

Antibiotics for bronchiectasis exacerbations in children: rationale and study protocol for a randomised placebo-controlled trial

Background Despite bronchiectasis being increasingly recognised as an important cause of chronic respiratory morbidity in both indigenous and non-indigenous settings globally, high quality evidence to inform management is scarce. It is assumed that antibiotics are efficacious for all bronchiectasis exacerbations, but not all practitioners agree. Inadequately treated exacerbations may risk lung function deterioration. Our study tests the hypothesis that both oral azithromycin and amoxicillin-clavulanic acid are superior to placebo at improving resolution rates of respiratory exacerbations by day 14 in children with bronchiectasis unrelated to cystic fibrosis. Methods We are conducting a bronchiectasis exacerbation study (BEST), which is a multicentre, randomised, double-blind, double-dummy, placebo-controlled, parallel group trial, in five centres (Brisbane, Perth, Darwin, Melbourne, Auckland). In the component of BEST presented here, 189 children fulfilling inclusion criteria are randomised (allocation-concealed) to receive amoxicillin-clavulanic acid (22.5 mg/kg twice daily) with placebo-azithromycin; azithromycin (5 mg/kg daily) with placebo-amoxicillin-clavulanic acid; or placebo-azithromycin with placebo-amoxicillin-clavulanic acid for 14 days. Clinical data and a paediatric cough-specific quality of life score are obtained at baseline, at the start and resolution of exacerbations, and at day 14. In most children, blood and deep nasal swabs are also collected at the same time points. The primary outcome is the proportion of children whose exacerbations have resolved at day 14. The main secondary outcome is the paediatric cough-specific quality of life score. Other outcomes are time to next exacerbation; requirement for hospitalisation; duration of exacerbation; and spirometry data. Descriptive viral and bacteriological data from nasal samples and blood markers will also be reported. Discussion Effective, evidence-based management of exacerbations in people with bronchiectasis is clinically important. Yet, there are few randomised controlled trials (RCTs) in the neglected area of non-cystic fibrosis bronchiectasis. Indeed, no published RCTs addressing the treatment of bronchiectasis exacerbations in children exist. Our multicentre, double-blind RCT is designed to determine if azithromycin and amoxicillin-clavulanic acid, compared with placebo, improve symptom resolution on day 14 in children with acute respiratory exacerbations. Our planned assessment of the predictors of antibiotic response, the role of antibiotic-resistant respiratory pathogens, and whether early treatment with antibiotics affects duration and time to the next exacerbation, are also all novel.

Expressão de fatores de virulência, mecanismos de resistência aos agentes antimicrobianos e análise molecular da resistência aos beta-lactâmicos de enterobactérias isoladas de bolsas periodontais

Em estudo anterior, as espécies de enterobactérias apresentando perfis variados de resistência aos antimicrobianos foram detectadas em 20% dos sítios com lesões periodontais de pacientes sadios do ponto de vista sistêmico. Tais cepas microbianas foram submetidas a investigações com o intuito de determinar à expressão de enzimas hidrolíticas para substratos diversos, a multirresistência aos agentes antimicrobianos e os mecanismos de resistência aos antimicrobianos da classe dos β lactâmicos. A maioria das amostras expressou atividade de gelatinase (65%), caseinase (30%) e elastase (10%). Lipase, lecitinase e DNase foram observadas apenas para Serratia marcescens. A multirresistência (considerado como a resistência a pelo menos dois agentes antimicrobianos de famílias diferentes) foi observada em 56% das amostras isoladas. A maioria das cepas foi resistentes à ampicilina (93,75%) e amoxicilina/ácido clavulânico (81,25%). Investigações sobre a resistência aos antibióticos β-lactâmicos mostraram que três amostras resistentes à cefalosporinas de 2 geração, apresentaram perfis plasmidiais de diferentes pesos moleculares. A expressão fenotípica de β-lacatamases, foi detectada nas cepas de Enterobacter cloacae (PcOM46 e PcOM5) e S. marcescens (PcOM63). No entanto, na análise molecular, não foi possível confirmar a expressão fenotípica de diferentes β-lactamases, com exceção do E. cloacae PcOM46, que apresentou amplificação para AmpC e blaTEM. Embora sensível à maioria dos antibióticos β-lactâmicos (exceção feita à ampicilina e amoxicilina / ácido clavulânico), amostra de S. marcescens PcOM68 apresentou amplificação para o gene blaSHV. Os experimentos de conjugação não detectaram a transferência de plasmídios para uma cepa de Escherichia coli K12 sensívei aos β-lactâmicos, o mesmo ocorreu nos procedimentos de transformação por eletroporação e por CaCl2, sugerindo uma resistência dependente de genes cromossomiais. A expressão de diferentes atividades enzimáticas, juntamente com a resistência aos antimicrobianos, aponta estes grupos de bactérias como agentes patogênicos potenciais capazes de contribuir para a patogênese e resposta à quimioterapia antimicrobiana nas doenças periodontais, além da disseminação sistêmica para outros locais do corpo, especialmente em indivíduos imunocomprometidos. A colonização prévia de lesões periodontais por espécies resistentes aos β-lactâmicos, pode contribuir para a disseminação destes genes relacionados à resistência aos antimicrobianos em ambientes hospitalares.

Modelling the impact of antibiotic use and infection control practices on the incidence of hospital-acquired methicillin-resistant Staphylococcus aureus: a time-series analysis

Objectives: Methicillin-resistant Staphylococcus aureus (MRSA) is a major nosocomial pathogen worldwide. A wide range of factors have been suggested to influence the spread of MRSA. The objective of this study was to evaluate the effect of antimicrobial drug use and infection control practices on nosocomial MRSA incidence in a 426-bed general teaching hospital in Northern Ireland.

Methods: The present research involved the retrospective collection of monthly data on the usage of antibiotics and on infection control practices within the hospital over a 5 year period (January 2000–December 2004). A multivariate ARIMA (time-series analysis) model was built to relate MRSA incidence with antibiotic use and infection control practices.

Results: Analysis of the 5 year data set showed that temporal variations in MRSA incidence followed temporal variations in the use of fluoroquinolones, third-generation cephalosporins, macrolides and amoxicillin/clavulanic acid (coefficients = 0.005, 0.03, 0.002 and 0.003, respectively, with various time lags). Temporal relationships were also observed between MRSA incidence and infection control practices, i.e. the number of patients actively screened for MRSA (coefficient = -0.007), the use of alcohol-impregnated wipes (coefficient = -0.0003) and the bulk orders of alcohol-based handrub (coefficients = -0.04 and -0.08), with increased infection control activity being associated with decreased MRSA incidence, and between MRSA incidence and the number of new patients admitted with MRSA (coefficient = 0.22). The model explained 78.4% of the variance in the monthly incidence of MRSA.

Conclusions: The results of this study confirm the value of infection control policies as well as suggest the usefulness of restricting the use of certain antimicrobial classes to control MRSA.