S 7

NOSOCOMIAL INFECTIONS: THERAPY AND MANAGEMENT

E. Schmutzhard
Department of Neurology (NICU), University Hospital Innsbruck, Austria

Infections acquired in the hospital are a major problem because of their frequency, severity and costs. Up to 5% of all patients admitted to acute care hospitals develop a new infection. With nosocomial infections problems are frequently encountered with their identification, definition, ascertainment, risk actors, reservoirs of pathogens and modes of spread. Many invasive devices act as conduits of infection. Certain sources and modes of transmission indicate already a selected range of pathogens, their knowledge is extremely helpful in early recognition of the nosocomial infections and their appropriate management. Prevention is certainly the mainstay of the optimised management of nosocomial infections. The spectrum of bacterial pathogens causing nosocomial infection is thus, that in many instances the wide range of Betalactam antibiotics can be and should be considered as optimal therapeutics. Piperacillin plus Tazobactam, broad spectrum Cephalosporins (Cefotaxime group) and Pseudomonas-Cephalosporins (Ceftazidime group), Monobactams and Carbapenems, including Imipenem and Meropenem (in rare instances also Ertapenem) are those antibiotic chemotherapeutics of the Betalactam group which play the most important role in the treatment of nosocomial bacterial infections. Beside pharmacokinetic data, their in vitro efficacy and side effects are discussed in detail. Alternatives to Betalactam antibiotics, in case of severe nosocomial infections, are Quinolones, Aminoglycosides, Glycopeptides, Streptogramines and Oxazolidinone. Finally it must be stressed that amni-spectrum antibiotics do not exist although omniresistant bacteria do exist.

S 8

PHARMACOECONOMIC CONSIDERATIONS IN THE USE OF ANTIBIOTICS IN HOSPITALS

F. Allerberger
Institute for Hygiene and Social Medicine, Innsbruck, Austria

The discussion of economic issues relating to antibiotics has to consider many facets. Austrian legislation requires each hospital to run a drug-commission. As drug-commissions have to make efforts to identify selected antibiotics to place on their formularies, the challenge to these decision-makers is to determine which agent will work best in their situation. Twelve possible approaches are listed. Each may, or may not, be associated with advantages:
(1) The use of antibiotics no longer protected by patent law;
(2) preference of “older” antibiotic groups instead of latest generation drugs;
(3) delaying the listing of new drugs until after the market introduction phase;
(4) reducing patients demand for antibiotics;
(5) improving selection of patients, i.e. avoiding unnecessary antibiotic usage;
(6) shortening the duration of perioperative prophylaxis and antibiotic therapy;
(7) improving patients compliance;
(8) preferring oral over iv drugs;
(9) switch therapy / early deescalation therapy;
(10) changing dosing schedules from multiple times daily to once daily;
(11) interventions by pharmacists, infectious-diseases consultants, antibiotic-consultants;
(12) educational programs.
The price of the antibiotic is a small percentage of the overall healthcare costs for treating patients with infections in the hospital. In addition to the cost of the antibiotic itself, there are other factors relating to antibiotic use in hospitals that have economic implications and need to be considered. Although the pharmacoeconomic considerations relating to use of antibiotics are complex, there appears to be no question that
the cost for hospital care can generally be reduced by encouraging optimal antibiotic therapy.

S 9

CLINICAL PRESENTATION OF EXTRAPULMONARY TUBERCULOSIS

P. Khaykin
Dnipropetrovsk Medical Academy, Ukraine

The problem of an extrapulmonary tuberculosis is actual in many regions, however for countries of Eastern Europe in particular. A feature of development of extrapulmonary tuberculosis is the hidden clinical picture and early loss by “ill” organ of its functions. The initial manifestations of disease at minimum lesions usually are not specific. In accordance with diffusion of the process its symptomatology depends on the damaged organ. Extrapulmonary tuberculosis is more often observed in adults. Tuberculous lesions can be considered as metastases from the primary site in the lung, like metastases from a primary neoplasm. Tuberculosis can involve any organ. Genitourinary tuberculosis is one of the most common sites for extrapulmonary (metastatic) tuberculosis. Other forms of extrapulmonary tuberculosis are: tuberculous meningitis, generalized hematogenous or lymphohematogenous tuberculosis, tuberculous peritonitis, pericarditis, lymphadenitis, tuberculosis of bones and joints, gastrointestinal tuberculosis, tuberculosis of the liver and some rare localization. The correct diagnosis of extrapulmonary tuberculosis is the key to early and adequate treatment.