Diazgranados CA, Cardo DM, McGowan JE Jr. Antimicrobial resistance: international control strategies, with a focus on limited-resource settings. Int J Antimicrob Agents. 2008;32:1-9.
Microorganisms resistant to multiple anti-infective agents have increased worldwide. These organisms threaten both optimal care of patients with infection as well as the viability of current healthcare systems. In addition, antimicrobials are valuable resources that enhance both prevention and treatment of infections. As resistance diminishes this resource, it is a societal goal to minimise resistance and therefore to reduce forces that produce resistance. This review considers strategies for minimising resistance that are needed at several different levels of responsibility, ranging from the patient care provider to international agencies. It then describes responses that might be appropriate according to the resources available for control, focusing on limited-resource settings. Antimicrobial resistance represents an international concern. Response to this problem demands concerted efforts from multiple sectors both in developed and developing countries, as well as the strengthening of multinational/international partnerships and regulations. Both medical and public health agencies should be in the forefront of these efforts.

Richard JL, Sotto A, Jourdan N, et al. Risk factors and healing impact of multidrug-resistant bacteria in diabetic foot ulcers. Diabetes Metab. 2008;34:363-369.
AIM: To determine the risk factors for acquiring multidrug-resistant organisms (MDRO) and their impact on outcome in infected diabetic foot ulcers. METHODS: Patients hospitalized in our diabetic foot unit for an episode of infected foot ulcer were prospectively included. Diagnosis of infection was based on clinical findings using the International Working Group on the Diabetic Foot-Infectious Diseases Society of America (IWGDF-ISDA) system, and wound specimens were obtained for bacterial cultures. Each patient was followed-up for 1 year.

Santos RP, Mayo TW, Siegel JD. Healthcare epidemiology: active surveillance cultures and contact precautions for control of multidrug-resistant organisms: ethical considerations. Clin Infect Dis. 2008;47:110-116.

Infection control personnel are required to develop institutional guidelines for prevention of transmission of multidrug-resistant organisms, especially methicillin-resistant Staphylococcus aureus, within health care settings. Such guidelines include performance of active surveillance cultures for patients after admission to health care facilities or to high-risk-patient care units, to detect colonization with target multidrug-resistant organisms. Patients who are colonized with these potential pathogens are placed under contact precautions to prevent transmission to other patients. Such screening programs are labor and resource intensive and raise the following ethical considerations: (1) autonomy versus communitarianism, (2) indication for informed consent for obtainment of active surveillance cultures, and (3) identification of the appropriate payer. Relevant infection control, public health, and ethical principles are reviewed in an effort to provide guidance for ethical decision making when designing a multidrug-resistant organism control program that includes active surveillance cultures and contact precautions. We conclude that a program of active surveillance cultures and contact precautions is part of standard medical care that requires patient education but not a specific informed consent and that the cost for such programs should be assigned to the health care institution, not the individual patient.

Snyder GM, Thom KA, Furuno JP, et al. Detection of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci on the gowns and gloves of healthcare workers. Infect Control Hosp Epidemiol. 2008;29:583-589.

OBJECTIVE: To assess the rate of and the risk factors for the detection of methicillin-resistant S. aureus (MRSA) and vancomycin-resistant enterococci (VRE) on the protective gowns and gloves of healthcare workers (HCWs). METHODS: We observed the interactions between HCWs and patients during routine clinical activities in a 29-bed medical intensive care unit at the University of Maryland Medical Center, an urban tertiary care academic hospital. Samples for culture were obtained from HCWs' hands prior to their entering a patient's room, from HCWs' disposable gowns and gloves after they completed patient care activities, and from HCWs' hands immediately after they removed their protective gowns and gloves. RESULTS: Of 137 HCWs caring for patients colonized or infected with MRSA and/or VRE, 24 (17.5%; 95% confidence interval, 11.6%-24.4%) acquired the organism on their gloves, gown, or both. HCW contact with the endotracheal tube or tracheostomy site of a patient (P < .05), HCW contact with the head and/or neck of a patient (P < .05), and HCW presence in the room of a patient with a percutaneous endoscopic gastrostomy and/or jejunostomy tube (P < .05) were associated with an increased risk of acquiring these organisms. CONCLUSIONS: The gloves and gowns of HCWs frequently become contaminated with MRSA and VRE during the routine care of patients, and particularly during care of the patient's respiratory tract and any associated indwelling devices. As part of a larger infection control strategy, including high-compliance hand disinfection, they likely provide a useful barrier to transmitting antibiotic-resistant organisms among patients in an inpatient setting.

Shahid SK. Cefepime and its role in pediatric infections. Recent Patents Anti-Infect Drug Disc. 2008;3:145-148.

Cefepime is a semi-synthetic fourth generation cephalosporin with broader Gram-positive and excellent Gram-negative bacterial coverage. Its extended anti-microbial activity and infrequent tendency to develop resistance makes it popular for treatment of infections due to multi-drug resistant organisms. It has good efficacy against beta-lactamase and ESBL (extended spectrum beta-lacatamase)-secreting pathogens, and it has shown great promise in management of children with severe and nosocomial infections. It possesses superior bactericidal action compared to other cephalosporins and is a cheaper and safe alternative to the carbapenems. It is well-tolerated but needs dose adjustments in newborns, and in children with renal insufficiency. Cefepime is a valuable antibiotic but it should be used judiciously as unnecessary, improper and prolonged use may lead to emergence of cefepime-insensitive bacteria and risk of drop in the efficacy of cefepime. Various recent patents of cefepime have been launched which deal with improvements in its preparation, and with its combinations with beta-lactamase inhibitors and newer antibiotics such as linezolid. These developments may further augment the usefulness of cefepime in pediatric infections.

Gutiérrez F, Masiá M. Improving outcomes of elderly patients with community-acquired pneumonia. Drugs Aging. 2008;25:585-610.

Community-acquired pneumonia (CAP) is a major cause of morbidity and mortality in elderly patients. Therefore, efforts to optimize the healthcare process for patients with CAP are warranted. An organized approach to management is likely to improve clinical results. Assessing the severity of CAP is crucial to predicting outcome, deciding the site of care, and selecting appropriate empirical therapy. Unfortunately, current prognostic scoring systems for CAP such as CURB-65 (confusion, uraemia, respiratory rate, low blood pressure and 65 years of age) or the Pneumonia Severity Index have not been validated specifically in older adults, in whom assessment of mortality risk alone might not be adequate for predicting outcomes. Obtaining a microbial diagnosis remains problematic and may be particularly challenging in frail elderly persons, who may have greater difficulties producing sputum. Effective empirical treatment involves selection of a regimen with a spectrum of activity that includes the causative pathogen. Although most cases of CAP are probably caused by a single pathogen, dual and multiple infections are increasingly being reported. Streptococcus pneumoniae remains the overriding aetiological agent, particularly in very elderly people.

Lenz AM, Fairweather M, Cheadle WG. Resistance profiles in surgical-site infection. Future Microbiol. 2008;3:453-462.

Surgical-site infections (SSIs) remain a common complication, affecting some 5% of patients undergoing surgical procedures and can sometimes present a major challenge after surgery with life-threatening septic illness. The appearance of organisms that are often resistant to common antibiotic treatment is of great concern. Staphylococcus aureus is the organism most commonly recovered from infected surgical wounds, and usually contaminates wounds from the patients own skin. SSIs occur despite appropriate skin disinfection, sterilization of instruments, use of gown and gloves, appropriate sterile technique and prophylactic antimicrobials.

Drekonja DM, Johnson JR. Urinary tract infections. Prim Care. 2008;35:345-67, vii.

Urinary tract infection (UTI), with its diverse clinical syndromes and affected host groups, remains one of the most common but widely misunderstood and challenging infectious diseases encountered in clinical practice. Antimicrobial resistance is a leading concern, with few oral options available to treat infections caused by Gram-negative organisms resistant to trimethoprim-sulfamethoxazole and fluoroquinolones, especially for patients with upper tract disease. Efforts should be made not to detect or treat asymptomatic bacteriuria and funguria;