Local infection control measures, antibiotic consumption and patient demographics from 1999–2000 together with bacteriological analyses were investigated in 29 ICUs participating in the ICU-STRAMA programme. The median antibiotic consumption per ICU was 1147 (range 605–2143) daily doses per 1000 occupied bed d (DDD1000). Antibiotics to which >90% of isolates of an organism were susceptible were defined as treatment alternatives (TA90). The mean number of TA90 was low (1–2 per organism) for Enterococcus faecium (vancomycin:VAN), coagulase negative staphylococci (VAN), Pseudomonas aeruginosa (ceftazidime:CTZ, netilmicin: NET) and Stenotrophomonas maltophilia (CTZ, trimethoprim-sulfamethoxazole: TSU), but higher (3–7) for Acinetobacter spp. (imipenem:IMI, NET, TSU), Enterococcus faecalis (ampicillin:AMP, IMI, VAN), Serratia spp. (ciprofloxacin:CIP, IMI, NET), Enterobacter spp. (CIP, IMI, NET, TSU), E. coli (cefuroxime:CXM, cefotaxime/ceftazidime:CTX/CTZ, CIP, IMI, NET, piperacillin-tazobactam:PTZ, TSU), Klebsiella spp. (CTX/CTZ CIP, IMI, NET, PTZ, TSU) and Staphylococcus aureus (clindamycin, fusidic acid, NET, oxacillin, rifampicin, VAN). Of S. aureus isolates 2% were MRSA. Facilities for alcohol hand disinfection at each bed were available in 96% of the ICUs. The numbers of TA90 available were apparently higher than in ICUs in southern Europe and the US, despite a relatively high antibiotic consumption. This may be due to a moderate ecological impact of the used agents and the infection control routines in Swedish ICUs.

BACKGROUND:The purpose of this work was to study usage of antibiotics, its possible determinants, and patterns of bacterial resistance in Swedish intensive care units (ICUs).METHODS:Prospectively collected data on species and antibiotic resistance of clinical isolates and antibiotic consumption specific to each ICU in 1999 were analyzed together with answers to a questionnaire. Antibiotic usage was measured as defined daily doses per 1000 occupied bed days (DDD1000).RESULTS:Data were obtained for 38 ICUs providing services to a population of approximately 6 million. The median antibiotic consumption was 1257 DDD1000 (range 584-2415) and correlated with the length of stay but not with the illness severity score or the ICU category. Antibiotic consumption was higher in the ICUs lacking bedside devices for hand disinfection (2193 vs. 1214 DDD1000, p=0.05). In the ICUs with a specialist in infectious diseases responsible for antibiotic treatment the consumption pattern was different only for use of glycopeptides (58% lower usage than in other ICUs: 26 vs. 11 DDD1000,P=0.02). Only 21% of the ICUs had a written guideline on the use of antibiotics, 57% received information on antibiotic usage at least every 3 months and 22% received aggregated resistance data annually. Clinically significant antimicrobial resistance was found among Enterbacter spp. to cephalosporins and among Enterococcus spp. to ampicillin.CONCLUSIONS:Availability of hand disinfection equipment at each bed and a specialist in infectious diseases responsible for antibiotic treatment were factors that correlated with lower antibiotic consumption in Swedish ICUs, whereas patient-related factors were not associated with antibiotic usage.

Background: A study was designed to assess a computer‐based program for continuous registration of antibiotic resistance, statistics concerning severity of illness, and consumption of antibacterial drugs.Methods: The frequency of antibiotic resistance among bacteria in eight ICUs in southeastern Sweden was investigated yearly from 1995 through 1997. The antibiotic consumption in the ICUs was registered as defined daily doses (DDD) and compared to severity of illness (APACHE‐II scores).Results: There was a statistically significant increase in ampicillin resistance among Enterococcus spp. between 1996 and 1997, which was due to a shift from Enterococcus faecalis to Enterococcus faecium. A high prevalence of resistance among coagulase‐negative staphylococci to oxacillin (≈ 70%), ciprofloxacin (≈ 50%), fucidic acid (≈ 50%) and netilmicin (≈ 30%) was seen in all ICUs during the whole study period. There was a statistically significant increase in ciprofloxacin resistance among Escherichia coli and Enterococcus spp. The resistance among Enterobacter spp. to cefotaxime decreased but this change was not statistically significant. Efforts were made to avoid betalactam antibiotics, except carbapenems, for treatment of infections caused by Enterobacter spp. and the consumption of cephalosporins decreased whereas the consumption of carbapenems increased. The total antibiotic consumption decreased by 2.5% during the study period. There was no correlation between APACHE II scores and antibiotic consumption.Conclusions: Each ICU within a hospital ought to have a program for “on‐line” antibiotic resistance surveillance of drugs used in that unit so that changes in empirical treatment can be made when there is an increase in antibiotic‐resistant isolates within that unit.

BACKGROUND:A study was designed to assess a computer-based program for continuous registration of antibiotic resistance, statistics concerning severity of illness, and consumption of antibacterial drugs.METHODS:The frequency of antibiotic resistance among bacteria in eight ICUs in southeastern Sweden was investigated yearly from 1995 through 1997. The antibiotic consumption in the ICUs was registered as defined daily doses (DDD) and compared to severity of illness (APACHE-II scores).RESULTS:There was a statistically significant increase in ampicillin resistance among Enterococcus spp. between 1996 and 1997, which was due to a shift from Enterococcus faecalis to Enterococcus faecium. A high prevalence of resistance among coagulase-negative staphylococci to oxacillin (approximately 70%), ciprofloxacin (approximately 50%), fucidic acid (approximately 50%) and netilmicin (approximately 30%) was seen in all ICUs during the whole study period. There was a statistically significant increase in ciprofloxacin resistance among Escherichia coli and Enterococcus spp. The resistance among Enterobacter spp. to cefotaxime decreased but this change was not statistically significant. Efforts were made to avoid betalactam antibiotics, except carbapenems, for treatment of infections caused by Enterobacter spp. and the consumption of cephalosporins decreased whereas the consumption of carbapenems increased. The total antibiotic consumption decreased by 2.5% during the study period. There was no correlation between APACHE II scores and antibiotic consumption.CONCLUSIONS:Each ICU within a hospital ought to have a program for "on-line" antibiotic resistance surveillance of drugs used in that unit so that changes in empirical treatment can be made when there is an increase in antibiotic-resistant isolates within that unit.

The frequency of antibiotic resistance among bacteria in 4 intensive care units (ICUs) at a university hospital in Sweden was investigated annually from 1993 to 1996. An increase in ampicillin-resistant enterococci from 1993 to 1995 was seen which was due to a shift from Enterococcus faecalis to Enterococcus faecium. After a special infection control programme was instituted, the rate of ampicillin resistance among enterococci and the number of E. faecium isolates declined during 1996. The oxacillin resistance rates for Staphylococcus aureus were < or = 2%, while most of the coagulase-negative staphylococci (CNS) were oxacillin resistant. No vancomycin-resistant enterococci or staphylococci were seen. The ciprofloxacin resistance rate for CNS and Enterococci spp. were high. Relatively, high levels of resistance to cefotaxime and piperacillin/tazobactam among Enterobacter spp. were also seen. During 1995 and 1996 Pseudomonas aeruginosa showed increasing resistance to ceftazidime, ciprofloxacin and piperacillin/tazobactam. This was due to an outbreak among rather few patients. The overall resistance rates for Gram-negative bacteria were low for aminoglycosides and imipenem. From 1993 to 1996 the total antibiotic consumption decreased by 27% in the whole hospital and 16.5% in the ICUs. However, the reduced antibiotic consumption was paralleled with a 23% decrease in the total number of patients treated in the hospital from 1993 to 1996. In contrast there was an 11.5% increase in the number of ICU patients treated during this period. The conclusion is that all ICUs within a hospital should have a programme for 'on-line' antibiotic resistance surveillance of drugs used in that unit in order to change the empiric treatment when there is an increase in antibiotic resistance. It is also important to survey the antibiotic consumption in the ICUs in order to avoid further selective pressure on bacteria showing increased resistance rates.

The steady-state pharmacokinetics of tiopronin (2-mercaptopropionylglycine, 2-MPG), were studied in healthy volunteers after single (n = 10) and multiple (n = 7) oral doses. Similarly, 5 patients with cystinuria on maintenance doses of tiopronin were studied. The pharmacokinetics of tiopronin in the healthy volunteers did not differ significantly during 10 days of treatment, i.e. the area under the concentration-time curve, time to reach maximum plasma concentration, apparent oral clearance (CL/F), renal clearance (CLR), terminal elimination half-life (t½), and amount of dose excreted in urine were similar. The apparent volume of distribution (Vd/F) was, however, different and might have been due to altered plasma and tissue binding after multiple doses. The pharmacokinetics of tiopronin after multiple oral doses in healthy volunteers compared with maintenance doses in patients with cystinuria were generally the same. The terminal t½ of total tiopronin was somewhat longer owing to firm protein and tissue binding. The decreased CL/F and CLR found in the patients with cystinuria were probably a consequence of decreased glomerular filtration rate (51Cr-EDTA clearance) in this group. No differences in the pharmacokinetics of the metabolite 2-mercaptopropionic acid (2-MPA) were found between the 2 groups. The effects of tiopronin on cystine excretion in patients with cystinuria were confined to the first 12 hours after administration.

Ten patients with slight to moderate renal impairment were administered 500mg of tiopronin (2-mercaptopropionylglycine, 2-MPG) orally, and the pharmacokinetics of the drug and the metabolite, 2-mercaptopropionic acid (2-MPA), were evaluated and compared with previous results from 10 healthy volunteers.

The therapeutic effect of absorbing plasma from tumour patients with immobilized staphylococcal protein A was tested. Plasma prepared by centrifugation was passed over protein A-Sepharose and then reinfused into the patient. Five patients were thus treated. One with malignant melanoma and one with renal adenocarcinoma showed measurable regression of metastatic lesions. In another with malignant melanoma a subcutaneous metastasis showed histopathological changes compatible with a therapeutic effect. In two patients, one with malignant melanoma and one with renal adenocarcinoma, no signs of regression were found. No severe adverse effects of the treatment were observed.

Dichlorazepate (DPC) was given to eight healthy volunteers aged 22–38 years (five males and three females). The dose was 20 mg (48.9 μmol) given either as an IV or an IM injection. The interval between the injections was at least 1 week. Plasma samples were analysed for desmethyldiazepam (DMD) by HPLC before and after acid hydrolysis. The kinetics after both IV and IM administration could be explained by a one or two compartment open model. By comparing values before and after hydrolysis an estimate of di- and/or monopotassiumchlorazepate (MPC) could be made. The bioavailability was almost 100% after IM administration. The plasma half lives of DPC and DMD were independent of the form of administration (2.42 and 46.0 h respectively after IV and 2.29 and 45.1 h respectively after IM injection).

Dipotassium chlorazepate (DPC) was administered to ten patients (five males and five females), aged 18–37 years (mean 27.4), as a once daily dose of 50 mg until a steady state was reached. Plasma concentrations of the main metabolite N-desmethyldiazepam (DMD) were monitored by a high pressure liquid chromatographic (HPLC) method during the medication period and for 5 days after withdrawal of the drug. The plasma half life (t1/2), the elimination coefficient (Kβ), the steady state concentration \(\left( {\bar C_{ss} } \right)\), and the apparent volume of distribution (Vβ), were calculated at steady state and the mean values ±SEM were 44±5 h, 0.0184±0.0026 h-1, 1590±163 ng/ml and 1.41 ±0.17 l/kg, respectively. A moderate inter-individual variability was observed. There was no tendency towards dose dependent elimination.

Dipotassium chlorazepate was administered to 12 healthy volunteers (8 males and 4 females), aged 22–38 years, as a single daily dose of 20 mg for 14 days. Plasma concentrations of N-desmethyldiazepam were monitored with a gas-chromatographic method during the medication period and for 5 days after withdrawal of the drug. The plasma half-life (t1/2), the elimination coefficient (Kβ), the concentration (\(\bar C_{{\text{ss}}} \)), and the apparent volume of distribution (Vβ) were calculated at steady state, and the mean values±SEM were 53±6 h, 0.0147±0.0013 h-1, 884±73 ng/ml, and 1.13±0.08 l/kg, respectively. A moderate interindividual variability was observed regarding these parametes. There was no tendency toward a biexponential elimination. A significant difference in the apparent volume of distribution was found when males and females were compared.