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Clindamycin Information and Courses from MediaLab, Inc.

These are the MediaLab courses that cover Clindamycin and links to relevant pages within the course.

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Case Studies in Clinical Microbiology
Review 2

Suppola JP. Kuikka A. Vaara M. Valtonen VV. Comparison of risk factors and outcome in patients with Enterococcus faecalis vs Enterococcus faecium bacteremia. Scandinavian Journal of Infectious Diseases. 30(2):153-7, 1998. The purpose of our study was to determine retrospectively the risk factors for the acquisition of Enterococcus faecalis vs E. faecium bacteremia, as well as the clinical outcomes of these patients. 62 patients with Enterococcus faecalis bacteremia were compared to 31 patients with E. faecium bacteremia. Haematologic malignancies, neutropenia, high-risk source and previous use of aminoglycosides, carbapenems, cephalosporins and clindamycin were significantly associated with E. faecium bacteremia. Instead, urinary catheterization was found to be related to Enterococcus faecalis bacteremia. The mortality rates within 7 d and 30 d were 13% and 27%, respectively, in patients with E. faecalis bacteremia and 6% and 29%, respectively, in patients with E. faecium bacteremia. There was no difference in mortality between E. faecalis and E. faecium bacteremia, nor was there a difference in seriousness of disease at the time of bacteremia. In the subgroups of patients with monomicrobial or clinically significant E. faecalis vs E. faecium bacteremia, the mortality rates were similar to the results of all subjects. Our results do not support the theory that E. faecium would be a more virulent organism than E. faecalis.

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Review 2

Citron DM. Appelbaum PC.: How far should a clinical laboratory go in identifying anaerobic isolates, and who should pay? Clinical Infectious Diseases. 16 Suppl 4:S435-8, 1993 Identification of anaerobic bacteria in specimens from sites of infection due to mixed organisms can be time-consuming and expensive. Laboratories should limit anaerobic workups by testing only those specimens that have been properly collected and transported to the laboratory. Use of selective and differential media for initial processing can provide rapid and relevant information to the clinician. Anaerobes isolated from normally sterile sites and sites of serious infection should always be completely identified. Group-or genus-level identifications may suffice in other instances. The Bacteroides fragilis group of organisms should always be identified because of their virulence and resistance to many antimicrobial agents. Some of the other organisms that warrant identification include Clostridium septicum (associated with gastrointestinal malignancy); Clostridium ramosum, Clostridium innocuum, and Clostridium clostridioforme (which are resistant to antibiotics); Clostridium perfringens (a cause of myonecrosis and gas gangrene,potentially serious infection); anaerobic cocci (which may be resistant to metronidazole and clindamycin); and fusobacteria (which may be virulent and resistant to clindamycin and penicillin).

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Match the species of anaerobes and frequently associated conditions.View Page
Spleen Specimen

A 23-year-old man had complained of right lower quadrant abdomonal pain for approximately one week. Initially the pain was sharp and localized to a small area just above the right iliac crest. The pain subsided for approximately two days, but then recurred more diffusely over the lower abdomen, accompanied by cramping and mild diarrhea. The onset of fever and vomiting promted a visit to the emergency room. His temperature was 101 F, pulse was 90/minute, and palpation of the right lower abdomen elicited severe pain. The white blood count was 23,000/mm with a distinct left shift, including 5% metamyelocytes. Emergency surgery was performed for a large peri-appendiceal abscess. During surgery, multiple abscesses were noted in the spleen, which was removed (see image). Recovery was uneventful following five days of adjuvant clindamycin therapy.

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Review 1

Piscitelli SC., Shwed J., Schreckenberger P., Danziger LH. Streptococcus milleri group: renewed interest in an elusive pathogen. European Journal of Clinical Microbiology & Infectious Diseases.11:491-8, 1992 The following review examines the bacteriological characteristics, epidemiology, pathogenicity and antimicrobial susceptibility of the "Streptococcus milleri group". "Streptococcus milleri group" is a term for a large group of streptococci which includes Streptococcus intermedius, Streptococcus constellatus, and Streptococcus anginosus. Usually considered commensals, these organisms are often associated with various pyogenic infections including cardiac, intra-abdominal, subcutaneous and central nervous system infections, particularly with the formation of abscesses. Organisms of the "Streptococcus milleri group" are often unrecognized pathogens due to the lack of uniformity in classifications and difficulties in microbiological identification. Penicillin G, cephalosporins, clindamycin and vancomycin all possess activity against these streptococci. Use of agents with poor activity may promote infections with "Streptococcus milleri group" and allow it to exhibit its pathogenicity. An understanding of these organisms may aid in their recognition and proper treatment.

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Review 1

Newfield RS. Vargas I. Huma Z.: Eikenella corrodens infections. Case report in two adolescent females with IDDM. Diabetes Care. 19:1011-3, 1996 OBJECTIVE: To alert physicians caring for patients with diabetes to the microorganism Eikenella corrodens and to discuss the appropriate preventive and therapeutic measures to take against this potentially morbid opportunistic gram-negative bacilli. CASES: We present two cases of extra-oral E. corrodens infections in adolescent females with IDDM. The first patient had diabetes of four years' duration, which was moderately well controlled. Chronic finger biting resulted in a complex felon that evolved gradually and worsened while the patient received cephalexin orally. Delay in seeking further intervention resulted in necrosis of her distal fingertip and nail bed. The second patient had poorly controlled diabetes for five years. She developed an acute thigh abscess at an insulin injection site that resolved after drainage and intravenous antibiotics. CONCLUSIONS: E. corrodens commonly inhabits the human oral cavity and becomes a pathogen mostly when host defenses are impaired, causing abscesses and infections that are at times fatal. Patients with IDDM are compromised hosts and with daily microtrauma to their skin via glucose monitoring and insulin injections, are prone to develop E. corrodens infections that can be introduced through oral secretions by licking or biting their skin. Educational efforts aimed at preventing exposure of traumatized skin to oral secretions can minimize the risk of E. corrodens infections in compromised hosts. Early intravenous administration of antibiotics, bearing in mind E. corrodens resistance to clindamycin, metronidazole, and other antibiotics, coupled with prompt surgical intervention, is essential in successfully managing E. corrodens infections.

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Multi-drug Resistant Organisms: MRSA, VRE, and Clostridium difficile
Healthcare (Hospital)-Associated MRSA versus Community-Associated MRSA

As mentioned in the course introduction, MRSA infections fall into two general types: Healthcare-associated MRSA (HA-MRSA) Infections that occur in people who are, or have recently been, hospitalized. Community-acquired MRSA (CA-MRSA) Infections that are apparently acquired in the community There are a number of factors that distinguish HA-MRSA from CA-MRSA isolates. These factors are summarized in the table below. Factor HA-MRSA CA-MRSA Origin of strains Nosocomial infections Five isolates associated with healthcare settings: USA100, -200, -500, -600, -800 USA100 is the predominant isolate while USA 200 is the second most common isolate. USA700 has been isolated in both healthcare and community settings. Evolved from endemic methicillin susceptible S. aureus (MSSA) strains Two clones, USA300 and USA400, are associated with the majority of CA-MRSA infections in the United States. USA300 has emerged as the most prominent clone and is not found among hospital strains. Genetic lineage Isolates usually carry large SCCmec types I, II or III (34-67 kb) The larger size of SCCmecII and III permits the inclusion of other non-beta lactam resistance genes so that HA-MRSA strains tend to be multi-drug resistant Isolates carry a smaller SCCmec variant, predominantly type IV (24 kb), less often type V or variant VT. SCCmecIV (except for mecA) does not permit the inclusion of other non-beta lactam resistance genes so that CA-MRSA isolates exhibit resistance to only methicillin and erythromycin and are more often susceptible to other non-beta lactam antibiotics (eg., trimethoprim/sulfamethoxazole (SXT) and clindamycin). Affected population Largely affects older adults and people with weakened immune systems; those who have undergone surgical procedures are at increased risk. Healthy persons in the general population without established risk factors for MRSA acquisition Clinical syndromes Found at multiple sites, most commonly bloodstream infections, urinary tract infections (UTI) and respiratory tract infections Predominantly skin and soft tissue infections (SSTIs), such as abscesses, cellulitis, folliculitis and impetigo and a serious form of pneumonia Genes for Panton-Valentine Leukocidin (PVL) are associated with SCCmecIV; the clinical spectrum of infections caused by CA-MRSA is directly related to the presence of PVL genes, coding for the production of a cytotoxin that causes tissue necrosis and leukocyte destruction.

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Future perspectives

With MRSA becoming the new "normal" in many areas, clinicians will have to define the role of up to a dozen anti-MRSA drugs; alternatives to vancomycin, including older drugs like clindamycin, doxycycline and trimethoprim/sulfamethoxazole, and newer agents like linezolid and daptomycin for serious infections. There are also a number of drugs under development including enhanced glycopeptides – dalbavancin, oritavancin, telavancin, and anti-MRSA cephalosporins.

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Future Perspectives (continued)

Important epidemiological and microbiological differences exist between CA- and HA-MRSA strains so strategies to prevent and treat these infections should also differ. To prevent clinical complications from CA-MRSA, it is recommended that culturing and susceptibility testing of S. aureus clinical isolates become routine practice along with more careful selection and use of antimicrobials when treatment is indicated. MRSA isolates are NOT susceptible to beta-lactam antibiotics, however CA-MRSA infections are susceptible to some currently available non- beta-lactam antibiotics such as clindamycin and trimethoprim/sulfamethoxazole.

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Clostridium difficile-associated Diarrhea

Clostridium difficile-associated diarrhea (CDAD) is a unique hospital infection that occurs almost entirely in patients who have received previous antimicrobial treatment. Anaerobic gut flora are crucial to colonization resistance, so any disruption of the normal colonic flora (through illness, therapeutic procedures or, most commonly, antibiotic use) is essential to the pathogenesis of C. difficile infection. The association of CDAD with antibiotic use is significant. Early attention (1970s) focused on clindamycin but later on (1980s,1990s & continuing today) the cephalosporins, especially third generation, and broad spectrum penicillins (e.g., amoxycillin/ampicillin) were also implicated. The risk of CDAD is increased if C. difficile is resistant to the particular antimicrobial. In the case of clindamycin, C. difficile resistance is variable. Risk of infection due to a clindamycin-resistant strain increases with use of the drug. For the third generation cephalosporins, C. difficile is universally resistant; thus, any toxigenic strain is capable of causing CDAD during cephalosporin use. Other less commonly implicated antibiotics are the macrolides, e.g., erythromycin, azithromycin, clarithromycin. However, prolonged courses of any antibiotics will increase the risk of disease. Even those antibiotics used to treat colitis (metronidazole, for example) have sometimes been reported to cause CDAD.The fluoroquinolones have been in use since the 1980s. Ciprofloxacin was approved in 1987, but it is only in recent years with the emergence of the epidemic strain 027/NAP1/BI, which is resistant to the fluoroquinolones, that this class of drugs has been implicated in Clostridium difficile disease. The fluoroquinolones were initially considered to be low risk but their use has been increasing, both with hospital inpatients and in the community, and fluoroquinolones are now implicated as a risk factor for C. difficile infection. The newer fluoroquinolones, e.g., gatifloxacin, moxifloxacin, have better activity against anaerobes, but poor in vitro activity against C. difficile, thus increasing the likelihood of CDAD. The CDC now recommends that all fluoroquinolones, as a class, be used sparingly as each poses an increased risk for CDAD.

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Risk Factors and Resistance

Enterococci are largely commensal organisms that are opportunistic pathogens. Underlying disease, an immunocompromised state, age, lengthy hospital stays or long term care, invasive treatments, and/or prior antimicrobial therapy are factors that are associated with significant infections with these species. As noted previously, Enterococci are intrinsically resistant to many antibiotics. Intrinsic resistance affects not only beta lactams (including a broad range of cepahlosporins) and aminoglycosides, but also clindamycin and trimethoprim/sulfamethoxazole. The standard recommended therapy for systemic infections is a combination of either penicillin or vancomycin and an aminoglycoside (gentamicin or streptomycin). The goal of combination therapy is to achieve a synergistic bacteriocidal effect between the cell wall agent and the aminoglycoside.In recent decades, increasing resistance to other antibiotics through acquired resistance mechanisms has become a growing therapeutic and infection control problem. Of key concern are high level resistance (HLR) to aminoglycosides and increasing resistance to glycopeptides such as vancomycin.

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Enterococci can possess both intrinsic and acquired resistance. Which of the following represents the intrinsic resistance of a typical Enterococcal strain?View Page


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