https___antibiotic.ecdc.europa.eu_ga_bi-ar-eolas_patient-stories_paolo_1.xml
1.1 2.1 2.2 2.3 3.1 3.2 3.3 4.1 4.2 4.3 4.4 4.5 4.6 5.1 5.2 6.1 6.2 6.3 7.1 7.2 7.3 7.4 7.5 7.6 7.7 8.1 8.2 8.3 9.1 10.1 10.2 10.3 11.1 11.2 11.3 12.1 12.2 13.1 13.2 13.3 13.4 14.1 14.2 14.3 14.4 14.5
Paolo Paolo fell ill with a serious urinary infection with an E.coli resistant to many antibiotics. It took two months and three courses of different antibiotics before Paolo's infection was successfully treated. Nobody knows where he picked up the infection. Paolo is a 55 year old University Professor in Rome, Italy. In August of 2010, Paolo had gone motor-boating alone to Ponza, a small island off the coast of Italy. After arrival in Ponza, he felt that he had symptoms of a urinary tract infection, but did not pay too much attention at the time, because he thought his symptoms could have been due to dehydration from the summer heat. After a while, however, he developed a fever with shaking chills and the symptoms of his urinary tract infection intensified. He consulted with his brother-in-law, who is a medical doctor and was spending his holidays in Ponza. His brother-in-law suggested that he take ciprofloxacin, a fluoroquinolone antibiotic which is one of the most frequently used antibiotics for urinary tract infections. Ciprofloxacin can be given by mouth, so is easy to take and is usually effective in treating urinary tract infections. His condition did not improve over the next three days and his fever did not abate. Despite this, he continued the course of ciprofloxacin for a week or more, with the hope of being well enough to motor-boat back to Rome and seek a full medical examination and laboratory tests. Paolo was on the island of Ponza where there was no possibility of laboratory testing of his urine to better understand which antibiotics the bug could be treated with. He was aware that it would be important to know the results of his urine culture in order for a doctor to prescribe the correct antibiotic. Since he was afraid to motor-boat back to Rome by himself in case he became very ill, his brother-in-law accompanied him. On arrival at the mainland, he immediately went to a large hospital in Rome where he had a urine culture and clinical examination, which confirmed he had a complicated urinary tract infection. He was also found to have an enlarged prostate gland, which was the likely cause of his infection. The culture showed that he was infected with a bacterium called Escherichia coli (E. coli), which produced an extended-spectrum beta-lactamase (ESBL) and was resistant to many antibiotics, including ciprofloxacin. The laboratory results showed that the only antibiotics that Paolo’s E. coli was sensitive to were amoxicillin/clavulanic acid, trimethoprim-sulfamethoxazole, fosfomycin and finally, a class of last line antibiotics called the carbapenems. Paolo could not take trimethoprim-sulfamethoxazole, which is an oral antibacterial agent, because he was allergic to it. Carbapenems can only be given intravenously, meaning spending some time at the hospital. He was prescribed amoxicillin/clavulanic acid, which he took by mouth for four weeks. His condition improved, but four days after his treatment was discontinued, he began having fever again and his symptoms of a urinary tract infection returned. He then called a friend of his, an infectious disease specialist, who suggested that he take fosfomycin by mouth in the correct dose for his infection. He took this for 21 days. His symptoms resolved after that and he has been well ever since. Commentary: case notes While on holiday, Paolo developed a complicated urinary tract infection with an E. coli isolate that produced extended-spectrum-beta lactamases (ESBL). ESBLs are enzymes that make bacteria, most commonly E. coli and Klebsiella pneumoniae, resistant to most B-lactam antibiotics, including penicillins, cephalosporins and aztreonam. Paolo’s E. coli was found to be sensitive only to amoxicillin/clavulanic acid, trimethoprim-sulfamethoxazole, fosfomycin and to the carbapenems, a class of last-line antibiotics, which are the treatment of choice for bacteria that produce ESBLs. Important points to note in this case are that Paolo had developed an infection with a community-acquired highly resistant E. coli. Notably, hisE. coli was resistant to the fluoroquinolones, a class of antibiotics that can also be taken by mouth to treat urinary tract infections, including complicated ones. The carbapenems, to which his E.coli was sensitive, are the antibiotics of choice in patients with infections with ESBL-producing bacteria. Aside from the carbapenems, which are given intravenously and require some type of hospital stay, there were only few antibiotics that he could take that would be effective against his infection, and few that he could take by mouth. Additionally, he was allergic to one of them, trimethoprim-sulfamethoxazole. The antibiotic that Paolo ended up taking was amoxicillin-clavulanic acid, which he took by mouth. This antibiotic can appear sensitive in the laboratory, but is actually not effective against ESBL E. coli when given for treatment in humans. This is why his condition apparently improved during amoxicillin-clavulanic acid treatment, but the infection was not eradicated and suddenly relapsed after the therapeutic course. It is concerning that such highly resistant bacteria are spreading in the community and causing infections in patients with no contact with the hospital. Globally, ESBL- producing bacteria are being found as the cause of community-acquired infections, and very frequently urinary tract infections. It is important to treat with the right antibiotic, since these types of highly resistant bacteria can cause patients to be sicker and to have a worse outcome. An important message for patients is that the right antibiotic needs to be prescribed for treatment. It is therefore necessary to see a doctor and to have microbiological testing performed.
1.1 2.1 2.2 2.3 3.1 3.2 3.3 4.1 4.2 4.3 4.4 4.5 4.6 5.1 5.2 6.1 6.2 6.3 7.1 7.2 7.3 7.4 7.5 7.6 8.1 8.2 8.3 9.1 10.1 10.2 10.3 11.1 11.2 12.1 12.2 13.1 13.2 13.3 13.4 14.1 14.2 14.3 14.4 14.5
Paolo Tháinig ionfhabhtú fuail tromchúiseach ar Paolo, agus é faoi réir bhaictéar E. coli a bhí frithsheasmhach in aghaidh a lán antaibheathach. Chuaigh dhá mhí thart agus tugadh faoi thrí chúrsa antaibheathach difriúil sular cuireadh cóireáil go rathúil ar Paolo in aghaidh an ionfhabhtaithe. Níl duine ar bith eolach ar cén áit ar thóg sé an t-ionfhabhtú. Is Ollamh Ollscoile sa Róimh san Iodáil é Paolo atá 55 bliain d’aois. I Lúnasa 2010 chuaigh Paolo amach i mótarbhád ina aonar go Ponza, oileán beag amach ó chostas na hIodáile. Tar éis dó Ponza a shroicheadh, bhraith sé go raibh airíonna ionfhabhtú conair fuail ag teacht air, ach níor thug sé mórán airde air ag an am, toisc gur cheap sé gurbh fhéidir gur tháinig na hairíonna sin air mar gheall ar díhiodráitiú de bharr bhrothall an tsamhraidh. Tar éis tamaill, áfach, tháinig fiabhras air agus é ag crith le fuacht agus chuaigh airíonna an ionfhabhtaithe ina chonair fuail in olcas. Chuaigh sé i gcomhairle lena dheartháir céile, atá ina dhochtúir leighis agus a bhí ag caitheamh a laethanta saoire i Ponza. Mhol a dheartháir céile dó ciprofloxacin a thógáil, antaibheathach fluaracuineolóin atá ar na hantaibheathaigh is coitianta a úsáidtear chun ionfhabhtuithe conair fuail a leigheas. Is féidir le duine ciprofloxacin a thógáil trína bhéal, mar sin tá sé éasca le tógáil agus is gnách dó a bheith éifeachtach in ionfhabhtuithe conair fuail a leigheas. Níor tháinig feabhas ar bith air sna trí lá ina dhiaidh sin agus níor tháinig aon mhaolú ar an bhfiabhras ach an oiread. Ina ainneoin seo, lean sé den chúrsa ciprofloxacin ar feadh seachtaine nó níos mó agus é ag súil leis go mbeadh sé maith go leor le dul ar ais sa mhótarbhád go dtí an Róimh agus dul faoi scrúdú leighis iomlán agus tástálacha saotharlainne. Bhí Paolo ar oileán Ponza, áit nach raibh seans ar bith go ndéanfaí tástáil saotharlainne ar a fhual chun tuiscint níos fearr a fháil ar cén t-antaibheathach lena bhféadfaí an frídín a chóireáil. Thuig sé go mbeadh sé tábhachtach torthaí a chultúr fuail a bheith ar eolas aige, ionas go bhféadfadh dochtúir an t-antaibheathach ceart a thabhairt dó mar oideas. Toisc go raibh eagla air dul sa mhótarbhád ina aonar go dtí an Róimh ar eagla go dtiocfadh tinneas air, chuaigh a deartháir céile in éineacht leis. Nuair a shroich sé an mhórthír, chuaigh sé go dtí ospidéal mór sa Róimh láithreach bonn, áit a ndearnadh scrúdú cultúr fuail agus cliniciúil air, rud a dheimhnigh go raibh ionfhabhtú casta conair fuail air. Fuarthas amach chomh maith go raibh faireog atá phróstatach aige agus gur dhócha gurbh é sin cúis dhóchúil an ionfhabhtaithe. Léirigh an cultúr go raibh sé ionfhabhtaithe le baictéar darb ainm Escherichia coli (E. coli), rud a chruthaigh béite-lachtamáisí le speictream leathnaithe (ESBL) agus go raibh sé frithsheasmhach in aghaidh cuid mhaith antaibheathach, lenar áiríodh ciprofloxacin. Léirigh na torthaí saotharlainne gurbh iad na hantaibheathaigh amháin a raibh E.coliPaolo íogair ina leith ná aigéad clavulanic/amoxicillin, trimethoprim-sulfamethoxazole, fosfomycin agus faoi dheireadh, aicme antaibheathaigh líne deireanaí darb ainm carbaipeineimí. Níorbh fhéidir le Paolo trimethoprim-sulfamethoxazolea thógáil, rud atá ina oibreán frithbhaictéarach béil, toisc go raibh ailléirge air leis. Ní féidir carbaipeineimí a thabhairt ach go hinfhéitheach, rud a chiallaíonn gur gá am a chaitheamh san ospidéal. Ordaíodh aigéad clavulanic/amoxicillin dó, rud a thóg sé trína bhéal ar feadh ceithre seachtaine. Tháinig feabhas ar a chás, ach tháinig fiabhras air arís ceithre lá tar éis do dheireadh teacht leis an gcóireáil, agus tháinig airíonna an ionfhabhtaithe ina chonair fuail ar ais arís. Chuir sé glao ar chara leis ansin, duine atá ina speisialtóir ar ghalair thógálacha, a mhol dó fosfomycin a thógáil trína bhéal mar dháileog cheart dá ionfhabhtú. Thóg sé é seo ar feadh 21 lá. Tháinig deireadh leis na hairíonna ansin agus tá sé ar fónamh ó shin. Tráchtaireacht: nótaí an cháis Tháinig ionfhabhtú casta conair fuail le haonarán E. coli a chruthaigh béite-lachtamáisí le speictream leathnaithe (ESBL) ar Paolo, fad is a bhí sé ar a laethanta saoire. Is einsímí iad ESBLanna a chruthaíonn baictéir, E.coli agus klebsiella pneumoniae de ghnáth, rudaí atá frithsheasmhach in aghaidh mhóramh na n-antaibheathach B-lactam, lena n-áirítear peinicilliní, ceifileaspóiriní agus aztreonam. Fuarthas amach nach raibh E.coli Paolo íogair ach i leith aigéid clavulanic/amoxicillin, trimethoprim-sulfamethoxazole, fosfomycin agus leis na carbaipeineimí, aicme antaibheathach líne deireanaí, arb iad an rogha cóireáil in aghaidh na mbaictéar a chruthaíonn ESBLanna. Pointí tábhachtacha ar chóir a thabhairt faoi deara sa chás seo ná gur tháinig ionfhabhtú ar Paolo a raibh E.coli thar a bheith frithsheasmhach a tógadh i measc pobail i gceist leis. Go háirithe, bhí an E.coli a bhí air frithsheasmhach in aghaidh na bhfluaracuineolón, ar aicme antaibheathach iad is féidir a chaitheamh tríd an mbéal chomh maith, chun ionfhabhtuithe conair fuail a chóireáil, lena n-áirítear cásanna casta de. Is iad na carbaipeineimí, a raibh an E.coli dá chuid íogair ina leith, an rogha antaibheathach i measc na n-othar a bhfuil ionfhabhtú baictéar a chruthaíonn ESBL orthu. Seachas na carbaipeineimí, rudaí a dtugtar go hinfhéitheach agus ar gá tréimhse a chaitheamh san ospidéal chun iad a fháil, ní raibh ach líon beag antaibheathach a d’fhéadfadh sé a thógáil a bheadh éifeachtach in aghaidh an ionfhabhtaithe agus ba bheag ceann acu a d’fhéadfadh sé a thógáil trína bhéal. Chomh maith leis sin, bhí ailléirge air le ceann acu, trimethoprim-sulfamethoxazole. Ba é an t-antaibheathach a bhí á thógáil ag Paolo faoi dheireadh ná aigéad clavulanic-amoxicillin, rud a thóg sé trína bhéal. D’fhéadfadh cuma íogair a bheith ar an antaibheathach seo sa tsaotharlann, ach níl sé éifeachtach in aghaidh E. coli ESBL i ndáiríre nuair a úsáidtear é mar chóireáil do dhaoine. Dealraíonn sé gurb é seo an fáth ar tháinig feabhas ar a chás nuair a rinneadh cóireáil air le haigéad clavulanic-amoxicillin, ach níor díbríodh an t-ionfhabhtú agus tháinig sé ar ais go tobann tar éis don chúrsa leighis a bheith críochnaithe. Is ábhar buartha é go bhfuil a leithéid de bhaictéir atá thar a bheith frithsheasmhach ag scaipeadh i measc an phobail agus mar chúis le hionfhabhtú i measc othar nach bhfuil teagmháil ar bith acu le hospidéal. Ar bhonn domhanda, aimsítear baictéir a chruthaíonn ESBLanna mar chúis le hionfhabhtú a thógtar i gcomhphobal agus le hionfhabhtú conair fuail go minic. Tá sé tábhachtach cóireáil a chur ar dhuine leis an antaibheathach ceart, ós rud é gur féidir le hothair éirí níos tinne agus toradh níos measa a bheith i gceist mar gheall ar na cineálacha seo baictéar atá thar a bheith frithsheasmhach. Teachtaireacht thábhachtach d’othair ná gur gá an t-antaibheathach ceart a ordú mar chóireáil. Mar sin, tá sé riachtanach dul chuig dochtúir agus go ndéanfaí tástáil mhicribhitheolaíochta ort.