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Epistaxis is one of the most common ear, nose and throat emergencies. The management of epistaxis has evolved significantly in recent years, including the use of nasal cautery and packs. However, a correct treatment requires the knowledge of nasal anatomy, potential risks, and complications of treatment. Epistaxis is often a simple and readily treatable condition, even though a significant bleed may have potentially severe consequences. At present, there are very few guidelines concerning this topic. The current Survey explored the pragmatic approach in managing epistaxis. A questionnaire, including 7 practical questions has been used. The current International Survey on epistaxis management reported a relevant prevalence (21.7%), mainly during childhood and senescence, an important hospitalization rate (11.8%), the common use of anterior packing and electrocoagulation, and the popular prescription of a vitamin supplement and intranasal creams. (www.actabiomedica.it)

Contains fulltext : 107887.pdf (Publisher’s version ) (Closed access) OBJECTIVE: To characterise commensal Escherichia coli and other Enterobacteriaceae with reduced susceptibility to cefotaxime that were collected in a large survey carried out among 3995 patients and healthy persons in two urban regions on Java, Indonesia, in 2001-2002. METHODS: The putative extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae were analysed using double-disk synergy tests, isoelectric focusing, PCR assays, DNA sequencing, and pulsed-field gel electrophoresis (PFGE). RESULTS: On the day of discharge after five or more days of hospitalisation, at least 95 of 999 (9.5%) patients carried ESBL-positive Enterobacteriaceae as dominant faecal flora. Six patients were simultaneously colonised with E. coli and Klebsiella pneumoniae isolates with ESBL activity. On admission, only 6 of 998 (0.6%) patients were colonised. Faecal carriage of ESBL-producing Enterobacteriaceae among healthy persons or persons visiting a public health centre was not detected. The 107 ESBL-positive strains included 68 E. coli, 35 K. pneumoniae, and four other Enterobacteriaceae. bla(CTX-M-15) was the most prevalent ESBL in both E. coli (47.1%) and K. pneumoniae (45.7%), but the E. coli O25b-ST131 clone was virtually absent. Other ESBL types found were: SHV-2, -2a, -5, -12, CTX-M-3, -9, -14, and TEM-19. PFGE revealed extensive genetic diversity among the isolates. CONCLUSIONS: In 2001-2002, faecal carriage of ESBL-producing Enterobacteriaceae as dominant flora in Indonesia was almost exclusively hospital-associated. The presence of various bla(ESBL) genes and the extensive genetic diversity among isolates argue against a single/dominant strain outbreak.

Item does not contain fulltext BACKGROUND: No detailed reports regarding extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae are currently available from Indonesia, the fourth most populous country in the world. METHODS: A survey was carried out to investigate the molecular epidemiology and genetic characteristics of clinical ESBL-producing Escherichia coli and Klebsiella pneumoniae isolates originating from the Dr. Soetomo Academic Hospital in Surabaya, Indonesia, over a 4 month period (January to April 2005). ESBLs were characterized by isoelectric focusing and PCR assays. Clonality of the isolates was assessed by PFGE and repetitive-sequence-based PCR (rep-PCR). Phylogenetic grouping was performed among CTX-M-15-producing E. coli. RESULTS: In total, 73 consecutive non-duplicate ESBL-positive E. coli and 72 K. pneumoniae strains were isolated. The bla(CTX-M-15) gene was found to be highly prevalent (69/73 strains, 94.5%) among the 73 ESBL-positive E. coli isolates. The gene was detected in both clonal and non-clonal isolates, as defined by PFGE and rep-PCR. Sixteen CTX-M-15-positive E. coli could be assigned to a single rep-PCR type and phylogenetic group B2 and belonged to the well-known O25b-ST131 clone. Among the 72 ESBL-positive K. pneumoniae isolates, bla(CTX-M-15) was again the most prevalent ESBL (40/72, 55.6%). Several SHV-type enzymes were also frequently detected: SHV-5 (n = 28); SHV-12 (n = 13); and SHV-2 (n = 6). TEM-type ESBLs were not detected in any of the isolates. CONCLUSIONS: Indonesia is another developing country affected by the emergence and spread of bacterial strains harbouring ESBL genes, including the CTX-M-15-producing B2-E. coli O25b-ST131 clone. 01 maart 2010

Contains fulltext : 88401.pdf (Publisher’s version ) (Closed access) SUMMARY OBJECTIVES: To identify determinants of carriage of resistant Staphylococcus aureus in both hospitalized patients and individuals from the community in two urban centres in Indonesia. METHODS: Staphylococcus aureus cultures and data on recent antibiotic use, demographic, socioeconomic, disease-related and healthcare-related variables were collected from 3995 community dwellers and hospitalized persons. Nasal S. aureus carriage was found in 362 persons (9.1%). Logistic regression analysis was performed to identify which variables were independently associated with carriage of resistant S. aureus. RESULTS: The penicillins were the most frequently used antibiotics both in the community and in hospitalized patients. In the community, admission to a hospital was associated with carriage of S. aureus resistant to any of the tested antibiotics [odds ratio (OR) 2.5, 95% confidence interval (95% CI) 1.3-4.9] and any tetracycline resistance (OR 2.4, 95% CI 1.1-5.1). Having no symptoms was associated with less carriage of S. aureus with resistance to any of the tested antibiotics (OR 0.5, 95% CI 0.3-0.9) and any tetracycline resistance (OR 0.5, 95% CI 0.3-0.9). Crowding (OR 4.5, 95% CI 1.2-4.9) and low income (OR 8.9, 95% CI 1.8-43.9) were associated with multidrug resistance. In hospitalized patients, the use of penicillins was associated with resistance to any of the tested antibiotics (OR 3.9, 95% CI 1.4-11.6) and any tetracycline resistance (OR 3.7, 95% CI 1.1-12.0). CONCLUSIONS: Antibiotic policies including proper diagnosis, treatment and drug delivery process should be made by healthcare providers in Indonesia to help limit the emergence of antibiotic resistance. 01 oktober 2010

Few data on the molecular characteristics and epidemiology of Staphylococcus aureus from Indonesia are available. The purpose of the present study was to define S. aureus reservoirs in both the Indonesian community and hospital using a collection of 329 nasal carriage isolates obtained during a survey of 3,995 healthy individuals and patients from Java, Indonesia. Only one strain (0.3%) was identified as methicillin-resistant S. aureus by mecA gene PCR. The Panton-Valentine leukocidin (PVL) genes were detected in 35 methicillin-sensitive S. aureus strains (10.6%). Molecular typing by pulsed-field gel electrophoresis of the 329 isolates showed extensive genetic diversity among both PVL-positive and PVL-negative strains. In Surabaya, Indonesia, however, a cluster was identified that was strongly associated with the presence of the PVL locus ( P < 0.0001). As determined by high-throughput amplified fragment length polymorphism, PVL-positive strains occurred throughout all major AFLP clusters (I to IV). Multilocus sequence typing of a subset of isolates showed that most PVL-positive strains belonged to sequence type (ST) 188, while most PVL-negative isolates belonged to ST45. The high prevalence of PVL-positive S. aureus strains in certain regions of Indonesia is of concern since these strains may cause severe infections in the community and in hospitals.

Although a variety of techniques are available for antimicrobial susceptibility testing, disk diffusion methods remain the most widely used. We compared the accuracy of disk diffusion zone diameters as obtained by manual zone measurements in a low resource country (Indonesia) to that by automated zone measurements (Oxoid aura image system) in a high resource setting (the Netherlands) to determine susceptibility categories (sensitive, intermediate susceptible or resistant). A total of 683 isolates were studied, including 294 Staphylococcus aureus, 195 Escherichia coli and 194 other Enterobacteriaceae. Antimicrobial agents included tetracycline, oxacillin, gentamicin, erythromycin, trimethoprim/sulfamethoxazole and chloramphenicol for S. aureus and ampicillin, gentamicin, cefotaxime, ciprofloxacin, trimethoprim/sulfamethoxazole, and chloramphenicol for E. coli and other Enterobacteriaceae. Of the 4098 drug-organism combinations, overall category agreement (CA), major discrepancy (MID) and minor discrepancy (mD) between the two methods were 82.4% (3379/4098), 6.0% (244/4098) and 11.6% (475/4098), respectively. One hundred and sixty three of 244 MDs were resolved using reference broth microdilution method. Overall very major error (VME), major error (ME) and minor error (mE) of manual zone measurement were 28.8%, 45.4% and 4.9%, respectively and for the aura image system 4.9%,16.0% and 4.9%, respectively. The results of this study indicate that the disk diffusion method with manual zone measurement in Indonesia is reliable for susceptibility testing. The use of an automated zone reader, such as the aura image system, will reduce the number of errors, and thus improve the accuracy of susceptibility test results for medically relevant bacteria. (C) 2008 Elsevier B.V. All rights reserved.

To report the beneficial effect of prophylactic methylene blue administration before induction of anesthesia in a patient with congenital methemoglobinemia. A 26-yr-old male patient known to have congenital methemoglobinemia was scheduled forturbinectomy under general anesthesia. The patient was clinically cyanotic with a pulse oximetry of 91 %. Arterial blood gas analysis showed a partial pressure of oxygen (PaO2) of 81.3 mmHg associated with a fractional oxyhemoglobin of 80.7%, and a methemoglobin fraction of 0.159. Preoperativeiv administration of 1 mg·kg-1 of methylene blue resulted, within five minutes, in a decrease of methemoglobin fraction down to 0.05 associated with an increase of the fractional oxyhemoglobin saturation up to 94.7%. After two hours, the methemoglobin fraction decreased to 0.01 and the fractional oxyhemoglobin concentration increased to 97.7%. Induction of anesthesia as well as intraoperative and postoperative course were uneventful without any episode of hypoxemia. Postoperatively, the methemoglobin fractions remained low for 24 hr, to be followed by a gradual increase up to 0.02 on the second day to reach 0.094 on the fifth day. The prophylactic preoperative methylene blue administration in a patient with congenital methemoglobinemia significantly decreased the methemoglobin level and increased the fractional oxygen saturation with a consequent increase of the safety margin against perioperative hypoxemia.

Objective: In this study, we evaluated a RandomAmplified Polymorphic DNA (RAPD) method, in thesubtyping of H. influenzae in middle ear effusions(MEE), obtained from 33 patients with otitis media witheffusion (OME) admitted to 3 medical centers in Beirut,Lebanon.Method: RAPD was initially evaluated on 15 H.influenzae isolates using three 10 mer primers alongwith a 21 mer primer.Results: Primer 1 (10 mer) and Primer 2 (20 mer) werethe most discriminatory when used in conjunction andwere selected to be used on DNA lysates obtained from33 MEE samples positive for H. influenzae by PCR.Conclusion: Our data have shown that 4 RAPD patternswere obtained on DNA of H. influenzae isolates and asingle RAPD pattern was seen on H. influenzae DNAfrom MEE samples. This indicates that a single strainmay have been implicated in these infections. Studiesare underway to determine the prevalence of H.influenzae as the etiology of otitis media with effusionin Lebanon and subtype the organism to determine apossible multi-strain involvement.Key words: Otitis, PCR, subtyping

Background Antimicrobial resistance is an increasing problem in developing countries and antibiotic use is widespread. Our previous surveys in Java, Indonesia, revealed that most antibiotic use was probably unnecessary or ineffective. The aim of this study was to explore a potential connection between resistance and substandard antibiotics sold in the area. Methods A cross-sectional field study using the simulated client method was conducted in Surabaya. Five first-line antibiotics were requested with or without prescription (OTC). A certified laboratory analysed the drug content using validated methods. Possible determinants of substandard quality were explored. Results In total, 104 samples from 75 pharmacies, ten drug stores and 39 roadside stalls (kiosks) were obtained. Pharmacy employees filled all OTC requests. Three quarters of kiosks sold antibiotics. Antibiotics were dispensed as single blister strips or repackaged (16%) without label. Ninety five percent of samples carried the label of 14 Indonesian manufacturers. The pharmaceutical quality did not meet BP standards for 18% of samples. Deviations (less active ingredient) were small. There was no association between low content and type of outlet, sold with or without prescription, registration type, price or packaging. Median retail prices of products carrying the same label varied up to 20 fold. Conclusions Antibiotics were available OTC in all visited pharmacies and sold in the streets of an Indonesian city. Most samples contained an active ingredient. We urge to increase enforcement of existing regulations, including legislation that categorizes antibiotics as prescription-only drugs for all types of medicine outlets, to limit further selection of antimicrobial resistance.

Staphylococcus sciuri strains were unexpectedly cultured from healthy persons and patients from Indonesia during a population-based survey on nasal Staphylococcus aureus carriage. Fifty-one S. sciuri isolates were further characterized. The S. aureus mecA gene was detected by PCR in 22 isolates (43.1%), whereas S. sciuri mecA was found in 33 isolates (64.7%). The staphylococcal cassette chromosome mec (SCC mec ) regions of S. aureus mecA -positive isolates contained elements of classical S. aureus SCC mec types II and/or III.

Antimicrobial resistance of bacteria is a worldwide and ever-growing problem, directly linked to the use of antimicrobial drugs. Resistant bacteria emerge under the selective pressure of antibiotics. In hospitals, where large-scale usage of antibiotics is common, bacteria frequently become resistant to several antibiotics which causes serious problems for the treatment of patients with infections by these microorganisms. Well-known (multi)-resistant bacteria causing problems in many countries all over the world are methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, penicillin-resistant pneumococci, extended-spectrum betalactamase-producing Klebsiella pneumoniae, carbapenem-resistant Acinetobacter baumannii, and multiresistant Mycobacterium tuberculosis

Contains fulltext : 71429.pdf (Publisher’s version ) (Closed access) OBJECTIVE: To optimize antimicrobial treatment of patients with fever upon admission to the department of internal medicine of Dr Soetomo Hospital in Surabaya, Indonesia. METHOD: Prospective intervention study. The intervention comprised development of a consensus guideline, an official declaration of the guideline by the head of department, distributing a guideline pocketbook, carrying out blood cultures free of charge, teaching sessions and refresher courses. The outcome was measured with reference to (i) percentage of patients with fever started on antibiotic therapy, (ii) amount of antibiotics used expressed as defined daily doses (DDD)/100 patient-days, (iii) percentage of appropriate prescriptions and of prescriptions without indication as assessed by independent reviewers, (iv) percentage of treatments in accordance with guidelines, (v) percentage of patients in whom blood cultures were taken before starting antimicrobial therapy, (vi) percentage of treatments appropriately stopped on re-evaluation of the patients at 72 h and (vii) mortality. RESULTS: The study involved 501 patients, 95 residents and 60 specialists. After the intervention 17% patients less were treated with antibiotics upon admission and antibiotic use fell from 99.8 to 73 DDD/100 patient-days. The percentage of patients with sepsis and dengue treated in accordance with the guideline increased by 23% and 30%. The percentage of appropriate therapies, therapies without indication and mortality did not change significantly. The percentage of patients for whom a blood culture was taken upon admission increased from 3% to 81%; however, almost all were taken after they commenced antibiotic therapy. Therapy was not adjusted after 72 h in any case. Interrupted time series analysis showed that the start of development of the guideline and the declaration of the guideline were the interventions with the greatest impact. CONCLUSION: The multifaceted intervention had limited success. A very important drawback to the prudent use of antibiotics was the absence of adequate microbiological diagnostics.