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      Antibiotic-Resistant Bugs in the 21st Century — A Clinical Super-Challenge

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      New England Journal of Medicine

      Massachusetts Medical Society

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          Most cited references 3

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          Extended-spectrum beta-lactamase-producing Enterobacteriaceae: an emerging public-health concern.

          The medical community relies on clinical expertise and published guidelines to assist physicians with choices in empirical therapy for system-based infectious syndromes, such as community-acquired pneumonia and urinary-tract infections (UTIs). From the late 1990s, multidrug-resistant Enterobacteriaceae (mostly Escherichia coli) that produce extended-spectrum beta lactamases (ESBLs), such as the CTX-M enzymes, have emerged within the community setting as an important cause of UTIs. Recent reports have also described ESBL-producing E coli as a cause of bloodstream infections associated with these community-onset UTIs. The carbapenems are widely regarded as the drugs of choice for the treatment of severe infections caused by ESBL-producing Enterobacteriaceae, although comparative clinical trials are scarce. Thus, more rapid diagnostic testing of ESBL-producing bacteria and the possible modification of guidelines for community-onset bacteraemia associated with UTIs are required.
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            Emergence and management of drug-resistant enterococcal infections.

            The treatment of multidrug-resistant enterococcal infections continues to be a challenge for clinicians. Glycopeptide and beta-lactam resistance is now a common feature of the majority of Enterococcus faecium hospital isolates, and resistance to aminoglycosides, quinupristin-dalfopristin, linezolid and daptomycin further complicates the problem. New antibiotics, such as tigecycline, lipoglycopeptides (dalbavancin, oritavancin and telavancin) and cephalosporins with activity against Enterococcus faecalis (ceftobiprole and ceftaroline), may have potential activity against certain resistant enterococcal strains in specific clinical settings, as may some older antibiotics, such as ampicillin, chloramphenicol, doxycycline, minocycline and nitrofurantoin. However, the treatment of endovascular infections (particularly endocarditis, where bactericidal therapy is important for optimal cure rates) caused by resistant enterococci continues to be an immense challenge even with the availability of new agents. The optimal therapy for these infections is not well established and clinical data are usually limited to case reports with conflicting results. Therefore, treatment decisions may have to be based on animal models and sporadic experiences and the best approach is for the physician to consider carefully each patient on a case by case manner and gather all the clinical and microbiological information possible regarding species identification and susceptibilities in order to choose a therapeutic regimen that would appear to be active.
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              Daptomycin treatment failure for vancomycin-resistant Enterococcus faecium infective endocarditis: impact of protein binding?

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                Author and article information

                Journal
                New England Journal of Medicine
                N Engl J Med
                Massachusetts Medical Society
                0028-4793
                1533-4406
                January 29 2009
                January 29 2009
                : 360
                : 5
                : 439-443
                Article
                10.1056/NEJMp0804651
                19179312
                © 2009
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