Clinical and economic evaluation of oral ciprofloxacin after an abbreviated course of intravenous antibiotics

PURPOSE: Oral ciprofloxacin has the requisite pharmacokinetic and antibacterial properties to rival the potency of intravenous antibiotics. This study was designed to determine whether oral ciprofloxacin could abbreviate the course of intravenous antibiotics in the treatment of serious infections. PATIENTS AND METHODS: Hospitalized adult patients were eligible for enrollment if they had a serious infection that was expected to require 8 or more days of intravenous antibiotic treatment. After conventional intravenous antibiotics were administered for 3 days, informed consent was obtained and patients were randomly assigned to either continue parenteral antibiotics (n = 53) or switch to oral ciprofloxacin 750 mg taken twice daily (n = 52). Ninety-nine of the 105 patients were evaluable for the assessment of efficacy. Clinical and bacteriologic efficacy, adverse events, and costs of the two treatments were compared. RESULTS: The two treatment groups were comparable for demographic characteristics, types of infections, bacteria isolated, initial intravenous antibiotic regimens, and duration of antibiotic treatment. The most common infections were of the skin and skin structure; bacteremia and infections of the lower respiratory tract, urinary tract, and bone and joint were also represented. The most commonly isolated pathogens were Staphylococcus aureus, Pseudomonas aeruginosa, and Escherichia coli. The most frequently prescribed intravenous antibiotics before randomization included aminoglycosides, cephalosporins, vancomycin, and nafcillin; 52 evaluable patients were treated with combination therapy while 47 received monotherapy. The clinical and bacteriologic outcomes and adverse reaction frequency with oral ciprofloxacin were comparable to those of the continued intravenous antibiotic regimens. Ciprofloxacin was associated with an average cost savings of $293 per patient. CONCLUSION: When used after 3 days of intravenous antibiotics, oral ciprofloxacin was as safe and effective as full courses of intravenous antibiotics and provided substantial cost savings.     

Efficacy of exclusively oral antibiotic therapy in patients hospitalized with nonsevere community-acquired pneumonia: a retrospective study and meta-analysis

PURPOSE: To assess the efficacy of oral antibiotics in patients hospitalized with community-acquired pneumonia and to identify factors precluding oral therapy. METHODS: In a meta-analysis, we compared inpatient oral and parenteral therapy in community-acquired pneumonia. Studies were reviewed independently and rated by two reviewers, and results were summarized. We also performed a retrospective cohort study of hospitalized patients with community-acquired pneumonia and compared outcomes in patients treated with oral versus parenteral therapy. RESULTS: For the meta-analysis, we identified seven studies involving 1366 patients. Study exclusions included severe pneumonia or impaired oral absorption. There was no significant difference in the relative risk of mortality at the end of treatment or at follow-up. Mean length of hospital stay was shorter (6.1 days vs. 7.8 days) in patients taking oral antibiotics than in those taking the parental form. In the retrospective cohort, 18% (124/698) of patients received oral-only therapy; these patients were younger (median age, 75 vs. 78 years, P = 0.01) and had lower mean pneumonia severity index scores (101 vs. 119, P <0.0001) than those who received parenteral therapy. In multivariable models, oral-only patients had a median length of stay that was 1.3 days shorter (95% CI: 0.4% to 2.2% days; P = 0.008) and a median antibiotic cost that was 56 dollars lower (95% CI: 53 dollars to 58 dollars; P <0.0001) than that of patients in the parenteral group, but mortality was similar. CONCLUSION: Although prospective data are limited, oral antibiotics in certain hospitalized patients with community-acquired pneumonia are effective. More data are needed to identify appropriate candidates for exclusively oral antibiotic therapy.     

Infectious disease consultations and antibiotic usage in a Turkish university hospital.

OBJECTIVES: The aim of this study was to investigate the various features of infectious disease (ID) consultations and the usage of antibiotics in a Turkish university hospital. METHODS: A total of 395 consultation requests were recorded during a three-year period. RESULTS: The departments most frequently requesting the consultation services of the ID department were Orthopedics (29.6%), Neurology (18.5%), Cardiology (11.8%) and Internal Medicine (10.4%). The main reasons were for diagnosis of unexplained fever (42.3%) and for antibiotic modification according to culture results (18%). Diagnoses made by the ID consultant were pneumonia (16.7%), urinary tract infections (9.3%), bone and joint prosthesis infections (9.1%) and in 15.7% of the investigated patients, no infectious focus was determined. It was recognized that the use of antibiotics had already been initiated in the great majority of patients (67.1%) before the consultation request. While the current therapy was changed in 57.4% of these patients, antibiotics were not necessary for 9.8%. CONCLUSIONS: Since the most common diagnoses were respiratory and urinary tract or bone and joint prosthesis infections, the ID specialists should have detailed knowledge of these problems. Usage of antibiotics without ID consultation was prevalent, therefore a continuous educational program is a necessity for healthcare workers in the hospital.     

Evaluation of outpatient treatment with ertapenem in a double blind controlled clinical trial of complicated skin/skin structure infections

OBJECTIVES: The patient characteristics and the efficacy and safety of ertapenem 1 g once daily vs. piperacillin-tazobactam 13.5 g divided Q6H were examined in patients who received outpatient parenteral antimicrobial therapy (OPAT) during a clinical trial of complicated skin/skin structure infections. METHODS: The population analyzed included 363 patients treated at US sites in a large randomized double-blind study. RESULTS: In this analysis, 146 (40%) patients at 19 (66%) sites were managed by OPAT. A lower proportion of treated patients who received OPAT had severe infection (12% vs. 20%, P=0.03). In evaluable patients managed by OPAT, 45 (83.3%) of 54 treated with ertapenem and 41 (82.0%) of 50 treated with piperacillin-tazobactam were cured at the test of cure assessment 10-21 days post-therapy (OR 1.2 (95% CI, 0.4-3.2), P=0.78). The safety profile of both drugs was generally similar; diarrhoea was the most common adverse event in both groups. CONCLUSIONS: In this trial of complicated skin/skin structure infection, OPAT was commonly used by US investigators. Among patients who received OPAT, ertapenem 1 g daily was as effective as piperacillin-tazobactam 3.375 g Q6H.     

Decision analysis of antibiotic and diagnostic strategies in ventilator-associated pneumonia

The optimal strategy for ventilator-associated pneumonia remains controversial. To clarify the tradeoffs involved, we performed a decision analysis. Strategies evaluated included antibiotic therapy with and without diagnostic testing. Tests that were explored included endotracheal aspirates, bronchoscopy with protected brush or bronchoalveolar lavage, and nonbronchoscopic mini-bronchoalveolar lavage (mini-BAL). Outcomes included dollar cost, antibiotic use, survival, cost-effectiveness, antibiotic use per survivor, and the outcome perspective of financial cost-antibiotic use per survivor. Initial coverage with three antibiotics was better than expectant management or one or two antibiotic approaches, leading to both improved survival (54% vs. 66%) and decreased cost (US dollars 55447 vs. US dollars 41483 per survivor). Testing with mini-BAL did not improve survival but did decrease costs (US dollars 41483 vs. US dollars 39967) and antibiotic use (63 vs. 39 antibiotic days per survivor). From the perspective of minimizing cost, minimizing antibiotic use, and maximizing survival, the best strategy was three antibiotics with mini-BAL.     

Accuracy of consultations performed by infectious diseases trainees and factors associated with adherence to them.

OBJECTIVES: Infectious diseases (ID) trainees should be familiar with duties relevant to consultation practice. In this study we aimed to analyze the ID trainee night/weekend shift consultation process in terms of consultant characteristics, types of recommendations, and compliance with recommendations. METHODS: All consultations performed by ID trainees on the night shift and at the weekends between 10 June and 10 August 2004 were recorded prospectively on standardized forms. Infectious diseases specialists assessed the appropriateness of recommendations the day after each consultation. Recommendations were considered complied with if they were carried out within 72 hours of the consultation. RESULTS: Of 440 consultations, 163 were for a clinically diagnosed infection (without specific antibiotic request) and 79 were for treatment continuation. Overall, 152 consultations were for requesting specific antibiotic(s), and 327 antibiotics were recommended or approved in 270 consultations. Eight of these recommendations were inappropriate. Overall compliance to ID recommendations was 75.3% (418/555). In univariate analysis, the compliance rate to non-treatment recommendations (microbiologic cultures, radiology, biochemistry, etc.) was found to be lower than the rate of compliance to antibiotic recommendations (186/308 vs. 232/247, p<0.05). In addition, compliance to recommendations made by the first-year trainees was lower than to the recommendations made by the other trainees. In logistic regression analysis only recommendations including antibiotic treatment was associated with higher compliance (p=0.0001, odds ratio=10.2, 95% CI=5.7-18.3). CONCLUSIONS: ID trainees are capable of evaluating patients and recommending appropriate antibiotics. Methodologies to improve the compliance to non-treatment-based recommendations and optimizing antibiotic selection seem to be necessary.     

Outpatient parenteral antimicrobial therapy with continuous infusion of meropenem: A retrospective analysis of three years of clinical experience

IntroductionData regarding outpatient parenteral antimicrobial therapy (OPAT) with continuous infusion of meropenem (CIM) remain scarce and controversial. We aimed to analyze its outcomes.MethodsWe conducted a retrospective analysis of a cohort of patients who received OPAT with CIM during a three-year period at a single center in northwest Spain. Demographics, clinical data and OPAT outcomes were recorded.ResultsSince January 2017–December 2019, 34 patients received 35 OPAT episodes with CIM. The median age was 75 years, and 18 (51.4%) had a Charlson comorbidity index > 2. Twelve (34.3%) had respiratory infection, 11 (31.4%) urinary tract infection, and 12 (34.3%) other infections. Twenty-one (60%) received a dose of 6 g/day, and 27 (77.1%) received combined antibiotic therapy. The duration of OPAT with CIM was 10 median days. Pseudomonas aeruginosa was the most frequently (34.3%) isolated microorganism and 10 (28.6%) infections were polymicrobial. During OPAT and hospital at home unit admission, 4 (11.4%) patients had any adverse reaction that required CIM withdrawal, 2 (5.7%) were readmitted, and 3 (8.8%) died (2 infection-related deaths). After 30 days from discharge 6 (18.8%) of 32 not-censored patients had unplanned readmissions (2 infection-related), 6 (18.8%) developed recurrence (3 relapses, 3 reinfections) and 1 (3.1%) died (none-infection-related death). Twenty-three (71.9%) of these 32 patients did not experience unplanned readmission, recurrence or death.ConclusionCIM can be an option to be administrated in OPAT programs in selected patients. Further studies are warranted to increase evidence regarding its use, and to externally validate our findings.     

Making a business case for quality by regional information sharing involving cardiothoracic surgery

A consortium of cardiac surgeons, nurses, and administrators in Virginia has developed a clinical/financial database to identify sites with best outcomes and replicate best practices statewide. The financial value of quality improvements is estimated from the incremental savings gained by reducing postoperative complications. The group studied 7,417 coronary artery bypass graft cases in 2003-2004. The average costs of atrial fibrillation, stroke, mediastinitis, renal failure, reoperation for bleeding, and prolonged use of ventilation were measured using charge data and ratios of costs-to-charges. Costs ranged from 18,093 US dollars to 28,136 US dollars in eight hospitals. Lower-cost hospitals had lower standardized mortality ratios. Average total costs were 19,049 US dollars for cases with no complications. Cases with postoperative atrial fibrillation were 21,415 US dollars, an incremental cost of 2,366 US dollars (p<0.0001), and reached 54,671 US dollars for mediastinitis (deep sternal wound infections) and 57,360 US dollars for renal failure. Overall, 16.1% of 5,230 coronary artery bypass graft patients developed atrial fibrillation in 2003. Incidence ranged from <5% to nearly 30% across 14 hospitals. Reducing the incidence of complications by small fractions can yield significant savings. Paying for performance may lead to more comparative analysis, peer-to-peer collaboration, and new approaches to quality improvement and efficiency measurement.     

Patient selection criteria and management guidelines for outpatient parenteral antibiotic therapy for native valve infective endocarditis.

Outpatient parenteral antibiotic therapy (OPAT) for infective endocarditis (IE) is being applied widely, despite the absence of controlled data that demonstrates that outcomes are equivalent to those with standard inpatient antibiotic therapy. We review existing OPAT guidelines, published data on the timing of complications from IE, and data on risk factors that can be used to predict complications. These data are used to propose more stringent criteria for patient selection and clinical management of OPAT for native valve IE. We recommend a conservative approach (inpatient or daily outpatient follow-up) during the critical phase (weeks 0-2 of treatment), when complications are most likely, and we recommend consideration of OPAT for the continuation phase (weeks 2-4 or 2-6 of treatment) when life-threatening complications are less likely.     

Effective medical waste management: it can be done

BACKGROUND: It was noticed that a large volume of medical waste was being generated for incineration at our hospital. The 2 incinerators at our facility were unable to effectively deal with the load of waste and, therefore, were operating for extended periods of time. This caused a significant amount of soot and other emissions to be produced as pollutants into the surrounding environment, which is considered to be a real health hazard. METHODS: A waste-management plan was introduced that included education, mandatory inservice training, auditing of the type and volume of waste generated by each department, and introduction of a written policy on waste management. RESULTS: Within a few months of implementation of the waste-management plan, the amount of medical waste was reduced by more than 58%, from 609 skips/mo (2000 kg/day) in the year 1999, to 256 skips/mo (850 kg/day) in the year 2000; skips are steel containers filled with infectious waste. This reduction was maintained throughout the year 2001 and lead to a 50% reduction in total financial costs (17,936 US dollars) with savings in fuel of 5262 US dollars, labor-cost savings of 8990 US dollars, and maintenance and spare parts savings of 3680 US dollars. CONCLUSIONS: This article discusses problems encountered in waste management in our health care facility, solutions and control measures introduced, and achievements. It also demonstrates that effective waste management can reduce health risk, save money, and protect the environment.     

Executive summary of outpatient parenteral antimicrobial therapy: Guidelines of the Spanish Society of Clinical Microbiology and Infectious Diseases and the Spanish Domiciliary Hospitalisation Society

Outpatient parenteral antimicrobial therapy (OPAT) programmes make it possible to start or complete intravenous antimicrobial therapy for practically any type of infection at home, provided that patient selection is appropriate for the type of OPAT programme available. Although the clinical management of infections in the home setting is comparable in many respects to that offered in conventional hospitalization (selection of antibiotics, duration of treatment, etc.), there are many aspects that are specific to this care modality. It is essential to be aware of them so that OPAT continues to be as safe and effective as inpatient care. The objective of this clinical guideline is therefore to provide evidence- and expert-based recommendations with a view to standardizing clinical practice in this care modality and contribute to a progressive increase in the number of patients who can be cared for and receive intravenous therapy in their own homes.     

Ambulatory antibiotic infusion devices: extending the spectrum of outpatient therapies

STUDY OBJECTIVE: To examine the safety and efficacy, as well as the economic impact, of outpatient intravenous antibiotic administration using an ambulatory infusion pump. DESIGN: Retrospective analysis of patients treated through a single home care pharmacy. SETTING: General community and skilled nursing facilities of the greater Monterey (California) area. PATIENTS: Ninety-eight consecutive patients with infections requiring parenteral antibiotics, treated outside the acute-care setting and not eligible for traditional intravenous minibag administration. INTERVENTIONS: Patients received intravenous antibiotics either in the home setting (86%) or in skilled nursing facilities (11%) using a Pharmacia Deltec CADD-VT ambulatory infusion device. MEASUREMENTS AND MAIN RESULTS: Between April 1, 1986, and July 30, 1988, 98 patients received parenteral antibiotics using an infusion pump, and complete data were available on 96 (98%). A total of 109 treatment courses were given over 1,917 treatment days, with a mean duration of therapy of 18 days. Twenty-three different infections were treated by the use of 12 separate antibiotics. The most common complications included vein irritation (11%) and the inability to maintain venous access (6.2%). Therapy costs were equivalent to or less than the intravenous minibag system depending on the frequency of antibiotic administration. Eighty percent of patients experienced successful resolution of their infection. CONCLUSIONS: Ambulatory antibiotic infusion pumps can be used safely and effectively in the outpatient setting. Use of these pumps should increase the number of patients eligible for out-of-hospital treatment, resulting in a marked reduction in treatment costs.     

Limited role for outpatient parenteral antibiotic therapy for community-acquired pneumonia

Background and objective: This study examined the potential utility of outpatient parenteral antibiotic therapy (OPAT) as a means of reducing the excessive number of patients hospitalized with low‐risk community‐acquired pneumonia (CAP). Methods: A prospective feasibility study was conducted, in which a selection algorithm was applied to a cohort of patients admitted with suspected CAP, to identify a group in whom admission may have been prevented by the use of OPAT. Numbers of potentially suitable patients, inpatient bed days saved and frequency of adverse events that may have led to readmission were measured. Results: There were 118 inpatients treated with confirmed CAP during the study period, of whom 27 had low‐risk disease (Pneumonia Severity Index grades I–III). Application of the selection algorithm identified eight (30% of those with low‐risk disease) patients who were potentially suitable for OPAT, and this group commonly experienced adverse events during follow up which may have resulted in readmission to hospital. Conclusions: In many hospitalized patients with CAP, outpatient therapy is precluded by either disease severity or active medical and psychosocial factors. This limits the role of OPAT as a tool for reducing the inpatient burden of CAP.     

Systemic antibiotic therapy for chronic osteomyelitis in adults

The standard recommendation for treating chronic osteomyelitis is 6 weeks of parenteral antibiotic therapy. However, oral antibiotics are available that achieve adequate levels in bone, and there are now more published studies of oral than parenteral antibiotic therapy for patients with chronic osteomyelitis. Oral and parenteral therapies achieve similar cure rates; however, oral therapy avoids risks associated with intravenous catheters and is generally less expensive, making it a reasonable choice for osteomyelitis caused by susceptible organisms. Addition of adjunctive rifampin to other antibiotics may improve cure rates. The optimal duration of therapy for chronic osteomyelitis remains uncertain. There is no evidence that antibiotic therapy for >4-6 weeks improves outcomes compared with shorter regimens. In view of concerns about encouraging antibiotic resistance to unnecessarily prolonged treatment, defining the optimal route and duration of antibiotic therapy and the role of surgical debridement in treating chronic osteomyelitis are important, unmet needs.     

Cost-effectiveness of outpatient parenteral antibiotics: a review of the literature

The results of studies completed on parenteral antibiotic therapy administered in an outpatient setting are reviewed. Although they varied in both size and sophistication, the studies all found that when patients and their families were carefully screened, outpatient therapy was a cost-effective, safe method of administering intravenous antibiotics. The methods used to compare the costs of inpatient and outpatient intravenous antibiotic therapy varied widely. Only direct costs were included in the early comparisons of inpatient and outpatient therapy, whereas the more recent studies included both direct and indirect costs and benefits. All studies found cost savings in the outpatient setting. Unfortunately, very few elderly patients were included because of a Medicare requirement that intravenous antibiotic therapy be administered or supervised by a physician. However, beginning in 1990, the Medicare Catastrophic Coverage Act of 1988 will cover intravenous drugs administered at home. Thus, it will be possible to study applicability of this therapy for the elderly population.     

Outpatient parenteral antimicrobial therapy‐treated bone and joint infections in a tropical setting

Background: Osteoarticular infections are a primary indication for outpatient parenteral antimicrobial therapy (OPAT). The climate and geographical diversity of tropical Australia, together with the prevalence of melioidosis, disseminated gonococcal disease and community‐acquired methicillin‐resistant Staphylococcus aureus renders this a challenging environment in which to manage such infections. We evaluated patients managed by the Royal Darwin Hospital Hospital in the Home service for bone and joint infections. Methods: A retrospective analysis of the therapeutic outcomes at the end of intravenous therapy was carried out for patients treated between 1 January 2006 and 15 September 2007. Results: Fifty‐five patients were treated, including 21 (38%) indigenous Australians and 18 (33%) from remote communities. Baseline characteristics were similar to other published data, but there were two cases each of gonococcal septic arthritis and melioidosis. During treatment, 39 (71%) lived at home, with five (9%) of these receiving treatment at community clinics. Thirteen (24%) resided in self‐care units in the hospital grounds. Three (5%) were managed at hostels or in prison. Median duration of parenteral therapy was 42 days, with a median of 22 days outside hospital, providing a total saving of 1307 bed‐days. Clinical success at end of therapy was 84%, with no significant difference between indigenous and non‐indigenous cohorts. Conclusion: OPAT for osteoarticular infections is both feasible and effective in a tropical environment, including for indigenous patients. Extension of treatment to remote‐dwelling patients is facilitated by the innovative use of self‐care units and administration of treatment at remote clinics.     

Use of silver-hydrogel urinary catheters on the incidence of catheter-associated urinary tract infections in hospitalized patients

BACKGROUND: Urinary tract infections (UTIs) account for 40% of all nosocomial infections, and about 80% of these are associated with the use of urinary catheters. They not only contribute to excess morbidity and mortality, but they also significantly add to the cost of hospitalization. Clinical trials with silver-coated urinary catheters have shown conflicting results. However, recent trials with silver-hydrogel urinary catheters have shown a reduction in nosocomial UTIs, and these catheters appear to offer cost savings. METHOD: The University of Massachusetts Medical Center is a teaching, tertiary hospital with 18% of its beds in intensive care units. The silver-hydrogel urinary catheters were introduced in October 1997. The rate of catheter-associated UTIs with silver-hydrogel urinary catheter use was compared with a historical baseline UTI rate that was established for January 1996 and January 1997 with the standard, noncoated catheters. The cost of a nosocomial catheter-associated UTI was estimated by calculating the hospital charges resulting from all urinary catheter-associated UTIs in 1 month. A cost-analysis of silver-hydrogel urinary catheter use was performed. RESULTS: The rate of catheter-associated UTIs for noncoated catheters was 4.9/1000 patient-days compared with 2.7/1000 patient-days for the silver-hydrogel catheters, a reduction of 45% (P =.1). The average cost (calculated with hospital charges) of a catheter-associated UTI at our institution was estimated to be $1214.42 US dollars, with a median of $613.72 US dollars. The estimated cost-saving ranged from $12,563.52 US dollars to $142,314.72 US dollars. CONCLUSIONS: The use of silver-hydrogel urinary catheters resulted in a nonsignificant reduction in catheter-associated UTIs and a modest cost-saving.     

Early discharge of infected patients through appropriate antibiotic use

BACKGROUND: Patients with infections are usually discharged from the hospital with antibiotics when afebrile and clinically improved. OBJECTIVES: To compare outcomes of early vs conventionally discharged patients and to examine the role of antibiotic use in the discharge process. METHODS: One hundred eleven patients hospitalized with cellulitis, community-acquired pneumonia, or pyelonephritis (urinary tract infection) discharged from the hospital early in their clinical course before defervescence by an infectious diseases hospitalist (L.J.E.) were compared in a case-controlled study with 112 patients discharged from the hospital according to conventional standards of care by internal medicine (IM) hospitalists. Patients were matched for age, sex, diagnosis, and comorbidities. Outcomes were determined for average lengths of stay, readmission to the hospital within 30 days with the same diagnosis, satisfaction with their discharge program, and time to return to their normal activities of daily living. RESULTS: Patients cared for by the infectious diseases hospitalist had a shorter average length of stay (mean difference, 1.7 days), no readmissions, higher satisfaction scores, and a shorter time to return to their activities of daily living, compared with those cared for by the IM hospitalists. Analysis of the antibiotics that patients were discharged with revealed that the infectious diseases hospitalist used outpatient parenteral antibiotic therapy more frequently than IM hospitalists in the treatment of cellulitis, and switched from intravenous to oral antibiotics sooner than IM hospitalists for patients with community-acquired pneumonia and urinary tract infection. CONCLUSIONS: The infectious diseases hospitalist discharged patients from the hospital earlier than the IM hospitalists by more efficient use of antibiotics. The earlier discharge did not adversely affect outcomes.