Severe sepsis and septic shock in pre-hospital emergency medicine: survey results of medical directors of emergency medical services concerning antibiotics,blood cultures and algorithms

Delayed antibiotic treatment for patients in severe sepsis and septic shock decreases the probability of survival. In this survey, medical directors of different emergency medical services (EMS) in Germany were asked if they are prepared for pre-hospital sepsis therapy with antibiotics or special algorithms to evaluate the individual preparations of the different rescue areas for the treatment of patients with this infectious disease. The objective of the survey was to obtain a general picture of the current status of the EMS with respect to rapid antibiotic treatment for sepsis. A total of 166 medical directors were invited to complete a short survey on behalf of the different rescue service districts in Germany via an electronic cover letter. Of the rescue districts, 25.6 % (n = 20) stated that they keep antibiotics on EMS vehicles. In addition, 2.6 % carry blood cultures on the vehicles. The most common antibiotic is ceftriaxone (third generation cephalosporin). In total, 8 (10.3 %) rescue districts use an algorithm for patients with sepsis, severe sepsis or septic shock. Although the German EMS is an emergency physician-based rescue system, special opportunities in the form of antibiotics on emergency physician vehicles are missing. Simultaneously, only 10.3 % of the rescue districts use a special algorithm for sepsis therapy. Sepsis, severe sepsis and septic shock do not appear to be prioritized as highly as these deadly diseases should be in the pre-hospital setting.     

Antibiotic use and cost indicators at a rural hospital: a pilot project

BACKGROUND: Recently, simple antibiotic use and cost indicators were developed for use in long-term care facilities. It was hypothesized that these indicators also may be applicable to the acute hospital setting. METHODS: For a 24-month period, data were collected quarterly on antibiotic use and cost indicators for 11 primary care physicians in a 40-bed rural hospital. Indicators included antimicrobial use ratio (AUR, ratio of the number of antibiotic days to the number of patient care days), cost per antibiotic day, and cost of antibiotics per patient care day. One-way analysis of variance and simple linear regression were used to analyze data. RESULTS: Quinolones (oral plus parenteral) accounted for 26% of the total antibiotic days (N = 6020) followed by ceftriaxone (19%) and cefuroxime (11.8%; oral plus parenteral). Overall trends in antibiotic use and cost included a significant increase in quarterly AUR (R(2) = 0.78, P =.004) and cost per patient care day (R(2) = 0. 82, P =.002) but no significant change in quarterly total antibiotic costs or cost per antibiotic day. Among physicians there was a significant difference in mean quarterly AUR (P <.001) and mean quarterly cost per patient care day (P <.001) but no significant difference in mean quarterly cost per antibiotic day. Variation in physician-specific cost per patient care day was best explained by variation in AUR (R(2) = 0.75, P <.001). CONCLUSIONS: Significant variation in simple antibiotic use and cost indicators was identified at a rural hospital from both the facility and physician perspective. Standardized methods for antibiotic use and cost monitoring, like the one described in this article, are required before the relationship between antibiotic use and resistance can be fully understood.     

Pulmonary nontuberculous mycobacterial infections: Antibiotic treatment and associated costs

Recent studies suggest an increasing prevalence of pulmonary nontuberculous mycobacteria (NTM) disease. In the absence of prevalence and cost data, the public health burden of pulmonary NTM disease is difficult to assess. The goal of this study was to assess costs associated with NTM disease treatment and to identify risk factors associated with increased costs. Records from subjects with pulmonary NTM disease enrolled in a natural history protocol were abstracted for presenting symptoms, comorbidities, microbiology, and treatment histories. Antibiotic frequency, duration, adverse reaction, and costs were noted, the total antibiotic burden and cost were calculated, and risk factors associated with high costs were analyzed. From Jan 2004 to Dec 2005, 33 subjects were enrolled; 27 met disease criteria and had sufficient data to assess antibiotic use. Mycobacterium avium complex was present in 89% and Mycobacterium abscessus was present in 21% of subjects. Subjects received a median of 5 (1–10) antibiotics. Adverse effects were common seen in up to 50% with common antibiotics and up to 100% with uncommonly used antibiotics. Median burden of treatment was 2638 (84–7689) drug-days and the median total cost per patient was $19,876 ($398–70,917). Subjects with high treatment costs had an adjusted 9.5 fold (95% CI 1.5–97.2) likelihood of having M. abscessus and a 4.2 fold (95% CI 0.6–59.3) increased likelihood of having more extensive disease. Pulmonary NTM represent an underappreciated disease burden in the US population, with an associated treatment cost comparable to that for other chronic diseases of infectious origin such as HIV/AIDS.     

Antibiotic guidelines lead to reductions in the use and cost of antibiotics in a university hospital

The object of this study was to improve the use of antibiotics at Aker University Hospital, a 600-bed university hospital. We developed and implemented guidelines for antibiotic treatment and prophylaxis. We describe the impact of these guidelines on the use and cost of antibiotics and evaluate compliance with the guidelines. From 1994 to 1996 there was an 11% reduction in the use of antibacterial agents and a 42% reduction in the use of antifungal agents. The use of broad-spectrum antibiotics was reduced by 23%. The use of penicillin V and G increased by 5%, dikloxacillin/kloxacillin by 46% and erythromycin by 33%. Compared with 1994 values there was a 27% reduction in antibiotic costs in 1995, amounting to US$ 319,300, and a 32% reduction in antibiotic costs in 1996, amounting to US$ 380,000. A point-prevalence investigation conducted 18 months after the introduction of the guidelines indicated that compliance was > 95%. It proved possible to reduce the use of broad-spectrum antibacterial and antifungal agents, with significant cost savings. Point-prevalence studies may be a useful tool to detect deviations from guidelines and provide physicians with educational feedback.     

Modern Management of Community-Acquired Pneumonia: Is It Cost-Effective and are Outcomes Acceptable?

Community-acquired pneumonia (CAP) is the most important cause of death from infectious diseases in the developed world and is associated with a high economic burden. Researchers have therefore sought ways to improve CAP outcomes while reducing costs. In this review, we highlight the current evidence supporting modern approaches to CAP management, including the use of severity indices to safely increase the proportion of patients treated at home, the use of procalcitonin to decrease antibiotic use, early intravenous to oral switch of antibiotic therapy, streamlining antimicrobials, and approaches to shorten antibiotic treatment duration. Although promising evidence exists for these modern strategies, there is still a considerable lack of high-quality evidence proving noninferiority of clinical outcomes and cost-effectiveness.     

Impact of mandatory inpatient infectious disease consultation on outpatient parenteral antibiotic therapy

BACKGROUND: Outpatient parenteral antibiotic therapy (OPAT) has had an important impact on infections historically requiring prolonged intravenous antibiotic treatment. Within the past decade, new antibiotics with oral/intravenous bioequivalence, plus recent data on infection management, have increased the potential role of the Infectious Disease (ID) consultant for OPAT. METHODS: We studied the impact of mandatory ID consultation on the use and outcomes of OPAT in patients initially hospitalized. The study was approved by the Institutional Review Board and the Executive Committee of the Medical Staff of Baystate Medical Center. Patients older than 18 years of age being considered for discharge to home on OPAT were identified, primarily through discharge planning. Formal ID consultation was performed to determine both need for OPAT and a variety of issues regarding antibiotic choice. Thirty-day telephone follow-up determined outcomes. Data regarding demographics, outcomes, and costs were analyzed. RESULTS: Forty-four patients received mandatory ID consultation, 39 (88.6%) of whom had some change in antibiotic recommendations. Seventeen (38.6%) were discharged on oral antibiotics, 1 (2.3%) had antibiotics discontinued, 13 (29.6%) had a change in parenteral antibiotic, 5 (11.4%) had a change in antibiotic dose, and 3 (6.8%) had a change in antibiotic duration. Follow-up demonstrated a single rehospitalization for unrelated issues. The total cost savings were 33,667.00 US dollars, approximately 760.00 US dollars per patient. Charges of consults were approximately 11,970.00 US dollars, still resulting in savings of close to 21,700.00 US dollars, or almost 500.00 US dollars per patient. CONCLUSIONS: Mandatory ID consultation resulted in substantial cost savings and excellent outcomes.     

Cost-effectiveness of prospective and continuous parenteral antibiotic control: experience at the Palo Alto Veterans Affairs Medical Center from 1987 to 1989

PURPOSE: Controlling inappropriate antibiotic usage is a major focus for hospital quality assurance and cost-containment programs. We assessed the impact of strengthening a parenteral antibiotic control policy and instituting continuous infectious disease service (IDS) reviews of the appropriateness of antimicrobial therapy on cost and patient outcomes. PATIENTS AND METHODS: All patients receiving intravenous antibiotics during a 3.5-year period from 1986 to 1989 were included in either the pre- or post-policy study group. Antibiotic costs 16 months before were compared with antibiotic costs 26 months after implementation of a new policy to restrict inappropriate usage of (1) broad-spectrum antibiotics when not necessary, (2) expensive agents when a less costly agent could be used, and (3) an excessive dosage or interval. Patient subgroups treated 4 months before and 4 months after policy implementation were compared further within diagnosis-related group (DRG) assignments using patient demographic, cost, and outcome measures. RESULTS: The average monthly antibiotic costs during the 26-month post-policy period were $7,600 less than during the 16-month pre-policy period (p less than 0.0001), resulting in an average yearly drug cost reduction of $91,200. The IDS team altered therapy in 611 (34.5%) of 1,769 reviews of antibiotic usage during the 26-month period. The comparisons among similar patient groups by DRG classification revealed the average number of antibiotic doses per study patient admission was decreased 24% (p = 0.005) and drug costs were reduced 32% (p = 0.004) after policy implementation. In two DRG categories (i.e., respiratory infections plus pneumonia), patients in the post-policy group had a 33% decrease in average number of doses (p = 0.05) and 45% decrease in antibiotic costs (p = 0.04) compared with the pre-policy group. Similar trends were observed in most DRG categories. There was an average $70 per admission decrease in drug cost and a reduction of eight antibiotic doses per admission after policy initiation. The overall prevalence of deaths (p = 0.22) and average length of antibiotic therapy (p = 0.29) were less in the post-policy period despite group similarities in patient characteristics and lengths of hospital stay. CONCLUSION: Antibiotic control policies can be developed to ensure quality care and can be designed to select for cost-effective agents. Prospective and continuous monitoring of antibiotic usage by the IDS resulted in a significant and sustained reduction in antibiotic costs without detrimental effect on the length of therapy or deaths.     

Cost effectiveness of a two-year home exercise program for the treatment of knee pain

OBJECTIVE: To assess the cost effectiveness of a 2-year home exercise program for the treatment of knee pain. METHODS: A total of 759 adults aged > or = 45 years were randomized to receive exercise therapy, monthly telephone contact, exercise therapy and telephone contact, or no intervention. Efficacy was measured using self-reported knee pain at 2 years. Costs to both the National Health Service and to the patient were included. RESULTS: Exercise therapy was associated with higher costs and better effectiveness. Direct costs for the interventions were pound 112 for the exercise program and pound 61 for the monthly telephone support. Participants allocated to receive exercise therapy were significantly more likely to incur higher medical costs than those in the no-exercise groups (mean difference pound 225; 95% confidence interval pound 218, pound 232; P < 0.001). CONCLUSION: Exercise therapy is associated with improvements in knee pain, but the cost of delivering the exercise program is unlikely to be offset by any reduction in medical resource use.     

Pharmacoeconomic study of antibiotic therapy for exacerbations of chronic bronchitis and chronic obstructive pulmonary disease in Latin America

Chronic obstructive pulmonary disease (COPD) and chronic bronchitis are highly prevalent diseases. Studies designed to analyze the economic impact of these diseases in Latin American countries have not previously been published. In the present study we analyzed the direct health care costs of treating patients with exacerbations of chronic bronchitis and COPD in Argentina, Brazil, Colombia, Ecuador, Mexico, Peru, and Venezuela, applying the real cost of drugs and medical acts in those 7 countries to the pattern of treatment and outcomes obtained from a study carried out in primary care settings in Spain. The mean direct health care cost ranged from US $98 in Colombia to $329 in Argentina. Most of the cost was related to failure of therapy, which accounted for 52% of the total cost of exacerbation, with the lowest rate in Colombia at 28.6% and the highest in Ecuador at 59.3% The cost of antibiotic therapy represented 19% of the total cost; the rest was owing to other drugs or medical visits. Exacerbations generate significant costs for health care systems. There are considerable variations related mainly to differences between systems. Antibiotic therapy represents a small part of the overall cost. The use of more effective antibiotics, if they can reduce failure rates, may be a cost-effective strategy.     

Economic evaluation of oral valdecoxib versus diclofenac in the treatment of patients with rheumatoid arthritis in a randomized clinical trial

In contrast to economic models that provide probabilistic estimates of economic impact, data extracted from clinical trials may be used to evaluate and compare actual resource utilization and costs. Health-care resource utilization and the costs of these resources were compared from the perspective of the UK National Health Service using data obtained in a 6-month clinical trial of oral valdecoxib 20 mg once daily and diclofenac 75 mg twice daily for the symptomatic treatment of rheumatoid arthritis. However, calculated health-care costs were exclusive of drug acquisition costs because the price of valdecoxib was not available at the time of analysis. While the efficacy of the two treatments was similar, use of valdecoxib was associated with a reduction in total health-care costs amounting to approximately 200 British pounds per patient. This lower cost was associated with reduced use of health-care resources for gastrointestinal serious adverse events (gastrointestinal SAEs). In particular, the incidence of hospitalization and number of hospital days for gastrointestinal SAEs was lower in the valdecoxib group. Analysis of cost per gastrointestinal SAE favoured valdecoxib (cost savings of 742 British pounds), suggesting that even when these events did occur they were less severe. When costs of gastrointestinal SAEs were averaged over the entire population, valdecoxib was suggested to have lower total costs per patient compared with diclofenac (cost savings of 115 British pounds per patient), mainly resulting from significant savings in hospitalization costs (76.49 British pounds per patient). These data are consistent with economic models and suggest that the favourable gastrointestinal profile of valdecoxib observed in clinical trials will be of economic benefit.     

The nonvalue of retrospective peer comparison feedback in containing hospital antibiotic costs

Antibiotics have accounted for an increasing percentage of hospital pharmacy charges. Recently, an inexpensive method, automated peer comparison feedback, has been developed to influence physician use of resources. The documented success of several implementations of this strategy led to a one-year experiment to influence hospital antibiotic utilization. Each month, attending physicians in the top 50 percentiles for expenditure were notified of their status in relation to their peers. Expenditures by feedback and control groups were compared to determine whether feedback would result in reduced expenditures by individuals, or whether there would be a generalized reduction in expenditure by the entire group (Hawthorne effect). Over the year, no significant reduction in expenditure was noted. However, some important utilization patterns were identified. Although more surgical patients received antibiotics than did nonsurgical patients, surgical antibiotic costs were less. Surgical therapy was typically of shorter duration and involved the use of less expensive antibiotics. Multiple-antibiotic prescribing was less frequent on surgical services. Thirty percent of attending physicians were responsible for 80 percent of all antibiotic costs; 60 percent of those in this top group were members of the medical cohort. In conclusion: (1) As implemented in the current study, automated peer comparison feedback was not an effective method for reducing antibiotic utilization; (2) Differences in prescribing patterns between services may dictate the best strategies for improving antibiotic utilization; (3) More attention should be directed toward the relatively small "reference group" of physicians responsible for most hospital antibiotic prescribing.     

Effect of a comprehensive, multidisciplinary, educational program on the use of antibiotics in a geriatric university hospital

OBJECTIVES: To assess the effect of a comprehensive, educational antibiotic management program designed to improve antibiotic use and reduce treatment costs in elderly patients with suspected urinary or respiratory tract infection. DESIGN: Interventional cohort study with 12 cross-sectional drug utilization reviews of antibiotic use before, during, and after the multifaceted intervention. SETTING: A 304-bed university hospital for geriatric patients. PARTICIPANTS: A total of 3,383 elderly patients. INTERVENTIONS: An educational program including distribution of guidelines on the diagnosis and treatment of urinary and respiratory tract infections; lectures on geriatric infectious diseases; weekly ward rounds for patients with suspected infection; and targeted, individual counseling on diagnosis and antibiotic treatment of infections. MEASUREMENTS: Antibiotic utilization data were collected from the patients' records. Antimicrobial costs were calculated using 1998 hospital wholesale prices. RESULTS: Of 3,383 screened patients, 680 (20%) received at least one antibiotic. During the study period, the mean number of prescribed drugs per patient increased from 5.9 to 7.6 (29%; P<.001). In contrast, a reduction of 15% was observed in the proportion of patients exposed to antibiotic agents (P=.08) and a drop of 26% in the number of antibiotics administered (P<.001). This resulted in a 54% decrease in cumulative daily antibiotic costs. In 83 (75%) of 110 surveyed patients, the guidelines were correctly implemented. The intervention had no measurable negative clinical effect. CONCLUSION: A comprehensive, multifaceted educational program for treating urinary and respiratory tract infections in the elderly was a safe and practical method to change physicians' antibiotic prescribing practice and significantly reduce the consumption and costs of antibiotics in a geriatric hospital.     

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.     

Eradication of epidemic methicillin-gentamicin-resistant staphylococcus aureus in an intensive care nursery

A methicillin-resistant strain of Staphylococcus aureus (phage type 47,54,75,83A) became epidemic in our 50 bed level III nursery, with a colonization rate of 70 percent and an infection rate of more than 25 percent. This prevalence and the appearance of gentamicin resistance necessitated epidemic control measures. Standard measures included separate housing for infants in whom colonization had occurred and infants in whom it had not, low nurse to patient ratios, and cohorting of all personnel. Use of all antibiotics was curtailed by the requirement of infectious disease consultation. Gentamicin was available only on order of the Director. The colonization rate fell from 55 percent to 25.4 percent, the first-week colonization rate from 31 percent to 0 percent, and the infection rate from 29.3 percent to 15.9 percent over eight weeks. The mean duration of antibiotic therapy decreased from 12.21 to 9.05 days per treated patient; however, the frequency of gentamicin usage and the proportion of gentamicin resistance were unchanged. Nurse to patient ratios were modified to allow increased admissions, but cohorting was continued for 12 weeks until all infants in whom colonization had occurred were discharged. With the elimination of the reservoir, no further colonization occurred and antibiotic resistance did not reappear. Standard infection control measures can eliminate epidemics of multiple antibiotic-resistant Staph. aureus, and control of antibiotic usage may present re-emergence of resistant strains.     

Role of clinical microbiology laboratories in the management and control of infectious diseases and the delivery of health care.

Modern medicine has led to dramatic changes in infectious diseases practice. Vaccination and antibiotic therapy have benefited millions of persons. However, constrained resources now threaten our ability to adequately manage threats of infectious diseases by placing clinical microbiology services and expertise distant from the patient and their infectious diseases physician. Continuing in such a direction threatens quality of laboratory results, timeliness of diagnosis, appropriateness of treatment, effective communication, reduction of health care-associated infections, advances in infectious diseases practice, and training of future practitioners. Microbiology laboratories are the first lines of defense for detection of new antibiotic resistance, outbreaks of foodborne infection, and a possible bioterrorism event. Maintaining high-quality clinical microbiology laboratories on the site of the institution that they serve is the current best approach for managing today's problems of emerging infectious diseases and antimicrobial agent resistance by providing good patient care outcomes that actually save money.     

Cost-effective choice of antimicrobial therapy for serious infections

The authors evaluated the financial and health implications of treatment choices for three serious classes of infection: hospital-acquired pneumonia, intra-abdominal infection, and sepsis of unknown origin. Data were obtained from a systematic review of clinical literature and published data bases, by written questionnaire from a panel of infectious disease authorities, and from actual costs at a tertiary-care hospital. For pneumonia and sepsis, the third-generation cephalosporin evaluated (ceftizoxime) was found to be less expensive than other regimens, when costs of dose preparation and administration, monitoring, and toxicity were added to drug acquisition costs. The lowestcost regimen for intra-abdominal infection was metronidazole plus gentamicin. Modest differences in efficacy would easily outweigh differences in toxicity, however, and could justify the use of more expensive regimens (e.g., mezlocillin plus gentamicin for hospital-acquired pneumonia, and cefoxitin plus gentamicin for intra-abdominal infection). If all regimens are assumed to be equally efficacious, then the third-generation cephalosporin was both lowest in cost and, owing to its low toxicity, greatest in net health benefit. Supported by a grant from Smith Kline and French Laboratories and by the Harvard Community Health Plan Foundation through the Institute for Health Research, a joint program of the Harvard Community Health Plan and Harvard University.     

A multidisciplinary hospital-based antimicrobial use program: Impact on hospital pharmacy expenditures and drug use

The authors' hospital embarked on a three-component, multidisciplinary, hospital-based antimicrobial use program to cut costs and reduce inappropriate antimicrobial use. Initially, antimicrobial use patterns and costs were monitored for 12 months. For the next two years, an antimicrobial use program was implemented consisting of three strategies: automatic therapeutic interchanges; antimicrobial restriction policies; and parenteral to oral conversion. The program resulted in a reduction in the antimicrobial portion of the total pharmacy drug budget from 41.6% to 28.2%. Simultaneously, the average cost per dose per patient day dropped from $11.88 in 1991 to $10.16 in 1994. Overall, mean monthly acquisition cost savings rose from $6,810 in 1992 to $27,590 in 1994. This study demonstrates that a multidisciplinary antimicrobial use program in a Canadian hospital can effect dramatic cost savings and serve as a quality assurance activity of physician antimicrobial prescribing behaviour.     

Role of the infectious disease specialist in containing costs of antibiotics in the hospital

Antimicrobial agents account for a significant proportion of drug expenditures and are used inappropriately approximately half the time in hospital practice. This has led to substantial increases in medical costs for hospitalized patients. Methods have been proposed to reduce inappropriate use of antibiotics, particularly in hospitalized patients. Two of these methods, education and control, were employed effectively by infectious disease specialists at a university teaching hospital to reduce inappropriate use of second-generation cephalosporins. These efforts resulted in significant savings of approximately $130,00 per year. The infectious disease specialist may also make major contributions to cost containment of antibiotics in other equally important areas, including other classes of antibiotics, inappropriate daily frequency, excessive duration of administration, and prevention of adverse drug reactions. The infectious disease specialist is better trained in appropriate antimicrobial use and clinically more knowledgeable in treating infections than other medical specialists and is the best-equipped member of the medical staff to educate the medical community on antibiotic use and to control antibiotic costs.     

Evaluation of clinical pharmacist's interventions in an infectious diseases ward and impact on patient's direct medication cost

BackgroundA clinical pharmacist is a key member of the antimicrobial multidisciplinary team involved in patients' pharmacotherapy monitoring. The aim of this study was to determine the frequency and type of medication errors, the type of clinical pharmacy interventions, acceptance of pharmacist interventions by health-care provider team, nursing staff satisfaction with clinical pharmacy services, and the probable impact of clinical pharmacy interventions on decreasing direct medication costs at an infectious diseases ward in Iran.MethodsAll clinical pharmacist interventions such as preventing medication errors were recorded in a previously designed pharmacotherapy monitoring forms. Direct medication cost of patients admitted during the study period was compared with that of subjects hospitalized at the same ward during the year before the intervention period to determine the impact of clinical pharmacy interventions on direct medication costs.ResultsThe 3 most frequent medication error types were incorrect dose (35.5%), omission error (24.3%), and incorrect medication (14.3%). The mean number of clinical pharmacist intervention per patient was 3.2. Forty percent of clinical pharmacists' interventions are moderate to major clinical significant. Thirty nine percent of clinical pharmacist's interventions had moderate to major financial benefits in present study. The direct medication cost per patient was decreased about 3.8% following clinical pharmacist's interventions.ConclusionOur data demonstrated that incorrect dose was the most frequent medication error in the infectious diseases ward. Major portion of clinical pharmacist interventions were accepted by physicians and nursing staff. Clinical pharmacist interventions non-significantly decreased the direct medication cost of patients.