Antibiotic prescribing for lower respiratory tract infections within secondary care

□ A systematic content analysis of the treatment guidelines for lower respiratory tract infection was performed on antibiotic formularies and policies obtained from hospital management units within the West Midlands and university hospitals from the rest of the United Kingdom □ Analysis of antibiotic formularies and policies demonstrated considerable variation between prescribing guidelines with regard both to the agents and dosages used □ A proportion of hospitals in the West Midlands and university hospitals from the rest of the UK gave no guidance regarding drug dosages, which may result in wide variations in therapy □ These findings have important consequences for quality of patient care, drug budget management and antibiotic resistance     

Moxifloxacin-induced Clostridium difficile-associated diarrhea

A 22-year-old woman was admitted to the hospital with pneumonia, urinary tract infection, anemia, thrombocytopenia, and leukocytosis. After receiving moxifloxacin for 5 days, she experienced diarrhea with cramping and abdominal pain. She was diagnosed with Clostridium difficile-associated diarrhea (CDAD) after C. difficile toxin was identified in a stool specimen. Metronidazole was begun, and the CDAD resolved with continued moxifloxacin administration. Virtually any antibiotic can lead to development of CDAD through disruption of the normal colonic flora, allowing for overgrowth of C. difficile. Although moxifloxacin is generally well tolerated, clinicians should be aware of its potential for inducing CDAD.     

Increased health burden associated with Clostridium difficile diarrhoea in patients with inflammatory bowel disease

Background Clostridium difficile (C. difficile) infection in hospitals in developed countries continues to be a major public health hazard despite increased control measures including review of antibiotic policies and hygiene measures. Patients with colitis are thought to be particularly vulnerable to C. difficile associated diarrhoea (CDAD). Identifying the clinical burden among hospitalised patients admitted with inflammatory bowel disease is an essential first step towards identifying and treating severe C. difficile infection in such individuals. Aim To determine excess morbidity and in‐hospital mortality associated with hospital acquired CDAD in patients with inflammatory bowel disease (IBD‐CDAD‐HAI) admitted to NHS hospitals in England compared with those admitted for inflammatory bowel disease alone. Methods Time trends study of all admissions to NHS hospitals between 2002/03 and 2007/08. We developed case definitions for IBD‐CDAD‐HAI patients. The primary outcomes were in‐hospital mortality and length of stay. The secondary outcome was gastrointestinal surgery. Results Patients in the IBD‐CDAD‐HAI group were more likely to die in hospital (adjusted OR 6.32), had 27.9 days longer in‐patient stays and higher gastrointestinal surgery rates (adjusted OR 1.87) than patients admitted for inflammatory bowel disease alone. Conclusion Patients with inflammatory bowel disease admitted to NHS hospitals in England with co‐existent C. difficile infection are at risk of greater in‐hospital mortality and morbidity than patients admitted for inflammatory bowel disease alone.     

Non-antibiotic strategies for the prevention/treatment of Clostridium difficile infection

Background: Clostridium difficile infection has become a serious concern in both hospital and secondary healthcare environments. In the presence of repeated or prolonged antibiotic treatment, the C. difficile spores can germinate in the colon and produce toxins that cause colonic inflammation and diarrhea. The standard treatment for C. difficile-associated disease (CDAD) usually involves the withdrawal of the antibiotic treatment that led to the CDAD followed by a course of oral metronidazole or vancomycin, but there has been an increasing number of treatment failures and recurrences of disease. Over the past 10 – 15 years, researchers have begun exploring the possibility of using alternative means to combat C. difficile infection. Objective/methods: Over the course of the past 5 years, there has been a considerable amount of patent literature focused on non-antibiotic alternatives, including passive and active immunizations, monoclonal antibodies, antitoxins, inert binders and probiotic therapies. Results/conclusion: Current antibiotic therapies for the treatment of CDAD are not as effective as they once were. There is some promising work on non-antibiotic alternatives for CDAD prevention and treatment.     

Amoxicillin-associated hemorrhagic colitis in the presence of Klebsiella oxytoca

Antibiotic-induced diarrhea can be a significant source of morbidity. Pseudomembranous colitis, or Clostridium difficile-associated diarrhea (CDAD), is an increasingly reported adverse effect of therapy with broad-spectrum antibiotics and can prolong the hospital stay of affected patients. Although sharing some of the same clinical symptoms as CDAD, antibiotic-associated hemorrhagic colitis is a distinctly separate form of colitis that is characterized by the absence of toxin-producing C. difficile and the presence of hematochezia. Colonoscopy usually reveals extensive hemorrhage and inflammation in the lamina propria, with lack of pseudomembranes. Spontaneous resolution usually occurs shortly after cessation of the antibiotic. Infection with Klebsiella oxytoca, a gram-negative facultative aerobic enterobacterium, has been suggested as a possible cause for antibiotic-associated hemorrhagic colitis. Some K. oxytoca strains isolated from patients with antibiotic-associated hemorrhagic colitis produce a cytotoxin that can induce epithelial cell death and may predispose certain patients to hemorrhagic colitis during exposure to antibiotics. We describe a patient who developed hemorrhagic colitis shortly after starting a course of amoxicillin therapy for sinusitis prophylaxis. His stool samples were negative for C. difficile antigens but grew K. oxytoca. The patient received supportive care in conjunction with antibiotic coverage consisting of metronidazole and piperacillin-tazobactam. He improved throughout his hospital stay and was discharged on hospital day 11. Given the increasing concern for CDAD, clinicians should be careful not to overlook other possible causes for antibiotic-induced diarrhea.     

Drug evaluation: OPT-80, a narrow-spectrum macrocyclic antibiotic

Optimer Pharmaceuticals Inc, in collaboration with Par Pharmaceutical Companies Inc, is developing OPT-80, a narrow-spectrum macrocyclic antibiotic secreted by the actinomycete Dactylosporangium aurantiacum, for the potential treatment of Clostridium difficile-associated diarrhea (CDAD) and vancomycin-resistant Enterococcus infection. A phase IIb/III clinical trial of OPT-80 in patients with CDAD is underway.     

Cost implications of the use of troponin I (cTnI) measurement to diagnose heart conditions

□ The measurement of cTnI provides a sensitive test for the diagnosis of myocardial infarction and also improves risk stratification in patients with unstable angina □ The use of cTnI analyses was introduced in the study site hospital on 1 January 1999 to help diagnose heart conditions □ The use of cTnI decreased the total cost of hospitalisation in the low risk acute coronary insufficiency (ACI) diagnostic subgroup     

Economic consequences of ACS-related rehospitalizations in the US

ABSTRACT

Background: Clostridium difficile associated diarrhea (CDAD) is an important cause of hospital-acquired diarrhea, and increasingly of community-acquired diarrhea. The occurrence of CDAD in the hospitalized patient is associated with increased length of stay, morbidity, mortality, and healthcare costs. Exposure to antimicrobials is the single most important predisposing factor for acquiring CDAD. The data suggesting that fluoro­quinolones are an important risk factor for CDAD is becoming stronger. Also, different fluoroquinolones may pose different risks for CDAD development.

Objectives: The aim of this commentary is to summarize the literature as it relates to the role that fluoroquinolones may have in CDAD.

Methods: PubMed and Ovid MEDLINE were searched using the terms fluoroquinolones, ciprofloxacin, levo­floxacin, gatifloxacin, and moxifloxacin in combination with C. difficile, CDAD, pseudomembranous colitis and antibiotic associated diarrhea.

Results: The evidence for an association between fluoroquinolone use and CDAD, especially CDAD due to the hypervirulent NAP1 strain or the polymerase chain reaction ribotype 027, is becoming stronger.

Conclusions: Fluoroquinolones appear to predispose patients to CDAD. The data are suggestive but not conclusive. More studies are needed to define the role that fluoroquinolones play in the development of CDAD. Meticulous and enhanced infection control practices at all times and the judicious use of antimicrobials will help contain the epidemic of CDAD.     

Implementing a system for tackling under‐eporting of adverse drug reactions within a district general hospital

□ The aim of the project was to produce a sustainable, stimulating ongoing programme to improve adverse drug reaction (ADR) reporting rates □ Baseline review revealed a serious shortfall in ADR reports within City Hospitals Sunderland Trust □ A variety of educational tools was employed to ensure retention of information by hospital staff □ Novel methods of promotion were implemented via short‐term, high impact awareness weeks together with continuous advertising     

抗感染新药非达霉素的药理作用与临床评价

非达霉素(fidaxomicin)是一种新型的大环内酯类抗生素,适用于艰难梭菌相关性腹泻(clos-tridium difficile-associated diarrhea,CDAD)的治疗。本文参考美国FDA的相关资料,对非达霉素的药理作用、药动学、临床评价、安全性评价及药物相互作用等进行综述。     

Clostridium difficile: recent epidemiologic findings and advances in therapy

Clostridium difficile-associated disease (CDAD) has become an important public health problem. The causative organism is acquired by the oral route from an environmental source or by contact with an infected person or a health care worker who serves as a vector. Disruption of the bowel microflora, generally by antibiotics, creates an environment that allows C. difficile to proliferate. Organisms produce toxins A and B, which cause intense inflammation of the colonic mucosa. The syndrome that results includes severe diarrhea, fever, abdominal pain, and leukocytosis. A new strain of C. difficile has become prevalent in the United States, Canada, and the United Kingdom. Identified by pulsed-field gel electrophoresis (PFGE), this strain is called North America PFGE type 1, abbreviated as NAP-1. Clostridium difficile NAP-1 characteristically generates large amounts of toxins A and B, as well as an additional binary toxin and is associated with enhanced morbidity and a poor response to antibiotic therapy. Mild cases of CDAD may respond to cessation of antibiotic therapy, perhaps related to antibody production by the infected person, but most infected persons require antimicrobial therapy. Vancomycin has been approved by the United States Food and Drug Administration for treatment of CDAD, but reluctance to use this antibiotic in the hospital setting has led to reliance on metronidazole as first-line therapy. Recent studies show a high rate of failure, due either to infection by NAP-1 or to the presence, in hospitals, of older and sicker adults who have been treated with many broad-spectrum antibiotics. Nitazoxanide, bacitracin, teicoplanin, and fusidic acid are additional agents that have published efficacy for this indication in humans. Rifaximin and PAR-101 are under investigation. Other therapies, including polymers that bind C. difficile toxin and monoclonal antibodies to toxins, and preventive measures such as toxoid vaccines are also under study.     

Audit of antibiotic usage in a medium-sized general hospital over an 11-year period

The objective of the present study was to evaluate trends in antibiotic expenditure over an 11-year period (1982–1992) in a 370-bed district general hospital in Northern Ireland and to examine the impact of two separate antibiotic policies on antibiotic usage. A further objective was to examine the attitudes of prescribers to the second policy. Drug utilization review was used to collect information on antibiotic expenditure and usage before and after introduction of separate antibiotic policies in 1985 (not intensively monitored) and 1989 (intensively monitored). A mail questionnaire was used to determine the attitudes of prescribers. The first policy (1985) showed no benefits with regard to the number of antibiotic entities stocked (45 before, 45 after), number of dosage units issued (9.3% increase) or expenditure (33.3% increase). The 1989 policy led to significant reductions in the number of antibiotic entities stocked (28.9%), number of antibiotics issued (11.9%) and expenditure (6.1%). Expenditure began to spiral upwards when active monitoring of the second policy was suspended. The majority of prescribers (87.2%) who responded to the questionnaire (56.5% response rate) felt that the 1989 policy made a positive contribution to antibiotic usage in the hospital.     

Association Between Use of Proton Pump Inhibitors and a Clostridium difficile-Associated Disease Outbreak: Case-Control Study

Background:

The use of proton pump inhibitors (PPIs) has been implicated as a potential contributor to the development of Clostridium difficile–associated disease (CDAD) because of the ability of these drugs to substantially reduce the bactericidal effect of gastric acid. This study focused on the impact of PPIs, among other known risk factors, during an outbreak of CDAD in a hospital setting.

Objectives:

The primary objective was to determine whether there was an association between current use of a PPI and the CDAD outbreak. Secondary objectives were to evaluate any correlations between the CDAD outbreak and past use of PPIs, use of antibiotics, diabetes mellitus, enteral feeding, cancer, gastrointestinal surgery, inflammatory bowel disease, and previous care or residence in an institutional setting.

Methods:

A retrospective case–control study was conducted. One hundred and fifty cases of hospital-acquired Clostridium difficile were identified. Patients were individually matched to controls for age, sex, date of admission to hospital, and hospital unit. The groups were compared with respect to each exposure.

Results:

Eight case patients could not be matched with suitable controls. Therefore, data from 142 cases and 142 controls were analyzed. There was no association between current use of a PPI and the CDAD outbreak (odds ratio [OR] 1.0, 95% confidence interval [CI] 0.99–1.01). Similarly, there was no correlation between the CDAD outbreak and diabetes, enteral feeding, cancer, gastrointestinal surgery, inflammatory bowel disease, or previous care or residence in an institution. However, the development of CDAD was positively associated with use of antibiotics within the 30 days preceding the infection (OR 12.0, 95% CI 4.0–35.7) and with past use of a PPI (OR 2.4, 95% CI 1.4–4.3).

Conclusions:

The development of CDAD during a hospital outbreak was associated with use of antibiotics and with past, not current, use of PPIs.     

A patient‐held medication record and a patient medication profile to support the continuity of acute cancer care

□ The sharing of care of patients receiving medical oncology care is vulnerable to errors in their documented drug history □ A patient‐held medication record identified over 90 per cent of patients' medications but was ‘forgotten’ by the patient in a third of contacts with a pharmacist □ Discrepancies between the medication records of GPs, community pharmacists and the medical oncology clinic were highly prevalent □ A posted patient medication profile issued by the hospital pharmacist to both the patient's GP and their community pharmacist was associated with a significant convergence in their records (discrepancies reduced from 17 to 6 % P<0.001) □ The patient‐held record had little impact on the accuracy of practitioners' records and its value lies more in facilitating patient education than rectifying errors in documentation     

Continuation of treatment of drug misusers between primary and secondary care in the South West

□ This study established the extent to which hospitals in the South West region have guidelines or protocols in place to ensure that continuation of care is provided to drug misusers □ An internet‐based questionnaire, using open and closed questions, was designed to explore the issue of continuous care policies for drug misusers within secondary care □ Formalised hospital‐wide policies, guidelines or protocols on continuous care for drug misusers were found to be lacking within the South West; however, several measures taken at ward level or on an individual case basis ensured continuation of care □ Regional‐wide guidelines within the South West to promote the continuous care of drug misusers when they are taken into and discharged from hospital need to be developed in liaison with primary care service providers.     

Risk assessment of intravenous dose presentation in secondary care

□ The Breckenridge report highlighted that intravenous drug additions were aseptic procedures and should be conducted under the direct control of a pharmacist □ This study attempts to determine the extent of intravenous drug preparation at ward level and apply a risk assessment model □ Observation and risk assessment of intravenous drug preparation was carried out in two clinical areas within a large hospital □ Two thirds of the intravenous drug administration events were graded as high risk □ In the absence of a centralised intravenous additive service, the use of ready to administer forms or novel reconstitution systems may significantly reduce the risks associated with intravenous administration events     

Pharmacists' and physicians' perception of antibiotic policies in New South Wales public hospitals

Background — The potential of antibiotic policies in hospitals to improve antibiotic use depends on the compliance of practitioners with these policies. It is conceivable that the way the policies are perceived by practitioners can influence their compliance. Objective— To determine the perception and awareness of pharmacists and physicians of their current hospital antibiotic policy. Setting — Public hospitals in New South Wales, Australia. Method — Pharmacists and physicians were surveyed using a structured questionnaire seeking the extent of agreement or disagreement with a series of statements about their hospital's antibiotic policy. All hospitals had at least one antibiotic policy. A simple one-stage cluster sample of 241 pharmacists and a two-stage cluster sample of 701 physicians were obtained. Factor analysis was used to identify the dimensions of perception. General linear modelling was used to investigate the effects of predictor variables on outcome variables. Results — The response rates were 91 per cent and 77 per cent for pharmacists and physicians, respectively. The proportion of respondents who were aware of their hospital's antibiotic policy was 86 per cent (190/220) for pharmacists and 61 per cent (332/542) for the physicians. Factor analysis identified three factors related to how practitioners perceived their current hospital's antibiotic policies. These were: the usefulness of antibiotic policies (utility), how the policy was applied in the hospital (application) and the perceived problems associated with the policy (problems). Pharmacists were significantly more likely than physicians to perceive problems with antibiotic policies and how the policies were applied. Conclusion — The level of practitioners' awareness of their hospital's antibiotic policy and pharmacists' perception of problems with such policies need to be addressed if these policies are to make a significant contribution to improved antibiotic use in hospitals.