Antimicrobials in acute exacerbations of chronic obstructive pulmonary disease - An analysis of the time to next exacerbation before and after the implementation of standing orders

OBJECTIVE:

To compare the mean time to next exacerbation in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) before and after the implementation of standing orders.

SETTING:

Tertiary care hospital, Halifax, Nova Scotia, Canada.

POPULATION STUDIED:

The records of 150 patients were analyzed, 76 were in the preimplementation group, 74 in the postimplementation group.

INTERVENTION:

The management and outcomes of patients admitted with an acute exacerbation of COPD before and after the implementation of standing orders were compared.

DESIGN:

A retrospective chart review.

MAIN RESULTS:

There was no difference in the mean time to next exacerbation between treatment groups (preimplementation group: 310 days, postimplementation group: 289 days, P=0.53). Antibiotics were used in 90% of the cases (preimplementation group: 87%, postimplementation group: 93%). The postimplementation group had a 20% increase in the use of first-line agents over the preimplementation group. Overall, first-line agents represented only 37% of the antibiotic courses.

CONCLUSIONS:

The implementation of standing orders encouraged the use of first-line agents but did not influence subsequent symptom resolution, length of hospital stay, or the infection-free interval in patients with acute exacerbations of COPD.Key Words: Antibiotics, Chronic obstructive pulmonary disease, ExacerbationIn Canada, chronic obstructive pulmonary disease (COPD) is a major health issue affecting over 750,000 people and the fourth ranked cause of mortality (1,2). Worldwide, it is the second most common chronic noncommunicable disease and the only leading cause of death that is increasing in prevalence (1,3,(4). The inpatient mortality associated with COPD exacerbations ranges from 3% to 4% (5). Each year, over 52,000 hospital admissions and 16,000 deaths in Canada are attributed to COPD (1,6). At our institution, Queen Elizabeth II Health Sciences Centre, COPD exacerbations are the third leading cause for admissions to the internal medicine service (preceded by pneumonia and congestive heart failure) (7).In patients with COPD, acute infectious exacerbations are the most common precipitating factor leading to hospitalization and the most common cause of death (8-10). Up to 80% of acute exacerbations of COPD are due to respiratory infections, with 50% to 70% of these caused by bacteria and only 10% to 30% caused by viruses (11-13). In September 2000, standing orders for patients with a COPD exacerbation were implemented at our institution (Figures ​(Figures11 and ​and2),2), with the rationale that prompt institution of optimal care, including controlled oxygenation and maximum bronchodilation, anti-inflammatory, and antibiotic therapy, would improve outcomes. The antibiotic choice included as first-line agents were trimethoprim/sulfamethoxazole (TMP/SMX) and doxycycline hyclate. Second-line agents were azithromycin dihydrate, amoxicillin trihydrate/clavulanate pottasium, cefuroxime sodium, and ciprofloxacin. It was our intent to assess the impact of these orders on clinical outcome (time to next exacerbation, clinical symptomatology), antimicrobial outcome (culture eradication), and resource utilization (antimicrobial use) via a quality assurance retrospective chart review.Open in a separate windowFigure 1Physician standing orders for acute exacerbations of chronic obstructive pulmonary disease (COPD) implemented at the Queen Elizabeth II Health Sciences Centre in September 2000-front page, emphasizing use of first-line antibiotics. ABG Arterial blood gas; ac Before meals; BID Twice a day; BP Blood pressure; C&S Culture and sensitivity; CAP Community-acquired pneumonia; CrCl Creatinine clearance; Fi0₂ Fraction of inspired oxygen; Ht Height; HR Heart rate; IV Intravenous; MDI Metered dose inhaler; PRN As requried; RMO Requisition made out; RR Rate of respiration; Wt WeightOpen in a separate windowFigure 2Physician standing orders for acute exacerbations of chronic obstructive pulmonary disease (COPD) implemented at the Queen Elizabeth II Health Sciences Centre in September 2000-back page, with second line antibiotic options. CrCl Creatinine clearance; DS Double Strength; HCNS Home care Nova Scotia; IBW Ideal body weight; po By mouth; Scr Serum creatinine; TMP Sulfa Trimethoprim/sulfamethoxazole     

Costs and cost-effectiveness of a clinical intervention to increase mammography utilization in an inner city public health hospital

BACKGROUND: Studies have demonstrated the cost-effectiveness of screening women for breast cancer; however, the cost-effectiveness of strategies to motivate women to receive breast cancer screening has been less well studied. METHODS: A total of 196 women, aged 50 to 74, who were enrolled in a public health hospital clinic, were noncompliant with mammography screening, and had at least one routine clinic appointment during the study period (15 months) were entered into a randomized, controlled trial of a motivational intervention to increase mammography rates. Costs were captured via a modified Delphi technique, accounting records, sampling of staff time logs, and an estimation of miscellaneous and overhead costs. Summary costs were calculated using Excel spread sheets. RESULTS: Overall, 49% of women who received the intervention had a mammogram within 8 weeks of an index visit compared with 22% of control women. Calculation of the cost-effectiveness of the project showed an additional cost of $151 (1996 U.S.$) for each woman receiving the intervention and $559 for each additional woman motivated to receive a mammogram. CONCLUSIONS: Cost tracking and cost-effectiveness analysis can be done when intervening in a clinical setting, thereby allowing clinics to make informed decisions about implementing programs to increase motivation of their patients to receive screening.     

Complex central cortex in pediatric patients with malformations of cortical development

We investigated whether malformations of cortical development yield a complex central cortex by studying nine children with malformations of cortical development and seven without malformations who underwent epilepsy surgery following extraoperative subdural somatosensory evoked potential and electrical stimulation to identify the sensorimotor cortex. We analyzed superficial structures of the central cortex, latency, amplitude, and location of N20 and P25. Sensorimotor responses in malformations of cortical development extended across the central sulcus in 1 to 4 of 3 to 12 electrodes (mean 32%) compared with 1 to 6 of 4 to 15 electrodes (mean 12%) in cases without malformations with a statistical significance (P < .05). N20 amplitudes were lower in epileptic than nonepileptic cortices (three with and three without malformations of cortical development) (P < .05). The central vein coursed partially along the central sulcus in eight cases of malformations of cortical development and five cases without malformations. We conclude that the sensorimotor cortex in malformations of cortical development is more complex than in cases without malformations, reduced N20 amplitude is indicative of epileptic sensorimotor cortex, and superficial veins do not indicate the sensory and motor cortical boundary.     

Radial organization of developing preterm human cerebral cortex revealed by non-invasive water diffusion anisotropy MRI

Cerebral cortical development involves a complex cascade of events which are difficult to visualize in intact, living subjects. In this study, we apply diffusion tensor imaging (DTI) to the evaluation of cortical development in human infants ranging from 26 to 41 weeks gestational age (GA). Apparent diffusion of water in cortex is maximally anisotropic at 26 weeks GA and anisotropy values approach zero by 36 weeks GA. During this period, the major eigenvector of the diffusion tensor in cerebral cortex is oriented radially across the cortical plate, in accord with a predominately radial deployment of its neuronal constituents. Values for the rotationally averaged water diffusion coefficient increase between 26 and 32 weeks GA, then decrease thereafter. These changes in DTI parameters are specific to cerebral cortex and reflect changes in underlying cortical architecture and formation of neuronal connections. Because of its correlation with tissue microstructure and non-invasive nature, DTI offers unique insight into cortical development in preterm human newborns and, potentially, detection of derangements of its basic cytoarchiteture.     

The sensitivity of scintigraphic myocardial imaging by the use of 99mTc-labelled pyrophosphate in the diagnosis of cardiomyopathy of various etiology.

A total of 10 patients were examined. In five children who suffered from secondary cardiomyopathy accompanying progressive muscular dystrophy scintigraphic examination of the myocardium was made using 99mTc-labelled pyrophosphate. In two cases the scan was distinctly positive, in three cases negative. Five men with poorly defined primary nonobstructive cardiomyopathy were examined too. The scan was positive in three cases and negative in two cases. The positivity of the pyrophosphate scan of the heart is therefore not pathonomonic of ischaemic damage. An increased accumulation of pyrophosphate in the myocardium in cardiomyopathy indicates an acute phase of the disease.     

Demonstration and evaluation of apparent cytoplasmic and vesicular serotonin compartments in human platelets

Thrombin has been used in conjunction with formaldehyde treatment to investigate the distribution of labeled serotonin between releasable and non-releasable compartments during the serotonin uptake process. The data indicate that serotonin accumulates in a predictable fashion in both compartments, which may represent, respectively, vesicular and cytoplasmic amine pools. The results also suggest that the cytoplasmic pool may reach sizable proportions under certain incubation conditions.