Impact of a Cost Visibility Tool in the Electronic Medical Record on Antibiotic Prescribing in an Academic Medical Center

Background:

Studies evaluating the impact of passive cost visibility tools on antibiotic prescribing are lacking.

Objective:

The objective of this study was to evaluate whether the implementation of a passive antibiotic cost visibility tool would impact antibiotic prescribing and decrease antibiotic spending.

Methods:

An efficiency and effectiveness initiative (EEI) was implemented in October 2012. To support the EEI, an antibiotic cost visibility tool was created in June 2013 displaying the relative cost of antibiotics. Using an observational study of interrupted time series design, 3 time frames were studied: pre EEI, post EEI, and post cost visibility tool implementation. The primary outcome was antibiotic cost per 1,000 patient days. Secondary outcomes included case mix index (CMI)–adjusted antibiotic cost per 1,000 patient days and utilization of the cost visibility tool.

Results:

Initiation of the EEI was associated with a $4,675 decrease in antibiotic cost per 1,000 patient days (P = .003), and costs continued to decrease in the months following EEI (P = .009). After implementation of the cost visibility tool, costs remained stable (P = .844). Despite CMI increasing over time, adjustment for CMI had no impact on the directionality or statistical significance of the results.

Conclusion:

Our study demonstrated a significant and sustained decrease in antibiotic cost per 1,000 patient days when focused medication cost reduction efforts were implemented, but passive cost visibility tool implementation was not associated with additional cost reduction. Antibiotic cost visibility tools may be of most benefit when prior medication cost reduction efforts are lacking or when an active intervention is incorporated.     

KPC and NDM-1 Genes in Related Enterobacteriaceae Strains and Plasmids from Pakistan and the United States

To characterize the genomic context of New Delhi metallo-β-lactamase-1 (NDM-1) and Klebsiella pneumoniae carbapenemase (KPC), we sequenced 78 Enterobacteriaceae isolates from Pakistan and the United States encoding KPC, NDM-1, or no carbapenemase. High similarities of the results indicate rapid spread of carbapenem resistance between strains, including globally disseminated pathogens.     

3种β-内酰胺类抗生素对老年糖尿病患者泌尿系感染的疗效比较

目的:比较应用3种β-内酰胺类抗生素对老年糖尿病患者泌尿系感染的临床疗效差异。方法:前瞻性选择120例罹患泌尿系感染的老年糖尿病患者,依据随机数字法所用β-内酰胺类抗生素不同分为:A组,予以头孢噻肟钠2 g,bid静滴治疗;B组,予以头孢他啶钠2 g,bid静滴治疗;C组,予以头孢替唑钠2 g,bid静滴治疗。3组患者均为40例,疗程均为7 d。治疗后比较3组的治疗有效率、细菌学清除率的差异,并对3组各种不良反应发生率进行比较。随访1月,比较3组患者泌尿系感染再发率差异。结果:3组的总有效率和显效率为A组>C组>B组(P<0.05),而无效率为B组>C组>A组(P<0.05)。3组的细菌学清除率存在A组最佳(P<0.05),而B组与C组无差异(P>0.05)。3组的各种不良反应发生率均无差异(P>0.05)。随访1月,3组患者泌尿系感染再发率为B组>C组>A组(P<0.05)。结论:头孢噻肟钠治疗老年糖尿病患者泌尿系感染的治疗有效率和细菌学清除率最高,且再发率最低。     

Current antibiotic prophylaxis in pancreatoduodenectomy in Japan

Background/Purpose

The aim of this study was to investigate the current use of antibiotic prophylaxis (AP) in association with pancreatoduodenectomy (PD) in Japan, and to determine its surgical implications.

Methods

We surveyed 2331 patients who underwent PD for treatment of disease in the periampullary region. Data, obtained during the period January 2002 through December 2003, from 111 major surgical services associated with the Japanese Society for Pancreatic Surgery, were analyzed with regard to patient characteristics, preoperative complications, AP, and postoperative morbidities.

Results

Eighty-five (78.7%) of the 108 eligible institutions chose a first- or second-generation cephalosporin for AP, given for a mean duration of 4.3 days. At all but 1 institution, the first dose was administered prior to surgical incision of the skin. At 42% of the institutions, an additional antibiotic was administered during surgery. The overall rate of wound infection was 6.8% of the 2266 patients for whom data were available. Preoperative jaundice was found in 55.3% of these 2266 patients, and 92.6% of these jaundiced patients were suffering from preoperative infections. In addition, those with preoperative infections were also diagnosed as having biliary infections. The number of patients with preoperative jaundice in combination with preoperative infections was significantly related to the rate of postoperative morbidity (P < 0.0001).

Conclusions

Administration of AP in association with PD in Japan seems appropriate. Icteric patients with biliary infections are at high risk for postoperative morbidities and need careful monitoring after surgery.     

Listeria grayi bacteremia in a heart transplant recipient

Abstract: Bacteria belonging to the genus Listeria have been isolated from food products of animal, plant, and fish origin, and are associated with infections in immunocompromised hosts, pregnant women, and infants. The species Listeria grayi has rarely been reported as a human pathogen. It has a unique antibiotic sensitivity profile. We describe a case of L. grayi bacteremia in a heart transplant recipient. The organism demonstrated a reduced sensitivity to ampicillin. The patient was successfully treated with a combination of vancomycin and ciprofloxacin.     

Antibiotic-resistant soil bacteria in transgenic plant fields

Understanding the prevalence and polymorphism of antibiotic resistance genes in soil bacteria and their potential to be transferred horizontally is required to evaluate the likelihood and ecological (and possibly clinical) consequences of the transfer of these genes from transgenic plants to soil bacteria. In this study, we combined culture-dependent and -independent approaches to study the prevalence and diversity of bla genes in soil bacteria and the potential impact that a 10-successive-year culture of the transgenic Bt176 corn, which has a blaTEM marker gene, could have had on the soil bacterial community. The bla gene encoding resistance to ampicillin belongs to the beta-lactam antibiotic family, which is widely used in medicine but is readily compromised by bacterial antibiotic resistance. Our results indicate that soil bacteria are naturally resistant to a broad spectrum of beta-lactam antibiotics, including the third cephalosporin generation, which has a slightly stronger discriminating effect on soil isolates than other cephalosporins. These high resistance levels for a wide range of antibiotics are partly due to the polymorphism of bla genes, which occur frequently among soil bacteria. The blaTEM116 gene of the transgenic corn Bt176 investigated here is among those frequently found, thus reducing any risk of introducing a new bacterial resistance trait from the transgenic material. In addition, no significant differences were observed in bacterial antibiotic-resistance levels between transgenic and nontransgenic corn fields, although the bacterial populations were different.     

Antibiotic strategy after the empiric phase in patients treated for a hematological malignancy

 Empiric broad-spectrum antibiotic therapy has become a generally accepted strategy in the treatment of febrile neutropenic patients. Particularly in patients with prolonged neutropenia, subsequent adaptation of such a regimen will be the rule rather than exception. Since there are no uniformly accepted guidelines for the modification of antibiotic therapy during the post-empiric phase, we assessed the impact of a set of rules that evolved during the first randomized trials. Evaluation of the clinician's compliance with these rules in 1951 febrile neutropenic episodes was the subject of the present analysis. Treatment was modified in 761 (39%) cases, and these changes were made according to the rules in 76%. For 75% of the alterations in treatment during the evening and night shifts, no reasonable explanation was established, while 93% of the modifications during the normal working hours were made for objective reasons. The empiric regimen was more frequently changed in patients with a clinical focus of infection at the onset of fever than in patients who showed fever as the only symptom of a possible infection. The perceived need for modification amounted to 69% in pulmonary infections, to 51% in skin and soft-tissue infections, to 44% in patients with abdominal complaints, and to 37% in upper respiratory tract infections. Glycopeptides constituted 22% of modifications, particularly in patients with a central venous catheter, and systemically active antifungals were administered in 16% of cases. Especially inexperienced clinicians tend to adjust antibiotic therapy, in spite of the fact that persistence of fever alone seldom reflects inadequate treatment when the clinical condition of the patient is stable or improving. On the other hand, the development of subsequent infectious events emphasizes that a genuine need for modification does frequently exist. Received: 4 December 1995 / Accepted: 7 December 1995     

Perspectives on "chronic Lyme disease"

There is much controversy about the treatment of Lyme disease with respect to 2 poorly defined entities: “chronic Lyme disease” and “posttreatment Lyme disease syndrome.” In the absence of direct evidence that these conditions are the result of a persistent infection, some mistakenly advocate extended antibiotic therapy (≥6 months), which can do great harm and has resulted in at least 1 death. The purpose of this brief report is to review what is known from clinical research about these conditions to assist both practicing physicians and lawmakers in making sound and safe decisions with respect to treatment.     

Association between point-of-care CRP testing and antibiotic prescribing in respiratory tract infections: a systematic review and meta-analysis of primary care studies

Background

Most patients with respiratory tract infections (RTIs) are prescribed antibiotics in general practice. However, there is little evidence that antibiotics bring any value to the treatment of most RTIs. Point-of-care C-reactive protein testing may reduce antibiotic prescribing.

Aim

To systematically review studies that have examined the association between point-of-care (POC) C-reactive protein testing and antibiotic prescribing for RTIs in general practice.

Design and setting

Systematic review and meta-analysis of randomised controlled trials and observational studies.

Method

MEDLINE^® and Embase were systematically searched to identify relevant publications. All studies that examined the association between POC C-reactive protein testing and antibiotic prescribing for patients with RTIs were included. Two authors independently screened the search results and extracted data from eligible studies. Dichotomous measures of outcomes were combined using risk ratios (RRs) with 95% confidence intervals (CIs) either by fixed or random-effect models.

Results

Thirteen studies containing 10 005 patients met the inclusion criteria. POC C-reactive protein testing was associated with a significant reduction in antibiotic prescribing at the index consultation (RR 0.75, 95% CI = 0.67 to 0.83), but was not associated with antibiotic prescribing at any time during the 28-day follow-up period (RR 0.85, 95% CI = 0.70 to 1.01) or with patient satisfaction (RR 1.07, 95% CI = 0.98 to 1.17).

Conclusion

POC C-reactive protein testing significantly reduced antibiotic prescribing at the index consultation for patients with RTIs. Further studies are needed to analyse the confounders that lead to the heterogeneity.     

The Natural Evolutionary Relationships among Prokaryotes

Two contrasting and very different proposals have been put forward to account for the evolutionary relationships among prokaryotes. The currently widely accepted three domain proposal by Woese et al. (Proc. Natl. Acad. Sci. USA (1990) 87: 4576-4579) calls for the division of prokaryotes into two primary groups or domains, termed archaebacteria (Archaea) and eubacteria (Bacteria), both of which are suggested to have originated independently from a universal ancestor. However, this proposal, which is based primarily on genes involved in the information transfer processes, is inconsistent with the ultrastructural characteristics of prokaryotes as well as with many gene phylogenies and provides no explanation as to how the structural and molecular differences seen between these groups arose and how other prokaryotic taxa are related or evolved from the common ancestor. It also postulates that the last common ancestor of all organisms was a hypothetical entity lacking a cell membrane, which is contrary to the basic requirement of a cell membrane to define and separate all forms of life from the surrounding environment. A second alternate proposal for the evolutionary relationships among prokaryotes has emerged from extensive analyses of numerous conserved inserts and deletions found in various proteins (Gupta, R. S., Microbiol. Mol. Biol. Rev. (1998) 62: 1435-1491; FEMS Microbiol. Rev. (2000) 24: in press. This proposal points to a specific relationship between archaebacteria and Gram-positive bacteria, both of which are prokaryotes bounded by a single cell membrane (monoderm prokaryotes). Gram-negative bacteria, which are bounded by two different membranes (diderm prokaryotes), are indicated to comprise a structurally and phylogenetically distinct taxa originating from Gram-positive bacteria. This proposal postulates that the earliest prokaryote was a Gram-positive bacteria from which both archaebacteria and diderm prokaryotes evolved by normal evolutionary mechanisms in response to the strong selection pressure exerted by antibiotics produced by certain groups of gram-positive bacteria. This proposal accounts for both the molecular as well structural differences seen among the main groups of prokaryotes by known evolutionary mechanisms without invoking any hypothetical process or entity and thus is a closer representation of the natural relationships among prokaryotes than the proposal for two distinct domains. Based on this new proposal, it is now possible to logically deduce the branching order of different prokaryotic taxa from the common ancestor, which is as follows: Gram-positive bacteria (Low G + C) (? Archaebacteria) ? Gram-positive bacteria (High G + C) (? Archaebacteria)? Deinococcus-Thermus ? Green nonsulfur bacteria ? Cyanobacteria ? Spirochetes ? Chlamydia- Cytophaga-Green sulfur bacteria ? Proteobacteria-1 (ε, δ)? Proteobacteria-2 (α) ? Proteobacteria-3 (β) ? Proteobacteria-4 (γ). A surprising but very important aspect of the relationship deduced here is that the main eubacterial phyla are related to each other linearly rather than in a tree-like manner, suggesting that the major evolutionary changes within prokaryotes (bacteria) have occurred in a directional manner.