Early switch from intravenous to oral antibiotics and early hospital discharge: a prospective observational study of 200 consecutive patients with community-acquired pneumonia

Derivation and validation of a model to predict treatment failure among under five children with severe community acquired pneumonia who are admitted at Debre Tabor specialized comprehensive hospital

BACKGROUND

Severe community-acquired pneumonia related treatment failure is persistence of features of severe pneumonia after initiation of antimicrobial therapy or a worsening clinical condition within 48-72 hours of the commencement of the antibiotics. Even though it is the most devastating public health problem in Ethiopia, there is no study to derivate and validate a model to predict treatment failure. To do this, nomogram was used to estimate the probability of treatment failure for each individual child and to classify their risk of treatment failure.

OBJECTIVE

to develop and validate the model to predict treatment failure among under five children with severe community-acquired pneumonia in Debre Tabor comprehensive specialized hospital.

METHOD

A secondary analysis of the previously collected prospective follow-up study was used for further analysis among 590 under-5 children hospitalized with severe community-acquired pneumonia. The STATA version 17 software was used for analysis. Descriptive analysis was summarized by frequency and percentage. A multivariable binary logistic regression was also conducted, and the model performance was evaluated using the receiver operating characteristics curve with its area under the curve and calibration curve. Internal validation of the model was assessed using the bootstrap technique. The decision curve analysis was also used to evaluate the usefulness of the nomogram.

RESULTS

The incidence of treatment failure among severe community-acquired pneumonia children was 28.1% (95% CI: 24.7%-30.8%). The previous history of severe community-acquired pneumonia, abnormal pulse rate, chest indrowing, anemia, HIV status, and plural effusion remained for the final model. The area under the curve for the original model and validated model was 0.7719 (95%CI: 0.729, 0.815) and 0.7714 (95% CI: 0.728-0.82), respectively. The decision curve analysis showed that the nomogram had a better net benefit across the threshold probability.

CONCLUSION

The incidence of treatment failure among children with severe community-acquired pneumonia was high in Debre Tabor comprehensive hospital. The previous history of severe community-acquired pneumonia, abnormal pulse rate, chest indrowing, anemia, HIV status, and plural effusion were the significant factors to develop the predictive model. The model had good discriminatory performance and internally valid. Similarly, the model has a good calibration ability with an insignificant loss of accuracy from the original. The models can have the potential to improve treatment outcomes in the clinical settings. But needs external validation before use.

Efficacy and Safety of Intravenous-to-Oral Lascufloxacin Switch Therapy in Community-Onset Pneumonia: A Single-Arm, Open-Label Clinical Trial

BACKGROUND AND OBJECTIVE

For treating community-acquired pneumonia (CAP) in adults, early switching from injectable to oral antimicrobials (switch therapy) is accepted once the clinical course is favorable. Lascufloxacin (LSFX) is a quinolone antibacterial agent, available in intravenous and oral formulations, demonstrating antibacterial activity against a relatively broad spectrum of community-onset pneumonia (COP). No switch therapy using the same drug from injectable to oral antimicrobials has been reported; therefore, we conducted the study to confirm the efficacy and safety of the switch therapy using LSFX.

METHOD

We conducted an open-label, uncontrolled, multicenter study across 16 hospitals from April 2023 to February 2024 to evaluate the efficacy and safety of LSFX switch therapy against mild-to-moderate COP. Once the switch criteria were fulfilled on days 3-5, switch therapy was initiated. The primary endpoint was the cure rate at the time of test of cure (TOC). Secondary endpoints included the proportion of patients receiving switch therapy, clinical efficacy at the end of treatment (EOT), early clinical response, microbiological response at the EOT, and adverse events. The adverse events were collected from the population for the safety analysis set.

RESULTS

The median age of the participants was 73 years, and the overall switch therapy implementation rate was 114/120 (95%), aligned with approximately 99/104 (95%) of the switch therapy performed by day three after initiating the therapy. The cure or effective rate was 100/104 (96.2%, 95% confidence interval (CI): 90.44-98.94) at TOC, 101/104 (97.1%, 95% CI: 91.80-99.40) at the early clinical efficacy testing, and 103/104 (99.0%, 95% CI: 94.76-99.98) at EOT. Adverse events related to the study drug were reported in 10.0% of the patients, with hepatic dysfunction as the most common adverse effect. Severe LSFX-induced adverse events were not observed, excluding worsening pneumonia.

CONCLUSION

Switch therapy using LSFX presented high efficacy and acceptable safety profiles against mild-to-moderate severity of COP. This strategy of using the same drug in both intravenous and oral formulations is quite innovative. LSFX may potentially emerge as one of the preferred options for treating COP.

Community-Acquired Pneumonia in the Immunocompromised Patients: An Observational Study from a Single Center, TURKEY

Purpose

Immunocompromised hosts are underrepresented in clinical trials. The goal of the study to search for the unmet needs in the management of CAP in immunocompromised hosts.

Patients and Methods

An observational study was conducted with CAP patients documented immunocompromise or those aged over 65 who have at least one chronic visceral disease. We clinically assessed the eligible patients at the time of the presentation with a follow-up assessment on day three of admission. The data were statistically analyzed to assess the impact of variables on mortality.

Results

During a 15-month study period, 140 CAP patients were observed. The overall 30-day mortality rate was 17.8%. The mortality rate was significantly higher in patients with sputum cultures positive for Pseudomonas aeruginosa, or two bacteria (p=0.049). Tachypnea was a stronger predictor of mortality. Failure to achieve a treatment response within three days of treatment identified the population with the worst outcomes. Less than half of such patients survived past one month.

Conclusion

Dynamic response assessment emerged as potentially the strongest predictor of outcomes in CAP of susceptible hosts. We propose that immunocompromised CAP patients who fail to respond early to treatment face extremely high rates of mortality, identifying an unmet need.

Exclusive oral antibiotic treatment for hospitalized community-acquired pneumonia: a post-hoc analysis of a randomized clinical trial

OBJECTIVES

In this study, we aimed to assess the efficacy of different ways of administration and types of beta-lactams for hospitalized community-acquired pneumonia (CAP).

METHODS

In this post-hoc analysis of randomized controlled trials (RCT) on patients hospitalized for CAP (pneumonia short treatment trial) comparing 3-day vs. 8-day durations of beta-lactams, which concluded to non-inferiority, we included patients who received either amoxicillin-clavulanate (AMC) or third-generation cephalosporin (3GC) regimens, and exclusively either intravenous or oral treatment for the first 3 days (followed by either 5 days of oral placebo or AMC according to randomization). The choice of route and molecule was left to the physician in charge. The main outcome was a failure at 15 days after the first antibiotic intake, defined as temperature >37.9°C, and/or absence of resolution/improvement of respiratory symptoms, and/or additional antibiotic treatment for any cause. The primary outcome according to the route of administration was evaluated through logistic regression. Inverse probability treatment weighting with a propensity score model was used to adjust for non-randomization of treatment routes and potential confounders. The difference in failure rates was also evaluated among several sub-populations (AMC vs. 3GC treatments, intravenous vs. oral AMC, patients with multi-lobar infection, patients aged ≥65 years old, and patients with CURB65 scores of 3-4).

RESULTS

We included 200 patients from the original trial, with 93/200 (46.5%) patients only treated with intravenous treatment and 107/200 (53.5%) patients only treated with oral therapy. The failure rate at Day 15 was not significantly different among patients treated with initial intravenous vs. oral treatment [25/93 (26.9%) vs. 28/107 (26.2%), adjusted odds ratios (aOR) 0.973 (95% CI 0.519-1.823), p 0.932)]. Failure rates at Day 15 were not significantly different among the subgroup populations.

DISCUSSION

Among hospitalized patients with CAP, there was no significant difference in efficacy between initial intravenous and exclusive oral treatment.

TRIAL REGISTRATION

This trial is registered with ClinicalTrials.gov, NCT01963442.

Treatment Failure and Clinical Stability in Severe Community-Acquired Pneumonia

Treatment failure and clinical stability are important outcomes in community-acquired pneumonia (CAP). It is essential to know the causes and risk factors for treatment failure and delay in reaching clinical stability in CAP. The study of both as well as the associated underlying mechanisms and host response are key to improving outcomes in pneumonia.

Intravenous to Oral Antibiotic Switch Therapy Among Patients Hospitalized With Community-Acquired Pneumonia

BACKGROUND

Community-acquired pneumonia (CAP) is a leading cause of hospital admissions and antimicrobial use. Clinical practice guidelines recommend switching from intravenous (IV) to oral antibiotics once patients are clinically stable.

METHODS

We conducted a retrospective cohort study of adults admitted with CAP and initially treated with IV antibiotics at 642 US hospitals from 2010 through 2015. Switching was defined as discontinuation of IV and initiation of oral antibiotics without interrupting therapy. Patients switched by hospital day 3 were considered early switchers. We compared length of stay (LOS), in-hospital 14-day mortality, late deterioration (intensive care unit [ICU] transfer), and hospital costs between early switchers and others, controlling for hospital characteristics, patient demographics, comorbidities, initial treatments, and predicted mortality.

RESULTS

Of 378 041 CAP patients, 21 784 (6%) were switched early, most frequently to fluoroquinolones. Patients switched early had fewer days on IV antibiotics, shorter duration of inpatient antibiotic treatment, shorter LOS, and lower hospitalization costs, but no significant excesses in 14-day in-hospital mortality or late ICU admission. Patients at a higher mortality risk were less likely to be switched. However, even in hospitals with relatively high switch rates, <15% of very low-risk patients were switched early.

CONCLUSIONS

Although early switching was not associated with worse outcomes and was associated with shorter LOS and fewer days on antibiotics, it occurred infrequently. Even in hospitals with high switch rates, <15% of very low-risk patients were switched early. Our findings suggest that many more patients could be switched early without compromising outcomes.

Short treatment duration for community-acquired pneumonia

PURPOSE OF REVIEW

Lower respiratory tract infections are one of the most common indications for antibiotic use in community and hospital settings. Usual guidelines for adults with community-acquired pneumonia (CAP) recommend 5-7 days of antibiotic treatment. In daily practice, physicians often prescribe 9-10 days of antibiotic treatment. Among available strategies to decrease antibiotic use, possibly preventing the emergence of bacterial resistance, reducing treatment durations is the safest and the most acceptable to clinicians. We aim to review data evaluating the efficacy of short antibiotic duration in adult CAP and which criteria can help clinicians to reduce antibiotic treatment.

RECENT FINDINGS

Several studies and meta-analyses demonstrated that the treatment duration of 7 days or less was sufficient for CAP. Two trials found that 3-day treatments were effective, even in hospitalized CAP.To customize and shorten duration, clinical and biological criteria have been studied and reflect patient's response. Indeed, stability criteria were recently shown to be effective to discontinue antibiotic treatment. Procalcitonin was also studied but never compared with clinical criteria.

SUMMARY

Treatment duration for CAP is still under debate, but several studies support short durations. Clinical criteria could be possibly used to discontinue antibiotic treatment.

Evaluation of Oral Tebipenem as a Step-Down Therapy following Intravenous Ertapenem against Extended-Spectrum β-Lactamase-Producing Escherichia coli in a Hollow-Fiber In Vitro Infection Model

Tebipenem is an orally bioavailable carbapenem in development for the treatment of patients with complicated urinary tract infections. Herein, we describe the results of studies designed to evaluate tebipenem's potential as an oral (p.o.) transition therapy from intravenous (i.v.) ertapenem therapy for the most common uropathogen, Escherichia coli. These studies utilized a 7-day hollow-fiber in vitro infection model and 5 extended-spectrum β-lactamase-producing E. coli challenge isolates. Human free-drug serum concentration-time profiles for tebipenem 600 mg p.o. every 8 h and ertapenem 1 g i.v. every 24 h were simulated in the hollow-fiber in vitro infection model. Samples were collected for bacterial density and drug concentration determination over the 7-day study period. Generally, ertapenem monotherapy resulted in a greater reduction in bacterial density than did tebipenem monotherapy. In the treatment arms in which ertapenem dosing was stopped following dosing for 1 or 3 days, immediate bacterial regrowth occurred and matched that of the growth control. Finally, in the treatment arms in which ertapenem dosing was stopped following dosing for 1 or 3 days and tebipenem dosing was initiated for the remainder of the 7-day study, the intravenous-to-oral transition regimen reduced bacterial burdens and prevented regrowth. Given that transition from intravenous to oral antibiotic therapy has been shown to reduce hospital length of stay, nosocomial infection risk, and cost, and improve patient satisfaction, these data demonstrate tebipenem's potential role as an oral transition agent from intravenous antibiotic regimens within the antibiotic stewardship paradigm.

Effectiveness of antimicrobial stewardship interventions on early switch from intravenous-to-oral antimicrobials in hospitalized adults: A systematic review

BACKGROUND

This review aimed to summarize the available evidence on the effectiveness and safety of antimicrobial stewardship interventions to improve the practice of IV-to-PO antimicrobial switch therapy in hospitalized adults.

METHODS

Following the PRISMA guidelines, we searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE/PubMed, and Scopus from inception to September 1, 2020, for original articles investigating any interventions aimed to improve the practice of IV-to-PO antimicrobial switch therapy in hospitalized adults with infectious diseases. We included randomized controlled trials (RCTs) and quasi-experimental studies. Studies were excluded if they evaluated drugs other than antimicrobials, head-to-head comparison of interventions, included pediatrics or oncology patients.

RESULTS

Of 506 unique citations identified, 36 studies met the inclusion criteria. The 36 included studies reported 92 interventions as a single (n = 10) or a bundle of interventions (n = 26). The most common interventions used were guideline/protocol/pathway (n = 25), audit and feedback (n = 20), and education (n = 17).

CONCLUSIONS

This review provides health care providers with a comprehensive summary on the interventions to promote IV-to-PO antimicrobial switch. While no one intervention could be identified as the safest and most effective as most of the included studies used a bundle of interventions, all interventions resulted in optimizing antibiotic use and reducing health care expenditures without compromising the clinical outcomes. As such, each hospital should design and utilize interventions that are applicable based on available resources and expertise.

The Impact of a Pharmacist-Led Intravenous to Oral Switch of Metronidazole: A Before-and-After Study

(1) Background. Intravenous (IV) to oral switch (IVOS) of antibiotics can reduce the length of hospitalisation, risk of IV catheter complications, and hospital costs. Pharmacists can play an instrumental role in implementing an IVOS initiative. The aim of this study is to evaluate the impact of pharmacist-led IVOS of metronidazole. (2) Method. This was an observational study conducted in a New Zealand hospital. During a 3-month intervention period, pharmacists identified patients receiving IV metronidazole; then initiated an IVOS for patients who met the criteria. The comparator groups were patients who were not switched by pharmacists in the post-intervention (post-IVOS) group, or patients treated with either IV or oral metronidazole prior to the intervention (pre-IVOS). Primary outcome measures were switch rate and duration of IV metronidazole treatment. Secondary outcome measures were readmission and/or repeat surgery within 90 days of discharge and the length of hospital stay. (3) Results. In total, 203 patients were included: 100 in the pre-IVOS and 103 in the post-IVOS groups. Pharmacists switched 63/93 (67.7%) of eligible patients to oral metronidazole in the post-IVOS period. Only 9/89 (10.1%) of IVOS eligible patients were switched in the pre-IVOS group. In the post-IVOS group, the mean duration of IV metronidazole treatment in patients switched by pharmacists was shorter than in those who were not switched by pharmacists (2.5 ± 2.8 days vs. 4.8 ± 5.9 days, p = 0.012). No significant difference was found in readmission or repeat surgery within 90 days of discharge for patients switched by pharmacists versus patients who were not switched by pharmacists. (4) Conclusion. Our data have demonstrated successful implementation of the hospital-approved pharmacist-led IVOS service.

Appropriate prescribing of azithromycin for community-acquired pneumonia

Azithromycin is prescribed for atypical antimicrobial cover in severe community‐acquired pneumonia. Inappropriate azithromycin administration incurs unnecessary financial costs, exacerbates antimicrobial resistance and risks QTc interval prolongation leading to cardiac arrhythmias. The present study demonstrated that a majority of patients were prescribed azithromycin without having electrocardiograms to assess the QTc interval and without meeting criteria for severe community‐acquired pneumonia based on CURB‐65 score.

Short and Concise Peer-to-Peer Teaching—Example of a Successful Antibiotic Stewardship Intervention to Increase Iv to Po Conversion

Antibiotic stewardship (ABS) programs aim to combine effective treatment with minimized antibiotic-related harms. Common ABS interventions are simple and effective, but their implementation in daily practice is often difficult. The aim of our study was to investigate if a single, short, peer-to-peer teaching intervention (junior doctor to junior doctor) during clinical routine can successfully improve antibiotic prescriptions. We performed a quasi-experimental before–after study on a regular care cardiology ward at a large academic medical center in Germany. We evaluated antibiotic use metrics retrospectively and calculated defined daily doses (DDD) with the anatomical therapeutic chemical/DDD classification system of the World Health Organization. We hypothesize that the over-representative use of intravenous administration is a potentially modifiable target, which can be proven by antibiotic use metrics analysis. After a single peer-to-peer teaching session with a focus on indications for iv to po conversion, the normalized percentage of intravenous compared to oral administration significantly decreased (from 86.5 ± 50.3% to 41.4 ± 70.3%). Moreover, after the intervention, antibiotics with high oral bioavailability were no longer administered intravenously at all during the following quarter. Our results indicate that even a single peer-to-peer training session is highly effective in improving the iv to po conversion rate in the short term.

Community-acquired pneumonia

Community-acquired pneumonia is not usually considered a high-priority problem by the public, although it is responsible for substantial mortality, with a third of patients dying within 1 year after being discharged from hospital for pneumoniae. Although up to 18% of patients with community-acquired pneumonia who were hospitalised (admitted to hospital and treated there) have at least one risk factor for immunosuppression worldwide, strong evidence on community-acquired pneumonia management in this population is scarce. Several features of clinical management for community-acquired pneumonia should be addressed to reduce mortality, morbidity, and complications related to community-acquired pneumonia in patients who are immunocompetent and patients who are immunocompromised. These features include rapid diagnosis, microbiological investigation, prevention and management of complications (eg, respiratory failure, sepsis, and multiorgan failure), empirical antibiotic therapy in accordance with patient's risk factors and local microbiological epidemiology, individualised antibiotic therapy according to microbiological data, appropriate outcomes for therapeutic switch from parenteral to oral antibiotics, discharge planning, and long-term follow-up. This Seminar offers an updated view on community-acquired pneumonia in adults, with suggestions for clinical and translational research.

Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia

This clinical policy from the American College of Emergency Physicians is a revision of the 2009 "Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia." A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In the adult emergency department patient diagnosed with community-acquired pneumonia, what clinical decision aids can inform the determination of patient disposition? (2) In the adult emergency department patient with community-acquired pneumonia, what biomarkers can be used to direct initial antimicrobial therapy? (3) In the adult emergency department patient diagnosed with community-acquired pneumonia, does a single dose of parenteral antibiotics in the emergency department followed by oral treatment versus oral treatment alone improve outcomes? Evidence was graded and recommendations were made based on the strength of the available data.

Economic analysis of ceftaroline fosamil for treating community-acquired pneumonia in Spain

Background: Adults admitted to hospital with community-acquired pneumonia (CAP) impose significant burden upon limited hospital resources. To achieve early response and possibly early discharge, thus reducing hospital expenditure, the choice of initial antibiotic therapy is pivotal.Methods: A cost-consequences model was developed to evaluate ceftaroline fosamil (CFT) as an alternative to other antibiotic therapies (ceftriaxone, co-amoxiclav, moxifloxacin, levofloxacin) for the empiric treatment of hospitalized adults with moderate/severe CAP (PORT score III-IV) from the perspective of the Spanish National Health System (NHS).Findings: Compared with ceftriaxone, the model predicted an increase in the number of CFT-treated patients discharged early (PDE) (30.6% vs. 26.1%) while decreasing initial antibiotic failures (3.8% vs. 7.6%). For patients with pneumococcal pneumonia, CFT was cost-saving vs. ceftriaxone (by 1.2%) and significantly increased PDE (32.1% vs. 24.6%). CFT resulted in cost-saving vs. levofloxacin, due lower initial antibiotic therapy costs and increased PDE (30.6% vs. 14.9%). Moxifloxacin and co-amoxiclav early response rate of 53.63% and 54.24% resulted in cost neutrality vs. CFT, with direct comparison hampered by the significantly different early response criteria utilized in the literature.Conclusions: Despite a higher unit cost, CFT is a reasonable alternative to other agents for adults hospitalized with moderate/severe CAP, given the projected higher PDE achieved with similar or lower total costs.

A clinical decision support system algorithm for intravenous to oral antibiotic switch therapy: validity, clinical relevance and usefulness in a three-step evaluation study

Objectives

To evaluate a clinical decision support system (CDSS) based on consensus-based intravenous to oral switch criteria, which identifies intravenous to oral switch candidates.

Methods

A three-step evaluation study of a stand-alone CDSS with electronic health record interoperability was performed at the Erasmus University Medical Centre in the Netherlands. During the first step, we performed a technical validation. During the second step, we determined the sensitivity, specificity, negative predictive value and positive predictive value in a retrospective cohort of all hospitalized adult patients starting at least one therapeutic antibacterial drug between 1 and 16 May 2013. ICU, paediatric and psychiatric wards were excluded. During the last step the clinical relevance and usefulness was prospectively assessed by reports to infectious disease specialists. An alert was considered clinically relevant if antibiotics could be discontinued or switched to oral therapy at the time of the alert.

Results

During the first step, one technical error was found. The second step yielded a positive predictive value of 76.6% and a negative predictive value of 99.1%. The third step showed that alerts were clinically relevant in 53.5% of patients. For 43.4% it had already been decided to discontinue or switch the intravenous antibiotics by the treating physician. In 10.1%, the alert resulted in advice to change antibiotic policy and was considered useful.

Conclusions

This prospective cohort study shows that the alerts were clinically relevant in >50% (n = 449) and useful in 10% (n = 85). The CDSS needs to be evaluated in hospitals with varying activity of infectious disease consultancy services as this probably influences usefulness.

Effectiveness of a Bundled Intervention Including Adjunctive Corticosteroids on Outcomes of Hospitalized Patients With Community-Acquired Pneumonia: A Stepped-Wedge Randomized Clinical Trial

IMPORTANCE

Community-acquired pneumonia remains a leading cause of hospitalization, mortality, and health care costs worldwide. Randomized clinical trials support the use of adjunctive corticosteroids, early progressive mobilization, antibiotic switching rules, and dietary interventions in improving outcomes. However, it is uncertain whether implementing these interventions will translate into effectiveness under routine health care conditions.

OBJECTIVE

To evaluate the effectiveness of a bundle of evidence-supported treatments under conditions of routine care in a representative population hospitalized for community-acquired pneumonia.

DESIGN, SETTING, AND PARTICIPANTS

A double-blind, stepped-wedge, cluster-randomized clinical trial with 90-day follow-up was conducted between August 1, 2016, and October 29, 2017, in the general internal medicine service at 2 tertiary hospitals in Melbourne, Australia, among a consecutive sample of patients with community-acquired pneumonia. The primary analysis and preparation of results took place between May 14 and November 25, 2018.

INTERVENTIONS

Treating clinical teams were advised to prescribe prednisolone acetate, 50 mg/d, for 7 days (in the absence of any contraindication) and de-escalate from parenteral to oral antibiotics according to standardized criteria. Algorithm-guided early mobilization and malnutrition screening and treatment were also implemented.

MAIN OUTCOMES AND MEASURES

Hospital length of stay, mortality, readmission, and intervention-associated adverse events (eg, gastrointestinal bleeding and hyperglycemia).

RESULTS

A total of 917 patients were screened, and 816 (351 women and 465 men; mean [SD] age, 76 [13] years) were included in the intention-to-treat analysis, with 401 patients receiving the intervention and 415 patients in the control group. An unadjusted geometric mean ratio of 0.95 (95% CI, 0.78-1.16) was observed for the difference in length of stay (days) between the intervention and control groups. Similarly, no significant differences were observed for the secondary outcomes of mortality and readmission, and the results remained unchanged after further adjustment for sex and age. The study reported higher proportions of gastrointestinal bleeding in the intervention group (9 [2.2%]) compared with the controls (3 [0.7%]), with an unadjusted estimated difference in mean proportions of 0.008 (95% CI, 0.005-0.010).

CONCLUSIONS AND RELEVANCE

This bundled intervention including adjunctive corticosteroids demonstrated no evidence of effectiveness and resulted in a higher incidence of gastrointestinal bleeding. Efficacy of individual interventions demonstrated in clinical trials may not necessarily translate into effectiveness when implemented in combination and may even result in net harm.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02835040.

Early switching of antibiotic therapy from intravenous to oral using a combination of education, pocket-sized cards and switch advice: A practical intervention resulting in reduced length of hospital stay

OBJECTIVES

To assess the effectiveness of a combined intervention on the timing and rate of switching from intravenous (IV) to oral antibiotic therapy.

MATERIALS AND METHODS

The study used a historically-controlled prospective intervention design. Interventions consisted of educating physicians, handing out pocket-sized cards and providing switch advice in the electronic patient record (EPR). All patients hospitalized at the surgery department who were treated with IV antibiotics for at least 24 h and who fulfilled the switch criteria within 72 h of IV treatment were included. Outcomes before and during the intervention were compared.

RESULTS

An early IV to oral switch took place in 35.4% (35/99) of the antibiotic courses in the baseline period and in 67.7% (42/62) of the antibiotic courses in the intervention period (odds ratio [OR] 3.84, 95% confidence interval [CI] 1.96-7.53). Duration of IV therapy was significantly reduced from 5 to 3 days (P<0.01). Length of hospitalization was reduced from 6 to 5 days (P<0.05).

CONCLUSIONS

The interventions were effective in promoting an early IV to oral antibiotic switch by shortening the length of IV therapy and hospital stay.

Effects of Hospital Practice Patterns for Antibiotic Administration for Pneumonia on Hospital Lengths of Stay and Costs

BACKGROUND

Hospital practice patterns vary for switching from intravenous to oral antibiotics for community-acquired pneumonia in pediatric patients, but it is unknown how these practice patterns affect hospital lengths of stay and costs.

METHODS

We conducted a retrospective study of 78673 pediatric patients (aged 3 months to 17 years) hospitalized for community-acquired pneumonia. Analyses were performed with data from the Pediatric Health Information System between 2007 and 2016, including discharge data from 48 freestanding children's hospitals. Patients who received antibiotics used to treat aspiration pneumonia and patients with a complex chronic condition were excluded to focus the study on uncomplicated cases. We modeled hospital practice patterns using hospital-level averages for the last day of service on which patients received antibiotics intravenously or first day of service on which patients received antibiotics orally.

RESULTS

We found that a 1-day decrease in the hospital-level average last day of service on which a patient received antibiotics intravenously reduced the average length of stay by 0.58 day (95% confidence interval [CI], -0.69 to -0.47 day) and average cost by $1332 (95% CI, -$2363 to -$300). Results were similar when hospital practice patterns were modeled using the average first day of service on which a patient received antibiotics orally. These reductions in lengths of stay and costs were not associated with a difference in 30-day readmission rates.

CONCLUSIONS

Given the reductions in lengths of stay and costs without sacrificing patient outcomes (readmissions), antimicrobial stewardship programs could target provider education on the duration of intravenous antibiotic therapy as a way to reduce resource utilization.

Short- vs long-course antibiotic therapy for pneumonia: a comparison of systematic reviews and guidelines for the SIMI Choosing Wisely Campaign

Reduction of the inappropriate use of antibiotics in clinical practice is one of the main goals of the Società Italiana di Medicina Interna (SIMI) choosing wisely campaign. We conducted a systematic review of secondary studies (systematic reviews and guidelines) to verify what evidence is available on the duration of antibiotic treatment in Pneumonia. A literature systematic search was performed to identify all systematic reviews and the three most cited and recent guidelines that address the duration of antibiotic therapy in pneumonia. Moreover, a meta-analysis of non-duplicate data from randomized controlled trials (RCTs) considered in the enrolled systematic reviews was performed together with a trial sequential analysis to identify the need for further studies. Two systematic reviews on antibiotic duration in community-acquired pneumonia (CAP) for a total of 17 RCTs (2764 patients) were enrolled in our study. Meta-analysis of non-duplicate RCTs show a non-significant difference in rate of treatment failure between short (≤ 7 days) and long (> 7 days) antibiotic treatment course: RR 1.05 (95% CI, 0.82-1.36). The trial sequential analysis suggests that further data would not affect current evidence or become clinically relevant. Selected guidelines suggest consideration of a short course, with a low grade of evidence and without citing the already published systematic reviews. Antibiotic treatment of CAP for ≤ 7 days is not associated with a higher rate of treatment failure than longer courses and should thus be taken in consideration. Guidelines should upgrade the evidence on this topic.

Disease-based antimicrobial stewardship: a review of active and passive approaches to patient management

Although new antimicrobial stewardship programmes (ASPs) often begin by targeting the reduction of antimicrobial use, an increasing focus of ASPs is to improve the management of specific infectious diseases. Disease-based antimicrobial stewardship emphasizes improving patient outcomes by optimizing antimicrobial use and increasing compliance with performance measures. Directing efforts towards the comprehensive management of specific infections allows ASPs to promote the shift in healthcare towards improving quality, safety and patient outcome metrics for specific diseases. This review evaluates published active and passive disease-based antimicrobial stewardship interventions and their impact on antimicrobial use and associated patient outcomes for patients with pneumonia, acute bacterial skin and skin structure infections, bloodstream infections, urinary tract infections, asymptomatic bacteriuria, Clostridium difficile infection and intra-abdominal infections. Current literature suggests that disease-based antimicrobial stewardship effects on medical management and patient outcomes vary based on infectious disease syndrome, resource availability and intervention type.

Impact of printed antimicrobial stewardship recommendations on early intravenous to oral antibiotics switch practice in district hospitals

Background:

Early intravenous to oral (IV-PO) antibiotics switch, which is one of the important elements in antimicrobial stewardship (AMS) is not well implemented in Malaysian district hospitals. A systematic interventional strategy is required to facilitate IV-PO antibiotic switch.

Objective:

This study aimed to evaluate the impact of printed AMS recommendations on early IV-PO antibiotics switch practice in district hospitals.

Methods:

This study was an interventional study conducted in medical wards of eight Sarawak district hospitals from May to August 2015. In pre-intervention phase, pharmacists performed the conventional practice of reviewing medication charts and verbally informed the prescribers on eligible IV-PO switches. In post-intervention phase, pharmacists attached printed checklist which contained IV-PO switch criteria to patients’ medical notes on the day patients were eligible for the switch. Stickers of IV-PO switch were applied to the antibiotic prescription to serve as reminders.

Results:

79 and 77 courses of antibiotics were studied in the pre-intervention phase and post-intervention phase respectively. Timeliness of switch was improved by 1.63 days in the post-intervention phase (95%CI 1.26:2.00 days, p<0.001). Mean duration of IV antibiotics in the post-intervention phase was shorter than pre-intervention phase (2.81 days (SD=1.77) vs 4.05 days (SD=2.81), p<0.001). The proportion of IV-PO switches that were only performed upon discharge reduced significantly in the post-intervention phase (31.2% vs 82.3%, p<0.001). Length of hospital stay in the post-intervention phase was shortened by 1.44 days (p<0.001). Median antibiotic cost savings increased significantly in the post-intervention phase compared to the pre-intervention phase [MYR21.96 (IQR=23.23) vs MYR13.10 (IQR=53.76); p=0.025)].

Conclusions:

Pharmacist initiated printed AMS recommendations are successful in improving the timeliness of IV-PO switch, reducing the duration of IV, reducing the length of hospitalisation, and increasing antibiotic cost savings.

Guideline for Antibiotic Use in Adults with Community-acquired Pneumonia

Community-acquired pneumonia is common and important infectious disease in adults. This work represents an update to 2009 treatment guideline for community-acquired pneumonia in Korea. The present clinical practice guideline provides revised recommendations on the appropriate diagnosis, treatment, and prevention of community-acquired pneumonia in adults aged 19 years or older, taking into account the current situation regarding community-acquired pneumonia in Korea. This guideline may help reduce the difference in the level of treatment between medical institutions and medical staff, and enable efficient treatment. It may also reduce antibiotic resistance by preventing antibiotic misuse against acute lower respiratory tract infection in Korea.

Disease characteristics and management of hospitalised adolescents and adults with community-acquired pneumonia in China: a retrospective multicentre survey

OBJECTIVES

To describe the clinical characteristics and management of patients hospitalised with community-acquired pneumonia (CAP) in China.

DESIGN

This was a multicentre, retrospective, observational study.

SETTING

13 teaching hospitals in northern, central and southern China from 1 January 2014 to 31 December 2014 PARTICIPANTS: Information on hospitalised patients aged ≥14 years with radiographically confirmed pneumonia with illness onset in the community was collected using standard case report forms.

PRIMARY AND SECONDARY OUTCOME MEASURES

Resource use for CAP management.

RESULTS

Of 14 793 patients screened, 5828 with radiographically confirmed CAP were included in the final analysis. Low mortality risk patients with a CURB-65 score 0-1 and Pneumonia Severity Index risk class I-II accounted for 81.2% (4434/5594) and 56.4% (2034/3609) patients, respectively. 21.7% (1111/5130) patients had already achieved clinical stability on admission. A definite or probable pathogen was identified only in 12.7% (738/5828) patients. 40.9% (1575/3852) patients without pseudomonal infection risk factors received antimicrobial overtreatment regimens. The median duration between clinical stability to discharge was 5.0 days with 30-day mortality of 4.2%.

CONCLUSIONS

These data demonstrated the overuse of health resources in CAP management, indicating that there is potential for improvement and substantial savings to healthcare systems in China.

TRIAL REGISTRATION NUMBER

NCT02489578; Results.

The IMPROVE-GAP Trial aiming to improve evidence-based management of community-acquired pneumonia: study protocol for a stepped-wedge randomised controlled trial

Background

Community-acquired pneumonia is a leading worldwide cause of hospital admissions and healthcare resource consumption. The largest proportion of hospitalisations now occurs in older patients, with high rates of multimorbidity and complex care needs. In Australia, this population is usually managed by hospital inpatient general internal medicine units. Adherence to consensus best-practice guidelines is poor. Ensuring evidence-based care and reducing length of stay may improve patient outcomes and reduce organisational costs. This study aims to evaluate an alternative model of care designed to improve adherence to four Level 1 or 2 evidence-supported interventions (routine corticosteroids, early switch to oral antibiotics, early mobilisation and routine malnutrition screening).

Methods/Design

The IMPROVing Evidence-based treatment Gaps and outcomes in community-Acquired Pneumonia (IMPROVE-GAP) trial is a pragmatic, investigator-initiated, stepped-wedge randomised trial. Patients hospitalised under a general internal medicine unit who meet a standard case definition for community-acquired pneumonia will be included. Eight general internal medicine units at two Australian hospitals in a single health service will be randomised using concealed allocation to: (i) usual medical, nursing and allied health care delivered according to existing organisational practice or (ii) care supported by a dedicated “community-acquired pneumonia service”: a multidisciplinary team deploying algorithm-based implementation of a bundle of the four evidence-based interventions. The primary outcome measure will be length of hospital stay. Secondary outcome measures include inpatient mortality, 30 and 90 day readmission rates and mortality and health-service utilisation costs. Protocol adherence will be measured and reported, and serious adverse events (rates of hyperglycaemia requiring new insulin; falls during mobilisation) will be collected and reported.

Discussion

IMPROVE-GAP represents an important and unique precedent for testing a new service-delivery model for improving compliance with a number of evidence-based interventions. Its stepped-wedge randomised controlled trial design provides a means to address some significant ethical, organisational and other methodological challenges to evaluating the effectiveness of health-service interventions in complex hospital populations. The new service-delivery model will effectively be fully implemented by trial completion, facilitating rapid, seamless translation into practice should care outcomes be superior. This trial is currently recruiting.

Trial registration

ClinicalTrials.gov, NCT02835040. Prospectively registered on 22 May 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2407-4) contains supplementary material, which is available to authorized users.

How Antibiotics Should be Prescribed to Hospitalized Elderly Patients with Community-Acquired Pneumonia

Elderly patients hospitalized with community-acquired pneumonia (CAP) should be administered antimicrobials in the emergency department prior to transfer to the ward or intensive care unit (ICU). For ward patients, a β-lactam with a macrolide or a respiratory fluoroquinolone alone should be given to cover typical and atypical pathogens. For ICU patients, a β-lactam with either a macrolide or a fluoroquinolone should be given. Other regimens are indicated if methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa is a concern. Patients who are hemodynamically stable and can tolerate oral intake can be considered for switch therapy as well as discharge if other co-morbidities are stable and a safe disposition plan exists. A number of special concerns for the elderly include noting adverse effects from antimicrobials, being watchful of comorbidity exacerbations, and vaccinating for pneumococcus and influenza.

Pharmacy-Administered IV to Oral Therapeutic Interchange Program: Development, Implementation, and Cost-Assessment

This study describes the development, implementation, and estimated vs. actual cost benefits of an IV to oral therapeutic interchange program. Secondary objectives were determining patient eligibility criteria and selecting medications for future inclusion in the program. Medical charts were reviewed to determine which patients were appropriate candidates for the interchange. Targeted medications were selected by reviewing the literature and the institution's drug expenditures. Five medications — famotidine, ciprofloxacin, levofloxacin, fluconazole, and azithromycin — were selected for the initial stages of the program. Preimplementation cost analysis suggested that the interchange would yield cost savings of more than $30,000 per year in medication costs alone. The interchange was piloted on a single nursing unit to determine best procedures and possible barriers to implementation. Data collected in the first 6 months after implementation indicated greater potential cost benefits than originally estimated. Including more medications in the interchange would further reduce drug acquisition costs.

Individualizing duration of antibiotic therapy in community-acquired pneumonia

International experts suggest tailoring antibiotic duration in community-acquired pneumonia (CAP) according to patients' characteristics. We aimed to assess the effectiveness of an individualized approach to antibiotic duration based on time in which CAP patients reach clinical stability during hospitalization. In a multicenter, non-inferiority, randomized, controlled trial hospitalized adult patients with CAP reaching clinical stability within 5 days after hospitalization were randomized to a standard vs. individualized antibiotic duration. In the Individualized group, antibiotics were discontinued 48 h after the patient reached clinical stability, with at least five days of total antibiotic treatment. Early failure within 30 days was the primary composite outcome. 135 patients were randomized to the Standard group and 125 to the Individualized group. The trial was interrupted by the safety committee because of an apparent inferiority of the Individualized group over the Standard treatment: 14 (11.2%) patients in the Individualized group experienced early failure vs. 10 (7.4%) patients in the Standard group, p = 0.200, at the intention-to-treat analysis. 30-day mortality rate was four-time higher in the Individualized group than the Standard group. Shortening antibiotic duration according to patients' characteristics still remains an open question.

Strategies to enhance rational use of antibiotics in hospital: a guideline by the German Society for Infectious Diseases

Introduction

In the time of increasing resistance and paucity of new drug development there is a growing need for strategies to enhance rational use of antibiotics in German and Austrian hospitals. An evidence-based guideline on recommendations for implementation of antibiotic stewardship (ABS) programmes was developed by the German Society for Infectious Diseases in association with the following societies, associations and institutions: German Society of Hospital Pharmacists, German Society for Hygiene and Microbiology, Paul Ehrlich Society for Chemotherapy, The Austrian Association of Hospital Pharmacists, Austrian Society for Infectious Diseases and Tropical Medicine, Austrian Society for Antimicrobial Chemotherapy, Robert Koch Institute.

Materials and methods

A structured literature research was performed in the databases EMBASE, BIOSIS, MEDLINE and The Cochrane Library from January 2006 to November 2010 with an update to April 2012 (MEDLINE and The Cochrane Library). The grading of recommendations in relation to their evidence is according to the AWMF Guidance Manual and Rules for Guideline Development.

Conclusion

The guideline provides the grounds for rational use of antibiotics in hospital to counteract antimicrobial resistance and to improve the quality of care of patients with infections by maximising clinical outcomes while minimising toxicity. Requirements for a successful implementation of ABS programmes as well as core and supplemental ABS strategies are outlined. The German version of the guideline was published by the German Association of the Scientific Medical Societies (AWMF) in December 2013.

Development of operationalized intravenous to oral antibiotic switch criteria

OBJECTIVES

Despite huge overlap in suggested criteria for a safe intravenous (iv)-to-oral antibiotic switch, there is considerable variation in their operationalization. The objective of this study was to develop a set of measurable conditions that should be met in adult hospitalized patients for a safe iv-to-oral switch.

METHODS

A RAND-modified Delphi procedure was performed to develop a set of operationalized iv-to-oral switch criteria. Switch criteria and their accompanying suggested measurable conditions were extracted from the literature and appraised by a multidisciplinary expert panel during two questionnaire rounds with a face-to-face meeting between these two rounds. In a final step, the experts could approve the set of developed operationalized switch criteria.

RESULTS

Seven switch criteria and 41 accompanying measurable conditions extracted from the literature were appraised. Sixteen measurable conditions that operationalize six switch criteria were selected: (i) stable systolic blood pressure; and the absence of (ii) fever, (iii) temperature <36°C, (iv) malabsorption syndrome, (v) short bowel syndrome, (vi) severe gastroparesis, (vii) ileus, (viii) continuous nasogastric suction, (ix) vomiting, (x) (severe) sepsis, (xi) fasciitis necroticans, (xii) CNS infection, (xiii) Staphylococcus aureus bacteraemia, and (xiv) endovascular infection. In addition, (xv) the patient should be cooperative and (xvi) adequate antimicrobial concentration should be achievable at the site of infection by oral administration.

CONCLUSIONS

These operationalized criteria can be used in daily clinical practice. Future use of these criteria in audits and as rules in clinical decision support systems will facilitate the performance and evaluation of iv-oral switch programmes.

Total duration of antimicrobial therapy in veterans hospitalized with uncomplicated pneumonia: Results of a national medication utilization evaluation

OBJECTIVE

Practice guidelines recommend the shortest duration of antimicrobial therapy appropriate to treat uncomplicated pneumonia be prescribed to reduce the emergence of resistant pathogens. A national evaluation was conducted to assess the duration of therapy for pneumonia.

DESIGN

Retrospective medication utilization evaluation.

SETTING

Thirty Veterans Affairs medical centers.

PATIENTS

Inpatients discharged with a diagnosis of pneumonia.

MEASUREMENTS

A manual review of electronic medical records of inpatients discharged with uncomplicated community-acquired pneumonia (CAP) or healthcare-associated pneumonia (HCAP) was conducted. Appropriate CAP therapy duration was defined as at least 5 days, and up to 3 additional days beginning the first day the patient achieved clinical stability criteria; the appropriate HCAP therapy duration was defined as 8 days. The duration of antimicrobial therapy for intravenous (IV) and oral (PO) inpatient administration, PO therapy dispensed upon discharge, Clostridium difficile infection (CDI), hospital readmission, and death rates were measured.

RESULTS

Of 3881 pneumonia admissions, 1739 met inclusion criteria (CAP [n = 1195]; HCAP [n = 544]). Overall, 13.9% of patients (CAP [6.9%], HCAP [29.0%]) received therapy duration consistent with guideline recommendations. The median (interquartile range) days of therapy were 4 days (3-6 days), 1 day (0-3 days), and 6 days (4-8 days) for inpatient IV, inpatient PO, and outpatient PO antimicrobials, respectively. CDI was rare but more common in patients who received therapy duration consistent with guidelines. Therapy duration was not associated with the readmission or mortality rate.

CONCLUSIONS

Antimicrobials were commonly prescribed for a longer duration than guidelines recommend. The majority of excessive therapy was completed upon discharge, identifying the need for strategies to curtail unnecessary use postdischarge. Journal of Hospital Medicine 2015;11:832-839. © 2015 Society of Hospital Medicine.

Getting Physicians to Make “The Switch”: The Role of Clinical Guidelines in the Management of Community-Acquired Pneumonia

The authors sought to assess physician awareness and usage of American Thoracic Society guidelines for early conversion from intravenous to oral antibiotics ("switch therapy") in those with community-acquired pneumonia (CAP). We then determined if adoption of a CAP guideline would improve either. Patients (N = 510) hospitalized with CAP from June 2002 to May 2003 were identified retrospectively, and chart reviews were done on a random sample (130 [25%]) of these. Physicians were surveyed before and after guideline adoption. Community-acquired pneumonia guideline implementation increased physician awareness of American Thoracic Society recommendations (5% to 40%) and use of switch therapy (60% to 86%). Such use resulted in decreased overall length of stay from 3.6 to 2.4 days (P < .05) and from 2.91 to 2.41 days (P < .05) among early-switch candidates. Early-switch therapy was not optimally used prior to implementation of this CAP guideline. Adoption of the guideline increased awareness and reduced length of stay among inpatients with CAP.

Shoot, Ready, Aim: Pneumonia Care Quality and Costs in a Community Hospital

Mandatory community-acquired pneumonia (CAP) protocol usage was proposed in our community-based teaching hospital because of senior medical staff perceptions that excessive variation in CAP care was adversely affecting clinical outcomes and costs. The purpose of our study was to examine CAP process of care variation, outcomes, and costs to ascertain whether the mandatory CAP protocol could be justified. The study consisted of an analysis of administrative and sampled chart data. We looked at pneumonia severity, orders for blood cultures or sputum staining, antibiotic usage, symptom resolution, length of stay, discharge status, readmission risk by follow-up time, and financial data. We found that process of care variation was low, clinical outcomes were generally good, and CAP care was profitable. Our data suggested that the proposed mandatory CAP protocol was not necessary. Our experience supports the management principle that fact finding should usually precede decision making, not the reverse.

Pharmacokinetic Alterations of Antimicrobials in the Critically Ill

Critical illness is accompanied by multiple physiologic alterations that affect the pharmacokinetics of antimicrobials. Although the pharmacokinetics of a number of antimicrobials have been studied in critically ill individuals, an understanding of the physiological alterations in critical illness and general pharmacokinetic principles of antimicrobials is imperative for appropriate selection, dosing, and prediction of toxicity.

Community Acquired Pneumonia in Internal Medicine: A One-Year Retrospective Study Based on Pneumonia Severity Index

Community acquired pneumonia (CAP) represents the sixth cause of death and the first cause of death for an infectious disease in the USA. The aim of the present study is to evaluate how CAP is managed in a hospital setting, with particular attention to the wards of internal medicine, compared to the recommendations based and validated PSI (Pneumonia Severity Index). 42 subjects were included in the study, 25 males and 17 females. According to the PSI, nine (21%) patients were classified in class I, two (5%) in class II, ten (24%) in class III, fifteen (36%) in class IV and six (14%) in class V. Three patients died during the stay in the hospital (2 males and 1 female), all in the highest PSI class (V). According to the criteria used to evaluate the adequacy of the admission to the hospital, twentyeight patients were classified in the HRG, with an appropriate admission, whilst fourteen (33%) were in the LRG, with an inappropriate admission to the hospital. The data of the study confirm the validity of a PSI based strategy for the management of CAP since admittance to the hospital. This approach is not yet widely implemented in Italy, and a better dialogue between hospital and health system representatives would be convenient, to reduce costs and ensure the safety of patients affected by CAP.

Effectiveness of sequential intravenous-to-oral antibiotic switch therapy in hospitalized patients with gram-positive infection: the SEQUENCE cohort study

Switching from intravenous to oral antibiotic therapy may improve inpatient management and reduce hospital stays and the complications of intravenous treatment. We aimed to assess the effectiveness of intravenous-to-oral antibiotic switch therapy and an early discharge algorithm in hospitalized patients with gram-positive infection. We performed a prospective cohort study with a retrospective comparison cohort, recruited from eight tertiary, acute-care Spanish referral hospitals. All patients included had culture-confirmed methicillin-resistant gram-positive infection, or methicillin-susceptible gram-positive infection and beta-lactam allergy and had received intravenous treatment with glycopeptides, lipopeptides, or linezolid. The study comprised two cohorts: the prospective cohort to assess the effectiveness of a sequential intravenous-to-oral antibiotic switch algorithm and early discharge, and a retrospective cohort in which the algorithm had not been applied, used as the comparator. A total of 247 evaluable patients were included; 115 in the prospective and 132 in the retrospective cohort. Forty-five retrospective patients (34 %) were not changed to oral antibiotics, and 87 (66 %) were changed to oral antibiotics without following the proposed algorithm. The duration of hospitalization was significantly shorter in the prospective cohort compared to the retrospective group that did not switch to oral drugs (16.7 ± 18.7 vs 23 ± 13.4 days, P  < 0.001). No differences were observed regarding the incidence of catheter-related bacteraemia (4.4 % vs 2.6 %, P = 0.621). Our results suggest that an intravenous-to-oral antibiotic switch strategy is effective for reducing the length of hospital stay in selected hospitalized patients with gram-positive infection.

Periprosthetic joint infection

Periprosthetic joint infections are a devastating complication after arthroplasty and are associated with substantial patient morbidity. More than 25% of revisions are attributed to these infections, which are expected to increase. The increased prevalence of obesity, diabetes, and other comorbidities are some of the reasons for this increase. Recognition of the challenge of surgical site infections in general, and periprosthetic joint infections particularly, has prompted implementation of enhanced prevention measures preoperatively (glycaemic control, skin decontamination, decolonisation, etc), intraoperatively (ultraclean operative environment, blood conservation, etc), and postoperatively (refined anticoagulation, improved wound dressings, etc). Additionally, indications for surgical management have been refined. In this Review, we assess risk factors, preventive measures, diagnoses, clinical features, and treatment options for prosthetic joint infection. An international consensus meeting about such infections identified the best practices and further research needs. Orthopaedics could benefit from enhanced preventive, diagnostic, and treatment methods.

Evaluation of a protocol-based intervention to promote timely switching from intravenous to oral paracetamol for post-operative pain management: an interrupted time series analysis

RATIONALE, AIMS AND OBJECTIVES

Timely switching from intravenous to oral therapy ensures optimized treatment and efficient use of health care resources. Intravenous (IV) paracetamol is widely used for post-operative pain management but not always switched to the oral form in a timely manner, leading to unnecessary increase in expenditure. This study aims to evaluate the impact of a multifaceted intervention to promote timely switching from the IV to oral form in the post-operative setting.

METHODS

An evidence-based prescribing protocol was designed and implemented by the clinical pharmacy team in a single district general hospital in Egypt. The protocol specified the criteria for appropriate prescribing of IV paracetamol. Doctors were provided with information and educational sessions prior to implementation. A prospective, quasi-experimental study was undertaken to evaluate its impact on IV paracetamol utilization and costs. Data on monthly utilization and costs were recorded for 12 months before and after implementation (January 2012 to December 2013). Data were analysed using interrupted time series analysis.

RESULTS

Prior to implementation, in 2012, total spending on IV paracetamol was 674 154.00 Egyptian Pounds (L.E.) ($23,668.00). There was a non-significant (P > 0.05) downward trend in utilization (-32 ampoules per month) and costs [reduction of 632 L.E. ($222) per month]. Following implementation, immediate decrease in utilization and costs (P < 0.05) and a trend change over the follow-up period were observed. Average monthly reduction was 26% (95% CI: 24% to 28%, P < 0.001).

CONCLUSION

A multifaceted, protocol-based intervention to ensure timely switching from IV-to-oral paracetamol achieved significant reduction in utilization and cost of IV paracetamol in the first 5 months of its implementation.

Quantitative determination of unbound levofloxacin by simultaneous microdialysis in rat pancreas after intravenous and oral doses

OBJECTIVE

We compared the pharmacokinetic profile of unbound levofloxacin in rat pancreas after an oral dose with that after an intravenous dose to determine if oral administration of levofloxacin could potentially be used.

METHOD

Levofloxacin was administered either intravenously or orally into male Sprague-Dawley rats at the concentration of 42 mg/kg per day, mimicking the human dose of 400 mg/day. The concentrations of levofloxacin in extracellular fluid (ECF) of rat pancreatic tissues were determined using microdialysis coupled with high-performance liquid chromatography (HPLC). Levofloxacin was equally distributed into ECF of rat pancreatic tissues with either intravenous route (AUCpancreas /AUCblood , 0.97 ± 0.02) or oral route (AUCpancreas /AUCblood , 0.96 ± 0.03).

KEY FINDINGS

The penetration rates (PR) of pancreas-to-blood on the same target site between the two routes were the same. The intravenous antibiotic AUC/MIC ratios of common Gram-positive pancreatic bacteria ranged from 83.43 to 667.44; meanwhile, the ratio of common Gram-negative pancreatic bacteria ranged from 41.71 to 2669.74. The oral antibiotic AUC/MIC ratios for common gram-positive and Gram-negative pancreatic bacteria were from 78.54 to 628.31, and 39.27 to 2513.22, respectively (P > 0.05).

CONCLUSIONS

Intravenous administration had similar penetration efficacy to oral administration at an equivalent dose. Furthermore, levofloxacin had a good penetration through the blood-pancreas barrier.