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Batchelder JI, Hare PJ, Mok WWK. Resistance-resistant antibacterial treatment strategies. FRONTIERS IN ANTIBIOTICS 2023; 2:1093156. [PMID: 36845830 PMCID: PMC9954795 DOI: 10.3389/frabi.2023.1093156] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Antibiotic resistance is a major danger to public health that threatens to claim the lives of millions of people per year within the next few decades. Years of necessary administration and excessive application of antibiotics have selected for strains that are resistant to many of our currently available treatments. Due to the high costs and difficulty of developing new antibiotics, the emergence of resistant bacteria is outpacing the introduction of new drugs to fight them. To overcome this problem, many researchers are focusing on developing antibacterial therapeutic strategies that are "resistance-resistant"-regimens that slow or stall resistance development in the targeted pathogens. In this mini review, we outline major examples of novel resistance-resistant therapeutic strategies. We discuss the use of compounds that reduce mutagenesis and thereby decrease the likelihood of resistance emergence. Then, we examine the effectiveness of antibiotic cycling and evolutionary steering, in which a bacterial population is forced by one antibiotic toward susceptibility to another antibiotic. We also consider combination therapies that aim to sabotage defensive mechanisms and eliminate potentially resistant pathogens by combining two antibiotics or combining an antibiotic with other therapeutics, such as antibodies or phages. Finally, we highlight promising future directions in this field, including the potential of applying machine learning and personalized medicine to fight antibiotic resistance emergence and out-maneuver adaptive pathogens.
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Affiliation(s)
- Jonathan I Batchelder
- Department of Molecular Biology and Biophysics, UConn Health, Farmington, CT, United States
| | - Patricia J Hare
- Department of Molecular Biology and Biophysics, UConn Health, Farmington, CT, United States.,School of Dental Medicine, University of Connecticut, Farmington, CT, United States
| | - Wendy W K Mok
- Department of Molecular Biology and Biophysics, UConn Health, Farmington, CT, United States
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2
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Wald-Dickler N, Holtom PD, Phillips MC, Centor RM, Lee RA, Baden R, Spellberg B. Oral Is the New IV. Challenging Decades of Blood and Bone Infection Dogma: A Systematic Review. Am J Med 2022; 135:369-379.e1. [PMID: 34715060 PMCID: PMC8901545 DOI: 10.1016/j.amjmed.2021.10.007] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/03/2021] [Accepted: 10/04/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND We sought to determine if controlled, prospective clinical data validate the long-standing belief that intravenous (IV) antibiotic therapy is required for the full duration of treatment for 3 invasive bacterial infections: osteomyelitis, bacteremia, and infective endocarditis. METHODS We performed a systematic review of published, prospective, controlled trials that compared IV-only to oral stepdown regimens in the treatment of these diseases. Using the PubMed database, we identified 7 relevant randomized controlled trials (RCTs) of osteomyelitis, 9 of bacteremia, 1 including both osteomyelitis and bacteremia, and 3 of endocarditis, as well as one quasi-experimental endocarditis study. Study results were synthesized via forest plots and funnel charts (for risk of study bias), using RevMan 5.4.1 and Meta-Essentials freeware, respectively. RESULTS The 21 studies demonstrated either no difference in clinical efficacy, or superiority of oral versus IV-only antimicrobial therapy, including for mortality; in no study was IV-only treatment superior in efficacy. The frequency of catheter-related adverse events and duration of inpatient hospitalization were both greater in IV-only groups. DISCUSSION Numerous prospective, controlled investigations demonstrate that oral antibiotics are at least as effective, safer, and lead to shorter hospitalizations than IV-only therapy; no contrary data were identified. Treatment guidelines should be modified to indicate that oral therapy is appropriate for reasonably selected patients with osteomyelitis, bacteremia, and endocarditis.
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Affiliation(s)
- Noah Wald-Dickler
- Los Angeles County + University of Southern California Medical Center, Los Angeles; Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles; Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles
| | - Paul D Holtom
- Los Angeles County + University of Southern California Medical Center, Los Angeles; Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles
| | - Matthew C Phillips
- Los Angeles County + University of Southern California Medical Center, Los Angeles
| | - Robert M Centor
- Department of Medicine, University of Alabama at Birmingham School of Medicine, Birmingham; Birmingham Veterans Affairs (VA) Medical Center, Birmingham, Ala
| | - Rachael A Lee
- Department of Medicine, University of Alabama at Birmingham School of Medicine, Birmingham; Birmingham Veterans Affairs (VA) Medical Center, Birmingham, Ala
| | - Rachel Baden
- Los Angeles County + University of Southern California Medical Center, Los Angeles
| | - Brad Spellberg
- Los Angeles County + University of Southern California Medical Center, Los Angeles.
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Bandy KS, Albrecht S, Parag B, McClave SA. Practices Involved in the Enteral Delivery of Drugs. Curr Nutr Rep 2020; 8:356-362. [PMID: 31606851 DOI: 10.1007/s13668-019-00290-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE OF REVIEW While the delivery of medications through enteral tubes is common in critically ill patients, there are complications and a lack of unified practices between institutions. The purpose of this review is to evaluate current practices and literature evidence regarding this administration route. The effect of this administration on the medication's efficacy, safety, tolerability, and pharmacokinetics was examined, as well as other considerations to ensure that this route of delivery is both safe and effective for patients. RECENT FINDINGS Studies have found crushed oral tablets are the most frequent cause of obstructed feeding tubes. Complications such as this are primarily due to inadequate personnel training and failure to properly access medications before enteral administration. There are many factors that should be considered in order to effectively administer drugs via enteral tubes. Formal training and use of a multi-disciplinary approach that includes pharmacists and dieticians has been shown to reduce tube obstructions and administration errors.
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Affiliation(s)
- Kathryn S Bandy
- Department of Pharmacy, University of Louisville Hospital, 530 S Jackson St., Louisville, KY, 40202, USA.
| | - Stephanie Albrecht
- Department of Pharmacy, University of Louisville Hospital, 530 S Jackson St., Louisville, KY, 40202, USA
| | - Bhavyata Parag
- Department of Pharmacy, Houston Methodist Clear Lake Hospital, 18300 Houston Methodist Dr, Houston, TX, 77058, USA
| | - Stephen A McClave
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville Hospital, 530 S Jackson St., Louisville, KY, 40202, USA.,Department of Digestive and Liver Health, University of Louisville Physicians Outpatient Center, 401 E. Chestnut St., Louisville, KY, 40202, USA
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Mouwen AMA, Dijkstra JA, Jong E, Buijtels PCAM, Pasker-de Jong PCM, Nagtegaal JE. 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. Int J Antimicrob Agents 2019; 55:105769. [PMID: 31362046 DOI: 10.1016/j.ijantimicag.2019.07.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 05/30/2019] [Accepted: 07/21/2019] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- A M A Mouwen
- Department of Clinical Pharmacy, Meander Medical Center, Amersfoort, The Netherlands
| | - J A Dijkstra
- Department of Clinical Pharmacy, Meander Medical Center, Amersfoort, The Netherlands
| | - E Jong
- Department of Internal Medicine, Meander Medical Center, Amersfoort, The Netherlands
| | - P C A M Buijtels
- Department of Microbial Diseases, Meander Medical Center, Amersfoort, The Netherlands
| | - P C M Pasker-de Jong
- Department of Epidemiology and Statistics, Meander Academy, Meander Medical Center, Amersfoort, The Netherlands
| | - J E Nagtegaal
- Department of Clinical Pharmacy, Meander Medical Center, Amersfoort, The Netherlands.
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Green K, Webster H, Watanabe S, Fainsinger RL. Management of Nosocomial Respiratory Tract Infections in Terminally Ill Cancer Patients. J Palliat Care 2019. [DOI: 10.1177/082585979401000407] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kerryn Green
- Palliative Care Program, Edmonton General Hospital, Edmonton, Alberta, Canada
| | - Heidi Webster
- Palliative Care Program, Edmonton General Hospital, Edmonton, Alberta, Canada
| | - Sharon Watanabe
- Palliative Care Program, Edmonton General Hospital, Edmonton, Alberta, Canada
| | - Robin L Fainsinger
- Palliative Care Program, Edmonton General Hospital, Edmonton, Alberta, Canada
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Mercuro NJ, Stogsdill P, Wungwattana M. Retrospective analysis comparing oral stepdown therapy for enterobacteriaceae bloodstream infections: fluoroquinolones versus β-lactams. Int J Antimicrob Agents 2018; 51:687-692. [DOI: 10.1016/j.ijantimicag.2017.12.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 11/16/2017] [Accepted: 12/16/2017] [Indexed: 01/10/2023]
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Taubert M, Lückermann M, Vente A, Dalhoff A, Fuhr U. Population Pharmacokinetics of Finafloxacin in Healthy Volunteers and Patients with Complicated Urinary Tract Infections. Antimicrob Agents Chemother 2018; 62:e02328-17. [PMID: 29339394 PMCID: PMC5913927 DOI: 10.1128/aac.02328-17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 01/09/2018] [Indexed: 02/01/2023] Open
Abstract
Finafloxacin is a novel fluoroquinolone with increased antibacterial activity at acidic pH and reduced susceptibility to several resistance mechanisms. A phase II study revealed a good efficacy/safety profile in patients with complicated urinary tract infections (cUTIs), while the pharmacokinetics was characterized by highly variable concentration-versus-time profiles, suggesting the need for an elaborated pharmacokinetic model. Data from three clinical trials were evaluated: 127 healthy volunteers were dosed orally (n = 77) or intravenously (n = 50), and 139 patients with cUTI received finafloxacin intravenously. Plasma (2,824 samples from volunteers and 414 samples from patients) and urine (496 samples from volunteers and 135 samples patients) concentrations were quantified by liquid chromatography-tandem mass spectrometry (LC-MS/MS). NONMEM was used to build a population pharmacokinetic model, and pharmacokinetic/pharmacodynamic relationships were investigated via simulations and logistic regression. A two-compartment model with first-order elimination described the data best (central volume of distribution [Vc] and peripheral volume of distribution [Vp] of 47 liters [20%] and 43 liters [67%], respectively, and elimination clearance and intercompartmental clearance of 21 liters/h [54%] and 2.8 liters/h [57%], respectively [median bootstrap estimates {coefficients of variation}]). Vc increased with body surface area, and clearance was reduced in patients (-29%). Oral absorption was described best by parallel first- and zero-order processes (bioavailability of 75%). No pharmacodynamic surrogate parameter of clinical/microbiological outcome could be identified, which depended exclusively on the MIC of the causative pathogens. Despite the interindividual variability, the present data set does not support covariate-based dose adjustments. Based on the favorable safety and efficacy data, the clinical relevance of the observed variability appears to be limited. (This study has been registered at ClinicalTrials.gov under identifier NCT01928433.).
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Affiliation(s)
- Max Taubert
- Department I of Pharmacology, Clinical Pharmacology Unit, University Hospital Cologne, Cologne, Germany
| | | | | | - Axel Dalhoff
- Institute for Infection Medicine, Christian Albrechts University of Kiel, Kiel, Germany
| | - Uwe Fuhr
- Department I of Pharmacology, Clinical Pharmacology Unit, University Hospital Cologne, Cologne, Germany
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Yan LZ, Herrington JD. Outcomes of hospitalized neutropenic oncology patients with Pseudomonas aeruginosa bloodstream infections: focus on oral fluoroquinolone conversion. J Oncol Pharm Pract 2015; 22:584-90. [DOI: 10.1177/1078155215591389] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Background Pseudomonas aeruginosa bacteremia is a major cause of morbidity and mortality, especially in neutropenic oncology patients. Few studies have been published in the last decade on treatment outcomes of neutropenic oncology patients with Pseudomonas aeruginosa bacteremia. In addition, there is a lack of data addressing the role of oral fluoroquinolones in this patient setting. Methods A retrospective chart review from 1999 to 2013 was conducted at a large academic medical center in neutropenic oncology patients with documented Pseudomonas aeruginosa bacteremia, who were initially treated with intravenous anti-pseudomonal antibiotics and then converted to an oral anti-pseudomonal fluoroquinolone. Patients were evaluated for the rate of cure and for the time from onset of intravenous antibiotic therapy to conversion to oral fluoroquinolones. Results Twenty-nine patients with Pseudomonas aeruginosa bacteremia were evaluated. The median absolute neutrophil count at the time of the first positive blood culture was 50 cells/mm3, and the median duration of time below an absolute neutrophil count of 1000 cells/mm3 was five days. The change to oral fluoroquinolones occurred at a median (range) of six (2–18) days after initiation of intravenous antibiotics and at a median absolute neutrophil count of 2610 (110–24790) cells/mm3. The initial cure was 93.1%, while ultimate cure was 91.7%. Conclusion Converting to oral fluoroquinolones after initial intravenous antibiotic therapy for Pseudomonas aeruginosa bacteremia in clinically stable neutropenic oncology patients appears to achieve successful outcomes. However, prospective trials are needed to validate these results in neutropenic oncology patients with Pseudomonas aeruginosa bacteremia who are converted to oral fluoroquinolones.
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Affiliation(s)
- Lily Z Yan
- Department of Pharmacy, Scott & White Memorial Hospital, Baylor Scott & White Health, Temple, Texas, USA
| | - Jon D Herrington
- Department of Pharmacy, Scott & White Memorial Hospital, Baylor Scott & White Health, Temple, Texas, USA
- Department of Medicine, Texas A&M University Health Science Center, Temple, Texas, USA
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Shawyer AC, Hatchell AC, Pemberton J, Flageole H. Compliance with published recommendations for postoperative antibiotic management of children with appendicitis: A chart audit. J Pediatr Surg 2015; 50:783-5. [PMID: 25783365 DOI: 10.1016/j.jpedsurg.2015.02.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 02/13/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND Recommendations for postoperative antibiotics for appendicitis were published by the American Pediatric Surgical Association (APSA) in 2010. However, implementation of practice recommendations often takes years. We measured compliance of pediatric surgeons (who receive reminders every 6months from the Division Chief) with the APSA recommendations. METHODS With Research Ethics Board approval, we completed a retrospective review of children who underwent appendectomy since 2010. Compliance with APSA recommendations was analyzed descriptively. Agreement between pediatric surgeons and pathologists was analyzed by kappa. RESULTS We reviewed 242 charts. Patients were excluded for missing data (n=5) and diagnosis other than appendicitis (n=27), resulting in 210 patients with appendicitis (119 acute, 91 perforated). Agreement of perforation status between surgeons and pathologists was good (κ=0.75; 95% CI: 0.66-0.83). Many patients with nonperforated appendicitis received antibiotics in excess of the APSA recommendations (62/119 (52%)), as did those with uncomplicated perforated appendicitis (52/84 (62%)). CONCLUSIONS Despite the availability of published recommendations, surgeons continue to prescribe postoperative antibiotics for appendicitis in excess of the recommendations. Overtreatment leads to potential medication errors and increased length-of-stay/medication costs. An intensive implementation program with ongoing education/monitoring may improve compliance with established recommendations to decrease the use of excess postoperative antibiotics and their associated costs/risks.
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Affiliation(s)
- Anna C Shawyer
- Department of Pediatric Surgery, McMaster Children's Hospital, Hamilton, Ontario, Canada.
| | - Alexandra C Hatchell
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Julia Pemberton
- McMaster Pediatric Surgery Research Collaborative, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Helene Flageole
- Department of Pediatric Surgery, McMaster Children's Hospital, Hamilton, Ontario, Canada; McMaster Pediatric Surgery Research Collaborative, McMaster Children's Hospital, Hamilton, Ontario, Canada
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Abstract
BACKGROUND Chronic osteomyelitis is generally treated with antibiotics and surgical debridement but can persist intermittently for years with frequent therapeutic failure or relapse. Despite advances in both antibiotic and surgical treatment, the long-term recurrence rate remains around 20%. This is an update of a Cochrane review first published in 2009. OBJECTIVES To determine the effects of different systemic antibiotic treatment regimens for treating chronic osteomyelitis in adults. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (October 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2012, Issue 9), MEDLINE (January 1948 to September Week 4 2012), EMBASE (January 1980 to 2012 Week 40), LILACS (October 2012), the WHO International Clinical Trials Registry Platform (June 2012) and reference lists of relevant articles. SELECTION CRITERIA Randomised controlled trials (RCTs) or quasi-RCTs addressing the effects of different antibiotic treatments given after surgical debridement for chronic osteomyelitis in adults. DATA COLLECTION AND ANALYSIS Two review authors independently screened papers for inclusion, extracted data and appraised risk of bias in the included trials. Where appropriate, we pooled data using the fixed-effect model. MAIN RESULTS We included eight small trials involving a total of 282 participants with chronic osteomyelitis. Data were available from 248 participants. Most participants were male with post-traumatic osteomyelitis, usually affecting the tibia and femur, where recorded. The antibiotic regimens, duration of treatment and follow-up varied between trials. All trials mentioned surgical debridement before starting on antibiotic therapy as part of treatment, but it was unclear in four trials whether all participants underwent surgical debridement.We found that study quality and reporting were often inadequate. In particular, we judged almost all trials to be at moderate to high risk of bias due to failure to conceal allocation and inadequate follow-up.Four trials compared oral versus parenteral route for administration of antibiotics. There was no statistically significant difference between the two groups in the remission at the end of treatment (70/80 versus 58/70; risk ratio (RR) 1.04, 95% confidence interval (CI) 0.92 to 1.18; four trials, 150 participants). There was no statistically significant difference between the two groups in the remission rate 12 or more months after treatment (49/64 versus 44/54; RR 0.94, 95% CI 0.78 to 1.13; three trials, 118 participants). There was also no significant difference between the two groups in the occurrence of mild adverse events (11/64 versus 8/54; RR 1.08, 95% CI 0.49 to 2.42; three trials, 118 participants) or moderate and severe adverse events (3/49 versus 4/42; RR 0.69, 95% CI 0.19 to 2.57; three trials, 91 participants). Superinfection occurred in participants of both groups (5/66 in the oral group versus 4/58 in the parenteral group; RR 1.08, 95% CI 0.33 to 3.60; three trials, 124 participants).Single trials with few participants found no statistical significant differences for remission or adverse events for the following four comparisons: oral only versus parenteral plus oral administration; parenteral plus oral versus parenteral only administration; two different parenteral antibiotic regimens; and two different oral antibiotic regimens. No trials compared different durations of antibiotic treatment for chronic osteomyelitis, or adjusted the remission rate for bacteria species or severity of disease. AUTHORS' CONCLUSIONS Limited and low quality evidence suggests that the route of antibiotic administration (oral versus parenteral) does not affect the rate of disease remission if the bacteria are susceptible to the antibiotic used. However, this and the lack of statistically significant differences in adverse effects need confirmation. No or insufficient evidence exists for other aspects of antibiotic therapy for chronic osteomyelitis.The majority of the included trials were conducted over 20 years ago and currently we are faced with a far higher prevalence of bacteria that are resistant to many of the available antibiotics used for healthcare. This continuously evolving bacterial resistance represents another challenge in the choice of antibiotics for treating chronic osteomyelitis.
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Affiliation(s)
- Lucieni O Conterno
- Department of General Internal Medicine and Clinical Epidemiology Unit, Marilia Medical School, Avenida Monte Carmelo 800, Fragata, Marilia, São Paulo, Brazil, 17519-030
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Sequential antibiotic therapy: Effective cost management and patient care. Can J Infect Dis 2012; 6:306-15. [PMID: 22550411 DOI: 10.1155/1995/165848] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/1995] [Accepted: 08/11/1995] [Indexed: 11/18/2022] Open
Abstract
The escalating costs associated with antimicrobial chemotherapy have become of increasing concern to physicians, pharmacists and patients alike. A number of strategies have been developed to address this problem. This article focuses specifically on sequential antibiotic therapy (sat), which is the strategy of converting patients from intravenous to oral medication regardless of whether the same or a different class of drug is used. Advantages of sat include economic benefits, patient benefits and benefits to the health care provider. Potential disadvantages are cost to the consumer and the risk of therapeutic failure. A critical review of the published literature shows that evidence from randomized controlled trials supports the role of sat. However, it is also clear that further studies are necessary to determine the optimal time for intravenous to oral changeover and to identify the variables that may interfere with the use of oral drugs. Procedures necessary for the implementation of a sat program in the hospital setting are also discussed.
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Goff DA, Bauer KA, Reed EE, Stevenson KB, Taylor JJ, West JE. Is the "low-hanging fruit" worth picking for antimicrobial stewardship programs? Clin Infect Dis 2012; 55:587-92. [PMID: 22615329 DOI: 10.1093/cid/cis494] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A new antimicrobial stewardship program can be overwhelmed at the breadth of interventions and education required to conduct a successful program. The expression "low-hanging fruit," in reference to stewardship, refers to selecting the most obtainable targets rather than confronting more complicated management issues. These targets include intravenous-to-oral conversions, batching of intravenous antimicrobials, therapeutic substitutions, and formulary restriction. These strategies require fewer resources and less effort than other stewardship activities; however, they are applicable to a variety of healthcare settings, including limited-resource hospitals, and have demonstrated significant financial savings. Our stewardship program found that staged and systematic interventions that focus on obvious areas of need, that is, low hanging fruit, provided early successes in our expanded program with a substantial cumulative cost savings of $832,590.
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Affiliation(s)
- Debra A Goff
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, 43210, USA.
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13
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File TM. Duration and cessation of antimicrobial treatment. J Hosp Med 2012; 7 Suppl 1:S22-33. [PMID: 23677632 DOI: 10.1002/jhm.988] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Revised: 09/07/2011] [Accepted: 09/18/2011] [Indexed: 11/09/2022]
Abstract
Shortening the duration of antimicrobial therapy is an important strategy for optimizing patient care and reducing the spread of antimicrobial resistance. It is best used in the context of an overall approach to infection management that includes a focus on selecting the right initial drug and dosing regimen for empiric therapy, and de-escalation to a more narrowly focused drug regimen (or termination) based on subsequent culture results and clinical data. In addition to reducing resistance, other potential benefits of shorter antimicrobial courses include lowered antimicrobial costs, reduced risk of superinfections (including Clostridium difficile-associated diarrhea), reduced risk of antimicrobial-related organ toxicity, and improved drug compliance. There have been relatively few randomized clinical trials that study the optimal treatment durations for such serious infections as pneumonia (community- and healthcare/hospital-acquired), complicated intra-abdominal infection, and catheter-related bloodstream infection (CRBSI). Nonetheless, a growing number of studies have explored the possibilities of reducing the duration of antimicrobial therapy for at least certain patients with these infections, under certain circumstances. Professional organizations have compiled these data and used them to develop clinical practice guidelines to aid clinicians in choosing optimal treatment durations for individual patients. Many patients with hospital-acquired pneumonia, ventilator-associated pneumonia, or healthcare-associated pneumonia can be treated for 7-8 days, while 4-7 days and 14-day treatment durations may suffice for many patients with complicated intra-abdominal infections and uncomplicated CRBSI, respectively. This article first provides a general background on the rationale and data supporting shortened courses of antimicrobial therapy, before using 3 case studies to explore the practical implications of current knowledge and treatment guidelines when making decisions about treatment duration for individual patients with healthcare-associated pneumonia, complicated intra-abdominal infection, and CRBSI.
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Affiliation(s)
- Thomas M File
- Infectious Disease Section, Northeast Ohio Medical University, Rootstown, OH, USA.
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Dasta JF, Boucher BA, Brophy GM, Cohen H, Hassan E, MacLaren R, Muzykovsky K, Martin SJ, Pass SE, Seybert AL. Intravenous to Oral Conversion of Antihypertensives: A Toolkit for Guideline Development. Ann Pharmacother 2010; 44:1430-47. [DOI: 10.1345/aph.1p086] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To provide a toolkit of information for hospitals to use in developing intravenous to oral conversion protocols for antihypertensives. Data Sources: Articles describing intravenous to oral conversion protocols for any therapeutic category were identified in an English-language MEDLINE search (1990-April 2010) using a wide variety of MeSH terms. References from selected articles were reviewed for additional material. Study Selection and Data Extraction: Experimental and observational English-language studies and review articles that focused on oral transition of intravenous drugs were selected. Data Synthesis: Most of the literature on conversion from intravenous to oral formulations involves antimicrobials. There is considerable evidence documenting reduced costs and improved patient flow through the health-care system following implementing these protocols with drugs like antimicrobials, histamine-2 receptor antagonists, and proton pump inhibitors. Although antihypertensives have not been studied, principles and implementation strategies used for other drug classes can be applied to antihypertensives. Guidance is provided on framing the problem, issues surrounding oral absorption principles, information pertaining to oral conversion in specific disease slates, and implementation and documentation strategies. Detailed tables of oral and intravenous antihypertensives are provided. Conclusions: We recommend that hospitals consider developing protocols on conversion of intravenous to oral antihypertensives in an attempt to reduce unnecessarily prolonged intravenous therapy. Information contained in this article can be used as a toolkit to select information specific to the characteristics of individual health-care systems.
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Affiliation(s)
- Joseph F Dasta
- The Ohio State University, Columbus, OH; Adjunct Professor, The University of Texas, Hutto, TX
| | - Bradley A Boucher
- Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, TN
| | - Gretchen M Brophy
- Pharmacotherapy & Outcomes Science and Neurosurgery, Virginia Commonwealth University, Medical College of Virginia Campus, Richmond, VA
| | - Henry Cohen
- Pharmacy Practice, Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Kingsbrook Jewish Medical Center, Brooklyn, NY
| | - Erkan Hassan
- Pharmacotherapy, Philips VISICU, Patient Monitoring Informatics, University of Maryland School of Pharmacy, Department of Pharmacy Practice and Science, Baltimore, MD
| | | | | | - Steven J Martin
- Department of Pharmacy Practice, College of Pharmacy, The University of Toledo, Toledo, OH
| | - Steven E Pass
- Texas Tech University Health Sciences Center School of Pharmacy, Dallas, TX
| | - Amy L Seybert
- Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA
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Abstract
Recent reports indicate that nalidixic acid susceptibility correlates well with the clinical outcome of patients with Salmonella Typhi infection treated with quinolones. We report a case of enteric fever caused by S Typhi in which the isolate was resistant to nalidixic acid, but showed in vitro susceptibility to ciprofloxacin. Following treatment with ciprofloxacin, the clinical outcome was not satisfactory and the patient had a relapse. However, after using a higher dose of ciprofloxacin, the patient was cured. We recommend that all Salmonella systemic infections resistant to nalidixic acid with in vitro but decreased susceptibility to fluoroquinolones be treated with other antibiotics like third-generation cephalosporins or azithromycin. These patients should be closely followed up and observed for further relapse.
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Affiliation(s)
- Ali Mohammed Somily
- Department of Pathology-Microbiology, King Saud College of Medicine, Riyadh, Saudi Arabia.
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Abstract
BACKGROUND Chronic osteomyelitis is generally treated with antibiotics and surgical debridement but can persist intermittently for years with frequent therapeutic failure. Despite advances in both antibiotics and surgical treatment, the long-term recurrence rate remains at approximately 20% to 30%. OBJECTIVES To determine the effects of different systemic antibiotic treatment regimens for treating chronic osteomyelitis in adults. SEARCH STRATEGY We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (October 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 3), MEDLINE (January 1966 to October 2008), EMBASE (January 1980 to October 2008), LILACS (October 2008) and reference lists of relevant articles. SELECTION CRITERIA Randomised or quasi-randomised controlled trials addressing the effects of different antibiotic treatments given after surgical debridement for chronic osteomyelitis in adults. DATA COLLECTION AND ANALYSIS Two authors independently screened papers for inclusion, extracted data and appraised the quality of included trials. Where appropriate, we pooled data using the fixed-effect model. MAIN RESULTS We included eight small trials (257 participants in total, with data available from 228). Study quality was often inadequate: in particular, concealment of allocation was not confirmed and there was an absence of blinding of outcome assessment. The antibiotic regimens, duration of treatment and follow-up varied between trials. Five trials compared oral versus parenteral antibiotics. There was no statistically significant difference between the two groups in the remission rate 12 or more months after treatment (risk ratio 0.94, 95% confidence interval 0.78 to 1.13; 3 trials). Antibiotic treatment for osteomyelitis was associated with moderate or severe adverse events in 4.8% of patients allocated oral antibiotics and 15.5% patients allocated parenteral antibiotics (risk ratio: 0.40, 95% confidence interval 0.13 to 1.22; 4 trials). Single trials with very few participants found no statistical significant differences for remission or adverse events for the following three comparisons: parenteral plus oral versus parenteral only administration; two oral antibiotic regimens; and two parenteral antibiotic regimens. No trials compared different durations of antibiotic treatment for chronic osteomyelitis, or adjusted the remission rate for bacteria species or severity of disease. AUTHORS' CONCLUSIONS Limited evidence suggests that the method of antibiotic administration (oral versus parenteral) does not affect the rate of disease remission if the bacteria are sensitive to the antibiotic used. However, this and the lack of statistically significant differences in adverse effects need confirmation. No or insufficient evidence exists for other aspects of antibiotic therapy for chronic osteomyelitis.
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Affiliation(s)
- Lucieni O Conterno
- Department of General Internal Medicine and Clinical Epidemiology Unit, Marilia Medical School, Avenida Monte Carmelo 800, Fragata, Marilia, São Paulo, Brazil, 17519-030
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Vouloumanou EK, Rafailidis PI, Kazantzi MS, Athanasiou S, Falagas ME. Early switch to oral versus intravenous antimicrobial treatment for hospitalized patients with acute pyelonephritis: a systematic review of randomized controlled trials. Curr Med Res Opin 2008; 24:3423-34. [PMID: 19032124 DOI: 10.1185/03007990802550679] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Acute pyelonephritis is a common infection with significant morbidity and mortality, particularly in pediatric populations. Early-switch strategies (from intravenous to oral treatment) may be an acceptable or even preferred option in the treatment of patients with acute pyelonephritis in terms of effectiveness and safety and can also reduce the economical burden associated with pyelonephritis. OBJECTIVE We sought to evaluate the effectiveness and safety of early-switch strategies in hospitalized patients with acute uncomplicated pyelonephritis. METHODS We searched in PubMed, Cochrane Central Register of Controlled Trials, and Scopus to identify randomized controlled trials (RCTs) that compared intravenous antibiotic regimens to regimens including an early switch to oral (after initial intravenous) treatment. RESULTS Eight RCTs (6 in children) were eligible for inclusion. In 5 RCTs the intravenous antibiotic treatment arms were not switched to oral treatment until the end of the study while in the remaining 3 RCTs the intravenous arms were switched late to oral treatment (after 5-10 days). Data regarding the incidence of renal scars, microbiological eradication, clinical cure, reinfection, persistence of acute pyelonephritis, and adverse events were provided in 4 (all pediatric trials), 6 (4 pediatric), 4 (2 pediatric), 5 (3 pediatric), 3 (1 pediatric), and 5 RCTs (3 pediatric), respectively. There were no differences regarding the above outcomes between the two compared treatment regimens in either pediatric or adult populations. CONCLUSION Early switch to oral antibiotic strategies seem to be as effective and safe as intravenous regimens for the treatment of hospitalized patients with acute pyelonephritis. These findings suggest that there is probably a potential to decrease the duration of intravenous treatment by 4-11 days in hospitalized patients with acute pyelonephritis without compromising their outcomes.
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Paladino JA, Gilliland-Johnson KK, Adelman MH, Cohn SM. Pharmacoeconomics of Ciprofloxacin plus Metronidazole vs. Piperacillin-Tazobactam for Complicated Intra-Abdominal Infections. Surg Infect (Larchmt) 2008; 9:325-33. [PMID: 18570574 DOI: 10.1089/sur.2007.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Joseph A. Paladino
- CPL Associates, LLC, Buffalo, New York
- State University of New York at Buffalo, Buffalo, New York
| | | | | | - Stephen M. Cohn
- The University of Texas Health Sciences Center, San Antonio, Texas
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20
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Iannini PB, Paladino JA, Lavin B, Singer ME, Schentag JJ. A case series of macrolide treatment failures in community acquired pneumonia. J Chemother 2008; 19:536-45. [PMID: 18073153 DOI: 10.1179/joc.2007.19.5.536] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
This was a retrospective, multi-center study of patients admitted to hospital with community-acquired pneumonia, caused by Streptococcus pneumoniae, after failing to respond to >2 days of outpatient macrolide therapy. 122 cases, treated between 2000-2004, were enrolled from 31 North American sites between January 2004 - March 2005. Non-susceptible isolates (predominately low-level resistance: erythromycin MICs of 1-16 mcg/ml) were recovered from 87 patients (71%). Bacteremia was present in 63 patients (52%). The in-hospital mortality rate was 5.7 %; all 7 patients who died were bacteremic, 6 had a non-susceptible isolate. We report here the largest series of macrolide failures published to date. The patients were notable for their high rates of macrolide resistance, bacteremia, and mortality. High-level macrolide resistance remains rare among US patients failing outpatient macrolides. The majority of cases and virtually all of the mortality occurred in patients with low-level resistant strains.
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Affiliation(s)
- P B Iannini
- Yale University School of Medicine, New Haven, CT, USA
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21
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Abstract
BACKGROUND Urinary tract infection (UTI), worldwide, is a major source of disease in children and adults. As it may have long-term consequences such as kidney failure and hypertension, it is important to treat patients with UTI adequately. Although standard management of severe UTI usually means intravenous (IV) therapy, at least initially, there are studies showing that oral therapy may also be effective. OBJECTIVES To assess whether the mode of administration of antibiotic therapy for severe UTI has an effect on cure rate, reinfection rate and kidney scarring. SEARCH STRATEGY The Cochrane Renal Group's specialised register, the Cochrane Central Register of Controlled Trials (CENTRAL, in The Cochrane Library), MEDLINE and EMBASE were searched. No language restriction was applied. Reference lists of relevant articles and reviews were checked for additional studies and authors of relevant articles/abstracts were contacted for further information. Date of last search: July 2007. SELECTION CRITERIA All randomised controlled trials (RCTs) comparing different modes of antibiotic application for patients with severe UTI (children and adults) were considered. DATA COLLECTION AND ANALYSIS Study quality was assessed and data extracted. Statistical analyses were performed using the random effects model and the results expressed as relative risk (RR) for dichotomous outcomes or mean difference (WMD) for continuous data with 95% confidence intervals (CI). MAIN RESULTS Fifteen RCTs (1743 patients) were included. Studies compared oral versus parenteral treatment (1), oral versus switch treatment (initial intravenous (IV) or intramuscular (IM) therapy followed by oral therapy) (5), switch versus parenteral treatment (6) and single dose parenteral followed by oral therapy versus oral (1) or switch therapy (3). There was a variety of short-term and long-term outcomes, but no pooled outcomes showed significant differences. Most included studies were small though and there were few outcomes for combination in a meta-analysis. AUTHORS' CONCLUSIONS There is no evidence suggesting that oral antibiotic therapy is less effective for treatment of severe UTI than parenteral or initial parenteral therapy. The results of this review suggest that the mode of application does not determine therapeutic success.
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Affiliation(s)
- A Pohl
- University Clinic Freiburg, Center of Clincial Studies, Elsässerstr. 2, Freiburg, Germany, 79110.
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22
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Paladino JA, Eubanks DA, Adelman MH, Schentag JJ. Once-Daily Cefepime Versus Ceftriaxone for Nursing HomeâAcquired Pneumonia. J Am Geriatr Soc 2007; 55:651-7. [PMID: 17493183 DOI: 10.1111/j.1532-5415.2007.01152.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To compare once-daily intramuscular cefepime with ceftriaxone controls. DESIGN Double-blind study. SETTING Six skilled nursing facilities. PARTICIPANTS Residents aged 60 and older with nursing home-acquired pneumonia. INTERVENTION Cultures were obtained, and patients were randomized to cefepime or ceftriaxone 1 g intramuscularly every 24 hours. MEASUREMENTS Clinical success: cure or improvement. Cure was defined as complete resolution of all symptoms and signs of pneumonia or a return to the patient's baseline state. Improvement was defined as clear improvement but incomplete resolution of all pretherapy symptoms or signs or incomplete return to the patient's usual baseline status. Safety and pharmacoeconomics were also assessed. RESULTS Sixty-nine patients were randomized; 61 were evaluable: (32 to cefepime, 29 ceftriaxone). Patients were predominately female (76%). They had a mean age+/-standard deviation of 85+/-6, with a mean 5.8+/-1.9 comorbidities; they had age-appropriate renal dysfunction, with a mean estimated creatinine clearance of 35+/-7 mL/min. Clinical success occurred in 78% of cefepime- and 66% of ceftriaxone-treated patients (P=.39). Fifty-seven patients (93%) were switched to oral antibiotics after 3 days. Antibiotic-related adverse events occurred in 5% of patients. Seven patients (11.5%) were hospitalized. The overall mortality rate was 8%. Mean antibiotic costs were 117+/-40 dollars for cefepime- and 215+/-68 dollars for ceftriaxone-treated patients (P<.001). Cost-effectiveness analysis of total costs showed that cefepime would cost 597 dollars and ceftriaxone 1,709 dollars per expected successfully treated patient. One- and two-way sensitivity analyses using a generic price for ceftriaxone and improving its comparative efficacy revealed that the results were robust. CONCLUSIONS Once-daily cefepime was a cost-effective alternative to ceftriaxone for the treatment of elderly nursing home residents who developed pneumonia and did not require hospitalization.
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Rigaud B, Malbranche C, Pioud V, Lochard A, Chemelle M, Aube H, Lazzarotti A, Guignard MH. [Good clinical practices and inpatient antibiotics: optimization of fluoroquinolone switch therapy]. Presse Med 2007; 36:1159-66. [PMID: 17449219 DOI: 10.1016/j.lpm.2007.01.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2006] [Revised: 12/28/2006] [Accepted: 01/10/2007] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Intravenous-to-oral switch therapy is strongly recommended in the medical literature. The aim of this study was to assess how we can improve fluoroquinolone switch therapy. METHODS In this comparative prospective study, we analyzed 243 intravenous ciprofloxacin treatments and assessed the impact of promoting a switch to oral step-down therapy. RESULTS This study found that switches from intravenous to oral therapy increased, mainly in medical wards, and led to significant savings in direct costs. DISCUSSION Promoting switch therapy has improved clinical practices in antibiotic use and led to lower direct and probably indirect drug-related costs. CONCLUSION Our findings will help define the role of switch therapy in improving clinical practices in inpatient antibiotic use.
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Falagas ME, Matthaiou DK, Vardakas KZ. Fluoroquinolones vs beta-lactams for empirical treatment of immunocompetent patients with skin and soft tissue infections: a meta-analysis of randomized controlled trials. Mayo Clin Proc 2006; 81:1553-66. [PMID: 17165634 DOI: 10.4065/81.12.1553] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare the effectiveness and safety of fluoroquinolones with beta-lactams in the treatment of patients with skin and soft tissue infections (SSTIs). METHODS We searched the PubMed database, Cochrane Database of Controlled Trials, and references of relevant articles for study reports published between January 1980 and February 2006. RESULTS Twenty randomized controlled trials that enrolled 4817 patients were included in the analysis. Fluoroquinolones as empirical treatment of patients with SSTIs were more effective than beta-lactams for the clinically evaluable patients (90.4% vs 88.2%; odds ratio [OR], 1.29; 95% confidence interval [CI], 1.00-1.66). This was also true in subset analyses of randomized controlled trials that studied ciprofloxacin (OR, 2.49; 95% CI, 1.45-4.26) and for patients with mild to moderate infections (OR, 1.83; 95% CI, 1.13-2.96). In contrast, no difference was found between the compared regimens for patients with moderate to severe infections (OR, 1.12; 95% CI, 0.80-1.55), for patients who did not receive third-generation cephalosporins as the comparator antibiotic (OR, 0.99; 95% CI, 0.73-1.34), or for the microbiologically evaluable patients (OR, 1.19; 95% CI, 0.89-1.59). Fluoroquinolones were also associated with more adverse effects (19.2% vs 15.2%; OR, 1.33; 95% CI, 1.13-1.57). CONCLUSION The high proportion of successfully treated patients in the compared groups of antibiotics and the development of more adverse effects associated with fluoroquinolone use suggest that these antibiotics do not have substantial advantages compared with beta-lactams for empirical treatment of patients with SSTIs.
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Affiliation(s)
- Matthew E Falagas
- Alfa Institute of Biomedical Sciences (AIBS), 9 Neapoleos St, 151 23 Marousi, Athens, Greece.
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25
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Rwabihama JP, Aubourg R, Oliary J, Mouly S, Champion K, Leverge R, Bergmann JF. Usage et mésusage de la voie intraveineuse pour l’administration de médicaments en médecine interne. Presse Med 2006; 35:1453-60. [PMID: 17028533 DOI: 10.1016/s0755-4982(06)74834-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
AIM Numerous intravenously-administered medications are also available in equally effective oral forms. To assess the number of avoidable intravenous infusions, we retrospectively analyzed consecutive infusions prescribed in a department of internal medicine. METHODS Between November and December 2004, we analyzed all patients who received at least one intravenous drug during hospitalization. Intravenous administration was considered unavoidable when prescribed for no more than 2 days in a patient unstable at admission, when oral administration or feeding was impossible, or when the drug was not available in oral form. RESULTS During the study period 133 patients were admitted to the department. In all, 65 infusions were prescribed, 30% of which lasted more than 2 days for no medical reason. Four intravenous antibiotics were prescribed in patients when their antibiotic susceptibility tests indicated that another oral antibiotic could easily be given. Infusions for 16 other patients continued longer than 48 hours, although the oral route was not contraindicated in these patients and the medication was available in oral form. CONCLUSION Systematic analysis of the daily prescriptions may be helpful in preventing or shortening use of intravenous medications and thereby decreasing iatrogenic infections and injuries, length of hospitalization, and costs.
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Davis SL, Delgado G, McKinnon PS. Pharmacoeconomic considerations associated with the use of intravenous-to-oral moxifloxacin for community-acquired pneumonia. Clin Infect Dis 2006; 41 Suppl 2:S136-43. [PMID: 15942880 DOI: 10.1086/428054] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Intravenous-to-oral (iv/po) conversion is one cost-effective approach to the management of community-acquired pneumonia (CAP). METHODS Consecutive patients with CAP were enrolled during 3 study periods (January-March of 2001, 2002, and 2004) with different pharmacy intervention (PI) strategies: iv beta -lactam plus a macrolide (no PI), iv beta-lactam plus a macrolide with iv/po PI (PI switch), and iv moxifloxacin with pharmacist-initiated automatic po moxifloxacin conversion (PI sequential). Costs and outcomes were compared among groups. RESULTS Two hundred fifty-one patients were enrolled. The average Fine score was 75, and the mean age of patients was 51 years. In the PI groups, the duration of treatment with iv antibiotics was decreased. Clinical success on day 3 of therapy was improved in the PI sequential group but was similar in all 3 groups on day 7 of therapy and at the end of therapy. The length of stay in the hospital was similar for patients in all 3 groups (mean, 4.39 days). Antibiotic costs were significantly reduced, by $110/patient, in the PI sequential group. CONCLUSIONS Conversion from iv to po therapy was accomplished more quickly when converting to the same agent with pharmacist-initiated automatic iv/po conversion, thus reducing the associated cost without compromising efficacy.
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Affiliation(s)
- Susan L Davis
- Anti-Infective Research Laboratory, Wayne State University, Detroit, Michigan, USA
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Paterson DL. The Role of Antimicrobial Management Programs in Optimizing Antibiotic Prescribing within Hospitals. Clin Infect Dis 2006; 42 Suppl 2:S90-5. [PMID: 16355322 DOI: 10.1086/499407] [Citation(s) in RCA: 124] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Managing serious infections is a balance between providing timely and appropriate broad-spectrum empirical therapy for individual patients, which has been consistently shown to improve outcomes, and reducing unnecessary use of antimicrobial agents, which may contribute to the development of antimicrobial resistance. To control the spread of antimicrobial resistance, hospitals commonly implement programs designed to optimize antimicrobial use, supported by infection-control measures. Hospital-based antimicrobial management programs--also called "antimicrobial stewardship programs"--are primarily based on education coupled with a "front-end" approach (i.e., restricting the availability of selected antimicrobial agents) or a "back-end" approach (i.e., reviewing broad-spectrum empirical therapy and then streamlining or discontinuing therapy, as indicated, on the basis of culture and susceptibility testing results and clinical response). Institutional efforts to optimize antimicrobial use should concentrate on patient outcomes, should have multidisciplinary support, and should use a combination of interventions customized to the needs, resources, and information technology infrastructure of the health care institution.
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Affiliation(s)
- David L Paterson
- Antibiotic Management Program and Transplant Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
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Itani KMF, Weigelt J, Li JZ, Duttagupta S. Linezolid reduces length of stay and duration of intravenous treatment compared with vancomycin for complicated skin and soft tissue infections due to suspected or proven methicillin-resistant Staphylococcus aureus (MRSA). Int J Antimicrob Agents 2005; 26:442-8. [PMID: 16289514 DOI: 10.1016/j.ijantimicag.2005.09.003] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2005] [Accepted: 09/02/2005] [Indexed: 12/12/2022]
Abstract
We compared the health outcomes in patients treated with linezolid or vancomycin for complicated skin and soft tissue infections (cSSTIs). This analysis is part of a randomised, open-label, multinational trial involving 1200 adult patients hospitalised with cSSTIs due to suspected or proven methicillin-resistant Staphylococcus aureus (MRSA). Subjects received linezolid 600 mg intravenous (i.v.) or oral, or vancomycin 1g i.v. every 12 h. A test-of-cure was assessed at 7 days post therapy. Compared with vancomycin, linezolid treatment was associated with significantly shorter length of stay (all P < 0.01), decreased i.v. antibiotic treatment duration (all P < 0.0001) and higher discharge rates (all P < 0.05). Thus, linezolid has the potential to reduce medical resource use for the treatment of cSSTIs.
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Affiliation(s)
- Kamal M F Itani
- Boston VA Health Care System and Boston University, Boston, MA, USA
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Luna CM, Monteverde A, Rodríguez A, Apezteguia C, Zabert G, Ilutovich S, Menga G, Vasen W, Díez AR, Mera J. [Clinical guidelines for the treatment of nosocomial pneumonia in Latin America: an interdisciplinary consensus document. Recommendations of the Latin American Thoracic Society]. Arch Bronconeumol 2005; 41:439-56. [PMID: 16117950 DOI: 10.1016/s1579-2129(06)60260-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- C M Luna
- Asociación Argentina de Medicina Respiratoria, Buenos Aires, Argentina.
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30
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Luna C, Monteverde A, Rodríguez A, Apezteguia C, Zabert G, Ilutovich S, Menga G, Vasen W, Díez A, Mera J. Neumonía intrahospitalaria: guía clínica aplicable a Latinoamérica preparada en común por diferentes especialistas. Arch Bronconeumol 2005. [DOI: 10.1157/13077956] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005; 171:388-416. [PMID: 15699079 DOI: 10.1164/rccm.200405-644st] [Citation(s) in RCA: 4111] [Impact Index Per Article: 216.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Pablos AI, Escobar I, Albiñana S, Serrano O, Ferrari JM, Herreros de Tejada A. Evaluation of an antibiotic intravenous to oral sequential therapy program. Pharmacoepidemiol Drug Saf 2004; 14:53-9. [PMID: 15534901 DOI: 10.1002/pds.1042] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
AIM This study was designed to analyse the drug consumption difference and economic impact of an antibiotic sequential therapy focused on quinolones. METHOD We studied the consumption of quinolones (ofloxacin/levofloxacin and ciprofloxacin) 6 months before and after the implementation of a sequential therapy program in hospitalised patients. It was calculated for each antibiotic, in its oral and intravenous forms, in defined daily dose (DDD/100 stays per day) and economical terms (drug acquisition cost). At the beginning of the program ofloxacin was replaced by levofloxacin and, since their clinical uses are similar, the consumption of both drugs was compared during the period. RESULTS In economic terms, the consumption of intravenous quinolones decreased 60% whereas the consumption of oral quinolones increased 66%. In DDD/100 stays per day, intravenous forms consumption decreased 53% and oral forms consumption increased 36%. CONCLUSIONS Focusing on quinolones, the implementation of a sequential therapy program based on promoting an early switch from intravenous to oral regimen has proved its capacity to alter the utilisation profile of these antibiotics. The program has permitted the hospital a global saving of 41420 dollars for these drugs during the period of time considered.
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Affiliation(s)
- Ana I Pablos
- Pharmacy Department, Doce de Octubre University Hospital, Madrid, Spain.
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Hulgan T, Rosenbloom ST, Hargrove F, Talbert DA, Arbogast PG, Bansal P, Miller RA, Kernodle DS. Oral quinolones in hospitalized patients: an evaluation of a computerized decision support intervention. J Intern Med 2004; 256:349-57. [PMID: 15367178 DOI: 10.1111/j.1365-2796.2004.01375.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine whether a computerized decision support system could increase the proportion of oral quinolone antibiotic orders placed for hospitalized patients. DESIGN Prospective, interrupted time-series analysis. SETTING University hospital in the south-eastern United States. SUBJECTS Inpatient quinolone orders placed from 1 February 2001 to 31 January 2003. INTERVENTION A web-based intervention was deployed as part of an existing order entry system at a university hospital on 5 February 2002. Based on an automated query of active medication and diet orders, some users ordering intravenous quinolones were presented with a suggestion to consider choosing an oral formulation. MAIN OUTCOME MEASURE The proportion of inpatient quinolone orders placed for oral formulations before and after deployment of the intervention. RESULTS There were a total of 15 194 quinolone orders during the study period, of which 8962 (59%) were for oral forms. Orders for oral quinolones increased from 4202 (56%) before the intervention to 4760 (62%) after, without a change in total orders. In the time-series analysis, there was an overall 5.6% increase (95% CI 2.8-8.4%; P < 0.001) in weekly oral quinolone orders due to the intervention, with the greatest effect on nonintensive care medical units. CONCLUSIONS A web-based intervention was able to increase oral quinolone orders in hospitalized patients. This is one of the first studies to demonstrate a significant effect of a computerized intervention on dosing route within an antibiotic class. This model could be applied to other antibiotics or other drug classes with good oral bioavailability.
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Affiliation(s)
- T Hulgan
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, 345 24th Avenue N, Suite 105, Nashville, TN 37203, USA.
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Hospitalist Management of Community-Acquired Pneumonia. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2004. [DOI: 10.1097/00019048-200409002-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The role of resistance and impact on appropriate antimicrobial use. Am J Ther 2004; 11 Suppl 1:S1-8. [PMID: 23570155 DOI: 10.1097/01.mjt.0000129047.29136.de] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Antibiotic resistance is a subject of growing concern throughout the medical community. Addressing drug resistance requires that practitioners understand the mechanisms of resistance and the methods of treating infections effectively while minimizing the emergence of resistant organisms. When making antibiotic selections, clinicians should consider a number of factors in addition to the drug's antimicrobial activity. These include the epidemiology of regional resistance and the antibiotic's pharmacokinetic and pharmacodynamic profile. Combination therapies should be considered and appropriate durations of therapy addressed. Developing clear practice guidelines for managing infectious disease can help practitioners reduce inappropriate antibiotic use and minimize the emergence of resistance.
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Nathwani D, Li JZ, Balan DA, Willke RJ, Rittenhouse BE, Mozaffari E, Tavakoli M, Tang T. An economic evaluation of a European cohort from a multinational trial of linezolid versus teicoplanin in serious Gram-positive bacterial infections: the importance of treatment setting in evaluating treatment effects. Int J Antimicrob Agents 2004; 23:315-24. [PMID: 15081078 DOI: 10.1016/j.ijantimicag.2003.09.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2003] [Accepted: 09/02/2003] [Indexed: 10/26/2022]
Abstract
In a recent multinational trial, hospital resource use and total cost of treatment were compared between linezolid and teicoplanin for severe Gram-positive bacterial infections among 227 European hospitalised patients. The results show that the linezolid group had a 3.2-day (6.3 for linezolid versus 9.5 for teicoplanin groups) shorter mean intravenous antibiotic treatment duration. Certain baseline variables, particularly the inpatient location at enrolment and the presence of outpatient/home parenteral antibiotic therapy (OHPAT), had substantial effects on length of stay (LOS) and cost of treatment. After adjusting for the between-treatment difference in these two variables and other baseline variables, the results showed non-significant shorter LOS and lower mean total cost of treatment for the linezolid group among patients with no access to OHPAT.
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Affiliation(s)
- Dilip Nathwani
- Infection and Immunodeficiency Unit, Ward 42, East Block, Ninewells Hospital and Medical School, Tayside University Hospitals, Dundee, Scotland DD1 9SY, UK.
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Slavik RS, Jewesson PJ. Selecting antibacterials for outpatient parenteral antimicrobial therapy : pharmacokinetic-pharmacodynamic considerations. Clin Pharmacokinet 2003; 42:793-817. [PMID: 12882587 DOI: 10.2165/00003088-200342090-00002] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Some infectious diseases require management with parenteral therapy, although the patient may not need hospitalisation. Consequently, the administration of intravenous antimicrobials in a home or infusion clinic setting has now become commonplace. Outpatient parenteral antimicrobial therapy (OPAT) is considered safe, therapeutically effective and economical. A broad range of infections can be successfully managed with OPAT, although this form of treatment is unnecessary when oral therapy can be used. Many antimicrobials can be employed for OPAT and the choice of agent(s) and regimen should be based upon sound clinical and microbiological evidence. Assessments of cost and convenience should be made subsequent to these primary treatment outcome determinants. When designing an OPAT treatment regimen, the pharmacokinetic and pharmacodynamic characteristics of the individual agents should also be considered. Pharmacokinetics (PK) is the study of the time course of absorption, distribution, metabolism and elimination of drugs (what the body does to the drug). Clinical pharmacokinetic monitoring has been used to overcome the pharmacokinetic variability of antimicrobials and enable individualised dosing regimens that attain desirable antimicrobial serum concentrations. Pharmacodynamics (PD) is the study of the relationship between the serum concentration of a drug and the clinical response observed in a patient (what the drug does to the body). By combining pharmacokinetic properties (peak [C(max)] or trough [C(min)] serum concentrations, half-life, area under the curve) and pharmacodynamic properties (susceptibility results, minimum inhibitory concentrations [MIC] or minimum bactericidal concentrations [MBC], bactericidal or bacteriostatic killing, post-antibiotic effects), unique PK/PD parameters or indices (t > MIC, C(max)/MIC, AUC(24)/MIC) can be defined. Depending on the killing characteristics of a given class of antimicrobials (concentration-dependent or time-dependent), specific PK/PD parameters may predict in vitro bacterial eradication rates and correlate with in vivo microbiologic and clinical cures. An understanding of these principles will enable the clinician to vary dosing schemes and design individualised dosing regimens to achieve optimal PK/PD parameters and potentially improve patient outcomes. This paper will review basic principles of useful PK/PD parameters for various classes of antimicrobials as they may relate to OPAT. In summary, OPAT has become an important treatment option for the management of infectious diseases in the community setting. To optimise treatment course outcomes, pharmacokinetic and pharmacodynamic properties of the individual agents should be carefully considered when designing OPAT treatment regimens.
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Affiliation(s)
- Richard S Slavik
- Clinical Service Unit Pharmaceutical Sciences, Vancouver Hospital and Health Sciences Centre, and Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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Enzweiler KA, Bosso JA, White RL. A novel method of estimating cost of therapy by using patient population characteristics: analysis of fluoroquinolones in various populations with different distributions of renal function. Pharmacotherapy 2003; 23:925-32. [PMID: 12885105 DOI: 10.1592/phco.23.7.925.32732] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Formulary decisions regarding a given drug class are often made in the absence of patient outcome and/or sophisticated pharmacoeconomic data. Analyses that consider factors beyond simple acquisition costs may be useful in such situations. For example, the cost implications of using manufacturers' recommendations for dosing in patients with renal dysfunction may be important, depending on the distribution of various levels of renal function within a patient population. METHODS Using four 1000-patient populations representing different renal function distributions and a fifth population of our medical center's distribution, we determined the costs of therapy for intravenous and oral levofloxacin, gatifloxacin, and moxifloxacin for a 10-day course of therapy for community-acquired pneumonia. Costs considered were average wholesale prices (AWPs), 50% of AWP, or same daily price, plus intravenous dose preparation and administration costs when applicable. Costs for each renal function distribution were examined for significant differences with an analysis-of-variance test. Also, costs of failing to adjust dosing regimens for decreased renal function were determined. RESULTS Differences in fluoroquinolone costs (AWP, 50% AWP, or when matched as the same daily price) among the populations were found. When considering same daily prices, differences among populations ranged from about 35,000 dollars with intravenous gatifloxacin to more than 51,000 dollars for intravenous levofloxacin (all fluoroquinolones, p>0.05). Within a population, differences in costs among the intravenous fluoroquinolones ranged from 47,000-99,000 dollars. Rank orders of the drugs and population costs of therapy were affected by the pricing structure used and varied by the specific population and drug. Differences among the fluoroquinolones or populations were much smaller (<2100 dollars) when considering oral regimens. Costs potentially incurred by failing to adjust dosing for renal function were substantial. CONCLUSION Formulary decisions can be facilitated by considering factors such as patient characteristics and related dosing in addition to simple acquisition costs. In our example, consideration of the distribution of renal function within a given patient population and related dosing for these fluoroquinolones revealed potentially important differences within the class.
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Affiliation(s)
- Kevin A Enzweiler
- Anti-Infective Research Laboratory, College of Pharmacy, Medical University of South Carolina, Charleston 29425, USA
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Crump JA, Barrett TJ, Nelson JT, Angulo FJ. Reevaluating fluoroquinolone breakpoints for Salmonella enterica serotype Typhi and for non-Typhi salmonellae. Clin Infect Dis 2003; 37:75-81. [PMID: 12830411 DOI: 10.1086/375602] [Citation(s) in RCA: 162] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2003] [Accepted: 03/20/2003] [Indexed: 11/03/2022] Open
Abstract
Salmonella enterica infections cause considerable morbidity and mortality worldwide. Antimicrobial therapy may be life-saving for patients with extraintestinal infections with S. enterica serotype Typhi or non-Typhi salmonellae. Because antimicrobial resistance to several classes of traditional first-line drugs has emerged in the past several decades, the quinolone antimicrobial agents, particularly the fluoroquinolones, have become the drugs of choice. Recently, resistance to nalidixic acid has emerged among both Typhi and non-Typhi Salmonella serotypes. Such Salmonella isolates typically also have decreased susceptibility to fluoroquinolones, although minimum inhibitory concentrations of the fluoroquinolones usually are within the susceptible range of the interpretive criteria of the NCCLS. A growing body of clinical and microbiological evidence indicates that such nalidixic acid-resistant S. enterica infections also exhibit a decreased clinical response to fluoroquinolones. In this article, we recommend that laboratories test extraintestinal Salmonella isolates for nalidixic acid resistance, we recommend that short-course fluoroquinolone therapy be avoided for infection with nalidixic acid-resistant extraintestinal salmonellae, and we summarize existing data and data needs that would contribute to reevaluation of the current NCCLS fluoroquinolone breakpoints for salmonellae.
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Affiliation(s)
- John A Crump
- Foodborne and Diarrheal Diseases Branch, Div. of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, MS A-38, Centers for Disease Control and Prevention, 1600 Clifton Rd., Atlanta, GA 30333, USA.
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Li JZ, Willke RJ, Rittenhouse BE, Rybak MJ. Effect of linezolid versus vancomycin on length of hospital stay in patients with complicated skin and soft tissue infections caused by known or suspected methicillin-resistant staphylococci: results from a randomized clinical trial. Surg Infect (Larchmt) 2003; 4:57-70. [PMID: 12744768 DOI: 10.1089/109629603764655290] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Complicated skin and soft tissue infections are common surgical indications usually requiring patients to be hospitalized, and are often caused by gram-positive bacteria, including methicillin-resistant staphylococci such as MRSA. Vancomycin has been the standard treatment for methicillin-resistant staphylococcal infections in many countries, but its intravenous-only formulation for systemic infections often confines patients to the hospital for the treatment. Linezolid, a novel oxazolidinone antibiotic available in intravenous and 100% bioavailable oral forms, was shown in a randomized trial to be as efficacious as vancomycin for suspected or proven methicillin-resistant staphylococcal infections. To determine if oral linezolid can reduce length of hospital stay (LOS) when compared to vancomycin, we compared the LOS for the 230 complicated skin and soft tissue infection patients enrolled in this trial. MATERIALS AND METHODS Patients received up to four weeks of linezolid (intravenous followed by optional oral) or vancomycin (intravenous only), followed by up to four weeks of observation. Unadjusted LOS was estimated using Kaplan-Meier survival functions, whereas the log-logistic survival analysis model was used to estimate the multivariate-adjusted LOS controlling for patient demographics and selected baseline clinical variables. Analysis was done on the intent-to-treat (n = 230) sample as well as on two subsamples of the clinically evaluable (n = 144) and surgical site infection (n = 114) patients. RESULTS The unadjusted Kaplan-Meier median LOS was five days shorter for the linezolid group than the vancomycin group in the intent-to-treat sample (9 vs. 14 days, p = 0.052). It was eight days shorter (8 vs. 16 days, p = 0.0025) in the clinically evaluable sample, but the difference in the surgical site infection sample was not significant (10 vs. 14 days; p = 0.29). The linezolid group's unadjusted mean LOS was 1.7, 5.3 and 0.8 days shorter in the intentto-treat, clinically evaluable, and surgical site infection samples, respectively. After adjusting for age, gender, race, geographic region, bacteremia, type of inpatient location, and number of concurrent medical conditions using the log-logistic model, between-treatment differences in the multivariate-adjusted median LOS decreased to 3, 6, and 3 days, whereas the differences in mean LOS increased to 3.1, 6.5 and 2.5 days for the intent-to-treat, clinically evaluable, and surgical site infection samples (p < 0.01, < 0.01, and < 0.10), respectively. When the between-treatment differences in LOS were expressed as odds ratio of hospital discharges, multivariate-adjustment increased the odds ratios in favor of linezolid for all the three samples. CONCLUSION Results from this randomized trial show that linezolid can significantly reduce LOS for patients with complicated skin and soft tissue infections from suspected or confirmed methicillin-resistant staphylococci.
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López H, Li JZ, Balan DA, Willke RJ, Rittenhouse BE, Mozaffari E, Vidal G, Zitto T, Tang T. Hospital resource use and cost of treatment with linezolid versus teicoplanin for treatment of serious gram-positive bacterial infections among hospitalized patients from South America and Mexico: results from a multicenter trial. Clin Ther 2003; 25:1846-71. [PMID: 12860502 DOI: 10.1016/s0149-2918(03)80173-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Linezolid is a novel oxazolidinone antibiotic that is effective for the treatment of gram-positive bacterial infections. The oral formulation has the potential to reduce length of stay (LOS) when used as a substitute for parenteral glycopeptide antibiotics. In a recent multinational trial comparing linezolid (i.v. followed by oral administration) with teicoplanin (i.v. alone or switched to i.m. administration), linezolid was found to have better efficacy (P = 0.005) and similar safety for treating serious gram-positive infections. OBJECTIVE The purpose of this study was to compare hospital resource use (primarily LOS) and cost of treatment between linezolid and teicoplanin for hospitalized patients with serious gram-positive infections in South America and Mexico using data from the multinational trial. METHODS In a multinational, Phase IIIb, open-label, comparator-controlled trial, data were collected from hospitalized patients in centers in 6 South America can countries and Mexico with suspected or confirmed serious gram-positive infections. Patients were randomly assigned to receive i.v. linezolid 600 mg BID (for the entire treatment period [7-28 days] or switched to oral linezolid 600 mg BID) or i.v. teicoplanin (for the entire treatment period or switched to i.m. teicoplanin) dosed per approved prescription information. Data on direct medical resource utilization were collected for each patient, including duration and doses of study medication, location of hospitalization and LOS, comedications, tests and procedures, and outpatient service usage. Unit costs for the medical resources were obtained from secondary sources. RESULTS A total of 203 patients (97 treated with linezolid and 106 treated with teicoplanin) were enrolled from these 7 countries. The unadjusted results showed that compared with teicoplanin, patients treated with linezolid had a 3.1-day shorter mean i.v. antibiotic treatment duration (P < 0.001), a 2.0- to 2.2-day shorter median and mean LOS (P = 0.03), and a 311 US dollars lower mean total cost of treatment (P = NS). After controlling for age, race, sex, site of infection, inpatient location when the antibiotic treatment started, number of historical and current comorbidities, and whether the patient had a diagnosis of systemic inflammatory response syndrome or sepsis, the multivariate adjusted results were similar to the unadjusted results. The linezolid group had a 1.6-day shorter adjusted LOS or 66% greater odds of early discharge (P = 0.049) and a 335 US dollars lower adjusted mean total cost of treatment (P = NS). CONCLUSION Linezolid was associated with shorter LOS and duration of IV antibiotic treatment than teicoplanin for serious gram-positive infections in the population studied. Linezolid therapy has the potential to reduce the total cost of treatment.
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Rebuck JA, Fish DN, Abraham E. Pharmacokinetics of intravenous and oral levofloxacin in critically ill adults in a medical intensive care unit. Pharmacotherapy 2002; 22:1216-25. [PMID: 12389872 DOI: 10.1592/phco.22.15.1216.33484] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To characterize the pharmacokinetic disposition of intravenous and oral levofloxacin in critically ill adults. DESIGN Prospective, open-label study. SETTING University teaching hospital. PATIENTS Thirty critically ill patients in a medical intensive care unit (ICU). INTERVENTIONS All patients received levofloxacin as part of their routine medical care. Pharmacokinetic evaluations were performed in 28 patients receiving intravenous levofloxacin. Ten of these patients subsequently were switched to oral levofloxacin and underwent a second pharmacokinetic evaluation during oral therapy. MEASUREMENTS AND MAIN RESULTS Mean +/- SD levofloxacin half-life, clearance at steady state, and volume of distribution in all 28 patients were 8.0 +/- 1.7 hours, 134 +/- 35 ml/minute, and 1.2 +/- 0.3 L/kg, respectively Maximum and minimum serum concentrations (Cmax and Cmin) and area under the serum concentration-time curve from 0-24 hours (AUC(0-24)) in patients receiving levofloxacin 500 mg intravenously were 7.5 +/- 0.8 mg/L, 1.0 +/- 0.5 mg/L, and 66.1 +/- 15.7 mg x hour/L, respectively Observed Cmax, Cmin, and time at which maximum concentration was achieved after oral doses of levofloxacin 500 mg were 5.5 +/- 1.1 mg/L, 0.8 +/- 0.4 mg/L, and 1.3 +/- 0.4 hours, respectively. These values were significantly different (p < 0.05) from those observed after intravenous dosing in the same patients; other pharmacokinetic parameters were similar. Statistically significant increases (p < 0.05) in Cmax, Cmin, half-life, and AUC(0-24) were found in critically ill patients administered multiple doses of intravenous levofloxacin compared with historical data from healthy volunteers. CONCLUSIONS The dosage regimen of intravenous levofloxacin 500 mg once/day appears adequate for most pathogens found in critically ill patients with normal renal function. Less susceptible pathogens may require an increased daily dose for more optimal therapy. Orally administered levofloxacin appears to be well absorbed in selected ICU patients and has pharmacokinetics similar to those of intravenously administered levofloxacin.
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Affiliation(s)
- Jill A Rebuck
- Department of Pharmacotherapy, Fletcher Allen Health Care, University of Vermont, Burlington, USA
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Paladino JA, Gudgel LD, Forrest A, Niederman MS. Cost-effectiveness of IV-to-oral switch therapy: azithromycin vs cefuroxime with or without erythromycin for the treatment of community-acquired pneumonia. Chest 2002; 122:1271-9. [PMID: 12377852 DOI: 10.1378/chest.122.4.1271] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVE To conduct a cost-effectiveness analysis of IV-to-oral regimens of azithromycin vs cefuroxime with or without erythromycin in the treatment of patients hospitalized with community-acquired pneumonia (CAP). PATIENTS Of the 268 evaluable patients enrolled into a randomized, multicenter clinical trial of adults, 266 patients had sufficient data to be included in this cost-effectiveness analysis. One hundred thirty-six patients received azithromycin, and 130 patients received cefuroxime with or without erythromycin. METHODS A pharmacoeconomic analysis from the hospital provider perspective was conducted. Health-care resource utilization was extracted from the clinical database and converted to national reference costs. Decision analysis was used to structure and characterize outcomes. Sensitivity analyses were performed, and statistics were applied to the cost-effectiveness ratios. RESULTS The clinical success and adverse event rates and antibiotic-related length of stay were 78%, 11.8%, and 5.8 days for the azithromycin group and 75%, 20.7%, and 6.4 days for the group receiving cefuroxime with or without erythromycin, respectively. Geometric mean treatment costs were 4,104 US dollars (95% confidence interval [CI], 3,874 to 4,334 US dollars) for the azithromycin group, and 4,578 US dollars (95% CI, 4,319 to 4,837 US dollars) for the group receiving cefuroxime with or without erythromycin (p = 0.06). The cost-effectiveness ratios were 5,265 US dollars per expected cure for the azithromycin group, and 6,145 US dollars per expected cure for group receiving cefuroxime with or without erythromycin (p = 0.05). CONCLUSIONS Despite a higher per-dose purchase price, overall costs with azithromycin tended to be lower due to decreased duration of therapy, lower preparation and administration costs, and reduced hospital length of stay. As empiric therapy, azithromycin monotherapy was cost-effective compared to cefuroxime with or without erythromycin for patients hospitalized with CAP who have no underlying cardiopulmonary disease, and no risk factors for either drug-resistant pneumococci or enteric Gram-negative pathogens.
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Affiliation(s)
- Joseph A Paladino
- CPL Associates LLC, State University of New York at Buffalo, Buffalo, NY, USA.
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Wiuff C, Lykkesfeldt J, Aarestrup FM, Svendsen O. Distribution of enrofloxacin in intestinal tissue and contents of healthy pigs after oral and intramuscular administrations. J Vet Pharmacol Ther 2002; 25:335-42. [PMID: 12423223 DOI: 10.1046/j.1365-2885.2002.00430.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The concentration of enrofloxacin in plasma, intestinal tissue, lymph nodes and intestinal contents was investigated in healthy pigs after oral (p.o.) and intramuscular (i.m.) administration of a single dose of 2.5 mg/kg bw. Tissue and content samples were collected from jejunum, ileum, caecum and colon from pigs killed at 2, 3 and 6 h after dosing. Intramuscular administration resulted in significantly higher concentrations in plasma, intestinal tissue and lymph nodes at 2 h but not at 3 or 6 h compared with p.o. administration. The absorption and distribution phase was longer after oral administration, and maximum concentrations in tissue and plasma were determined later than after i.m. administration. No difference between route of administration was observed in the intestinal content. Enrofloxacin concentrations in faeces during a 5-day dosing regimen with i.m. and p.o. administration were determined by both HPLC and bio-assay. Higher concentrations were found after i.m. administration during the first day, but the difference was not significant after 2 days. The biologically active concentrations determined by bio-assay constituted 48-75% of the total concentrations determined by HPLC. On the basis of these results it was concluded that in order to ensure an immediate high concentration of enrofloxacin, and thereby avoid an initial selection for resistant mutants, the intramuscular route seems to be preferable to the oral route.
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Affiliation(s)
- C Wiuff
- Danish Veterinary Institute, Bülowsvej 27, DK-1790 Copenhagen V, Denmark.
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Pelly L. IV-to-oral switch therapy for community-acquired pneumonia requiring hospitalization: focus on gatifloxacin. Adv Ther 2002; 19:229-42. [PMID: 12539883 DOI: 10.1007/bf02850363] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The majority of the 1.1 million patients hospitalized for community-acquired pneumonia (CAP) in the United States begin therapy with an intravenous antibiotic. A switch to oral therapy as soon as patients are clinically stable reduces the length of hospitalization and associated costs. Fluoroquinolones are appropriate candidates for switch therapy. Gatifloxacin is an excellent choice when a fluoroquinolone is being considered for sequential switch therapy in the treatment of CAP requiring hospitalization.
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Debon R, Breilh D, Boselli E, Saux MC, Duflo F, Chassard D, Allaouchiche B. Pharmacokinetic parameters of ciprofloxacin (500 mg/5 mL) oral suspension in critically ill patients with severe bacterial pneumonia: a comparison of two dosages. J Chemother 2002; 14:175-80. [PMID: 12017373 DOI: 10.1179/joc.2002.14.2.175] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
The authors determined the pharmacokinetic parameters of a new immediate-release ciprofloxacin suspension in tube-fed intensive care patients with bacterial pneumonia, to compare two dosage regimens: 500 mg b.i.d and 750 mg b.i.d. in this prospective clinical trial. The 20 patients were critically ill and on mechanical ventilation and enteral feeding with bacterial pneumonia. They were randomized to receive two different ciprofloxacin dosages: 500 mg b.i.d (group 1) versus 750 mg b.i.d. (group 2). Blood samples were collected from these patients after reaching steady-state and the pharmacokinetic parameters were determined. The mean (range) serum steady-state concentration at 2 h after enteral administration was: C(max 500) = 2.6 (1.2-4.3) mg/L in group 1 and C(max 750) = 3.5 (1.5-5.9) mg/L in group 2. The mean (range) calculated 12-h area under the serum concentration was high in both groups: AUC(0-12 (500)) = 24.7 (12.9-36.2) mg.h/L in group 1 and AUC(0-12 (750)) = 28.9 (18.3-47.5) mg.h/L in group 2. In conclusion, ciprofloxacin oral suspension was well absorbed via nasogastric route in intensive care patients with severe pneumonia, achieving reliable pharmacokinetic parameters for most of the pathogens and important cost reduction compared to intravenous delivery. However, with less susceptible pathogens such as Staphylococcus aureus or Pseudomonas aeruginosa, higher dosages than 750 mg b.i.d. should be given.
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Affiliation(s)
- R Debon
- Intensive Care Department, Hôtel-Dieu, Lyon, France
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Conort O, Gabardi S, Didier MP, Hazebroucq G, Cariou A. Intravenous to oral conversion of fluoroquinolones: knowledge versus clinical practice patterns. PHARMACY WORLD & SCIENCE : PWS 2002; 24:67-70. [PMID: 12061136 DOI: 10.1023/a:1015533503212] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
STUDY OBJECTIVES To assess the knowledge of prescribers regarding intravenous to oral conversions of fluoroquinolones, the frequency and time until conversion, and to compare prescriber knowledge with the data collected concerning the reasons stated for continuation of intravenous fluoroquinolones. DESIGN Prospective chart review and questionnaire. SETTING Large teaching hospital in Paris, France. PATIENTS Fifty-one males and females. INTERVENTION Data were collected on in-patients receiving intravenous fluoroquinolone for at least three days and hospitalized in one of six in-patient units. Patients receiving intravenous fluoroquinolone for less than three days were excluded. A questionnaire to assess the awareness of a potential conversion was distributed to those practitioners who had patients reviewed during the data-collection phase. MAIN RESULTS The questionnaire revealed the ten most common reasons for continuing intravenous administration for more than three days. However, the physicians agreed that most patients should be converted as soon as possible. Practice patterns differed, with only 17 of 51 patients actually converted to oral therapy. CONCLUSION In theory, the clinicians were aware of when to perform the conversion. However, in practice, the frequency of conversion was lower than optimum. Changes in clinical practice are needed to decrease the costs of intravenous therapy, without jeopardizing quality of care.
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Naber CK, Hammer M, Kinzig-Schippers M, Sauber C, Sörgel F, Bygate EA, Fairless AJ, Machka K, Naber KG. Urinary excretion and bactericidal activities of gemifloxacin and ofloxacin after a single oral dose in healthy volunteers. Antimicrob Agents Chemother 2001; 45:3524-30. [PMID: 11709334 PMCID: PMC90863 DOI: 10.1128/aac.45.12.3524-3530.2001] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2000] [Accepted: 08/15/2001] [Indexed: 11/20/2022] Open
Abstract
In a randomized crossover study, 16 volunteers (8 men, 8 women) received single oral doses of 320 mg of gemifloxacin and 400 mg of ofloxacin on two separate occasions in the fasting state to assess the urinary excretion and urinary bactericidal titers (UBTs) at intervals for up to 144 h. Ofloxacin showed higher concentrations in urine compared with those of gemifloxacin. The median (range) cumulative excretion of gemifloxacin was 29.7% (8.4 to 48.7%) of the parent drug administered, and median (range) cumulative excretion of ofloxacin was 84.3% (46.5 to 95.2%) of the parent drug administered. The UBTs, i.e., the highest twofold dilutions (with antibiotic-free urine as the diluent) of urine that were still bactericidal, were determined for a reference strain and nine uropathogens for which the MICs of gemifloxacin and ofloxacin were as follows: Escherichia coli ATCC 25922, 0.016 and 0.06 microg/ml, respectively; Klebsiella pneumoniae, 0.03 and 0.06 microg/ml, respectively; Proteus mirabilis, 0.125 and 0.125 microg/ml, respectively; Escherichia coli, 0.06 and 0.5 microg/ml, respectively; Pseudomonas aeruginosa, 1 and 4 microg/ml, respectively; Staphylococcus aureus, 0.008 and 0.25 microg/ml, respectively; Enterococcus faecalis, 0.06 and 2 microg/ml, respectively; Staphylococcus aureus, 0.25 and 4 microg/ml, respectively; Enterococcus faecalis, 0.5 and 32 microg/ml, respectively; and Staphylococcus aureus, 2 and 32 microg/ml, respectively. Generally, the UBTs for gram-positive uropathogens were higher for gemifloxacin than for ofloxacin and the UBTs for gram-negative uropathogens were higher for ofloxacin than for gemifloxacin. According to the UBTs, ofloxacin-resistant uropathogens (MICs, >or=4 mg/liter) should also be considered gemifloxacin resistant. Although clinical trials have shown that gemifloxacin is effective for the treatment of uncomplicated urinary tract infections, whether an oral dosage of 320 mg of gemifloxacin once daily is also adequate for the treatment of complicated urinary tract infections has yet to be confirmed.
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Affiliation(s)
- C K Naber
- Department of Pharmacology, University of Essen, Essen, Germany
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Soriano F. [Selection of antibiotic-resistant bacteria: microbiological and pharmacological factors]. Med Clin (Barc) 2001; 117:632-6. [PMID: 11714473 DOI: 10.1016/s0025-7753(01)72202-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- F Soriano
- Departamento de Microbiología Médica, Fundación Jiménez Díaz, Madrid, Spain
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