Candidates For Outpatient Therapy Research Articles

Characteristics of hospital admissions for pneumonia in HIV-positive individuals in Winnipeg, Manitoba: a cross-sectional retrospective analysis.

Lung infection in human immunodeficiency virus (HIV)-positive individuals remains an important cause of morbidity and mortality, even in the current antiretroviral therapy era. Pneumonia is the most common cause of admission in HIV-positive individuals in our centre as reported in a previously published study. The objective of this retrospective observational study was to further characterize these admissions, with respect to index of disease severity at presentation, organisms identified, and investigations pursued including bronchoalveolar lavage (BAL). There were 123 unique patients accounting for a total of 209 admissions from 2005 to 2015. An organism was isolated in only 33% of all admissions (68/209). The most common organism was Pneumocystis jirovecii with a frequency of 29% of all admissions. Eighty-seven percent of presentations were mild, and 13% were moderate by CURB-65 criteria. A total of 39 BALs were performed, of which 27 yielded an organism (69%). Considering the burden of disease, low diagnostic yield of the current diagnostic strategy and increased morbidity and mortality caused by pneumonia in HIV-positive individuals, further methods are needed to more accurately target therapy. The preponderance of mild disease in this study suggests that better diagnostic tests may identify individuals that can be candidates for outpatient therapy.

Targets for antibiotic and healthcare resource stewardship in inpatient community-acquired pneumonia: a comparison of management practices with National Guideline Recommendations

Community-acquired pneumonia (CAP) is the most common infection leading to hospitalization in the USA. The objective of this study was to evaluate management practices for inpatient CAP in relation to Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) guidelines to identify opportunities for antibiotic and health care resource stewardship. This was a retrospective cohort study of adults hospitalized for CAP at a single institution from 15 April 2008 to 31 May 2009. Of the 209 patients with CAP who presented to Denver Health Medical Center during the study period and were hospitalized, 166 (79 %) and 43 (21 %) were admitted to a medical ward and the intensive care unit (ICU), respectively. Sixty-one (29 %) patients were candidates for outpatient therapy per IDSA/ATS guidance with a CURB-65 score of 0 or 1 and absence of hypoxemia. Sputum cultures were ordered for 110 specimens; however, an evaluable sample was obtained in only 49 (45 %) cases. Median time from antibiotic initiation to specimen collection was 11 [interquartile range (IQR) 6-19] h, and a potential pathogen was identified in only 18 (16 %) cultures. Blood cultures were routinely obtained for both non-ICU (81 %) and ICU (95 %) cases, but 15 of 36 (42 %) positive cultures were false-positive results. The most common antibiotic regimen was ceftriaxone + azithromycin (182, 87 % cases). Discordant with IDSA/ATS recommendations, oral step-down therapy consisted of a new antibiotic class in 120 (66 %), most commonly levofloxacin (101, 55 %). Treatment durations were typically longer than suggested with a median of 10 (IQR 8-12) days. In this cohort of patients hospitalized for CAP, management was frequently inconsistent with IDSA/ATS guideline recommendations, revealing potential targets to reduce unnecessary antibiotic and healthcare resource utilization.

Delayed Versus Initial Risk-Categorization of Pediatric Cancer Patients with Prolonged Febrile Neutropenia. A Randomized, Prospective Clinical Trial.

Purpose:Hospitalization with empiric broad spectrum intravenous antibiotics has been the standard of care for treatment of high-risk febrile neutropenia. In an attempt to improved hospital utilization we attempt to identify a group of patients at a lower risk of sepsis that would be eligible for outpatient therapy. We hypothesized that patients initially considered at high risk for sepsis can be candidates for outpatient therapy if at 72 hours satisfied certain selection criteria.Patients and methods:A prospective, randomized clinical trial was conducted in 119 febrile neutropenic pediatric cancer patients. Patients were randomized into two groups depending on the time of risk-categorization: Initial (control) vs. delayed (study) groups. Patients in the study group were risk-assessed at 72 hours and accordingly considered for outpatient therapy if afebrile, had an absolute neutrophil count (ANC) > 100/uL, negative blood cultures, and no signs of infection among other carefully defined “Early Discharge Criteria”. Those randomized to the control group were treated in the hospital. We analyzed the clinical features, microbiological data, hospital course, duration of hospitalization and treatment cost. Intention-to-treat analysis was used. Results: We found a statistically significant difference between the duration of hospitalization in the group risk-assessed at 72 hours and control group (p<0.01). “Delayed Risk-categorization” correlated better with the duration of neutropenia, need for antibiotic change and episode outcome. Duration of hospitalization and per-episode median treatment cost were significantly less in the study group vs. control (p< 0.001). There was a significant tendency for blood cultures to cluster around the first 48 hours. Comparing the blood culture yield between patients treated in the hospital to those treated as outpatients after risk-assessment at 72 hours there was no statistically significant difference demonstrated [p=0.35].Readmission rate after early discharge was 3.3%.Conclusion: We conclude that pediatric febrile-neutropenic patients initially at considered at “high risk for sepsis” can be reevaluated at 72 hours for outpatient therapy. The practice of “Delayed Risk-Categoriztion” could be particularly useful to reduce the overall treatment costs, and duration of hospitalization. In addition, this practice could potenitally offer a superior quality of life.

Outpatient single dose ceftriaxone and amikacin vs. imipenem/cilastatin monotherapy in the empiric treatment of pediatric patients with high risk fever aneutropenia. A randomized, prospective clinical trial

8520 Background: The empiric usage of once daily ceftriaxone plus amikacin (C+A) for febrile neutropenia allows outpatient treatment for selected patients. We hypothesized that patients initially a...

Outpatient single dose ceftriaxone and amikacin vs. imipenem/cilastatin monotherapy in the empiric treatment of pediatric patients with high risk fever aneutropenia. A randomized, prospective clinical trial

8520 Background: The empiric usage of once daily ceftriaxone plus amikacin (C+A) for febrile neutropenia allows outpatient treatment for selected patients. We hypothesized that patients initially at high risk for sepsis can be candidates for outpatient therapy if at 48 hours satisfy strict “Selection Criteria”. Being a well established monotherapy agent, Imipenem was used as control. We compared the efficacy, treatment modification, toxicity, duration of hospitalization and cost between both groups. In addition we assessed risks of early discharge and rate of readmission. Design/Methods: A prospective, randomized crossover clinical trial involving 120 pediatric cancer patients with high-risk fever and neutropenia. Febrile patients at 72 hours were crossed-over together with adding vancomycin. Patients on C+A were assessed using Early Discharge Criteria, and if eligible continued treatment as outpatients. Intention-to-treat analysis was used. Results: We found a statistically significant difference between duration of hospitalization between the C+A [median 4.5 days] and control [9.5 days] (p<0.001), per episode antibiotic cost (p< 0.001) & total episode cost [study median $873 vs. control $1655, p<0.001]. Similar results were obtained using average admission costs in a corresponding North American institution. There was no statistically significant difference in the response to treatment at 72 hours, after crossover or at the end of episode. Cultures grew more Gram-positive bacteria (59%). Overall success rate was 95.8%. Conclusions: Pediatric febrile-neutropenic patients initially at high-risk for sepsis can be risk-assessed at some point in treatment for outpatient therapy. The convenience, less adverse effects and cost benefit of the once daily regimen of ceftriaxone plus amikacin will be particularly useful to reduce the overall treatment costs, and duration of hospitalization. Further studies are needed to clarify the role of risk categorization and outpatient therapy in the context of high-risk febrile neutropenia. No significant financial relationships to disclose.

Utilization and outcomes of enoxaparin treatment for deep-vein thrombosis in a tertiary-care hospital.

The availability of a low-molecular-weight heparin, enoxaparin, to treat deep-vein thrombosis (DVT) offers the option for outpatient therapy for certain DVT patients. We monitored the utilization and outcomes of enoxaparin treatment for DVT in our tertiary-care hospital. A retrospective chart survey was performed for all DVT patients treated at our facility between October 1998 and September 1999. We tracked treatment received (unfractionated heparin or enoxaparin), clinical outcomes (recurrent thromboembolism or bleeding), and whether the patient would have met practice guideline criteria for outpatient enoxaparin therapy. A total of 266 patients were either admitted to the hospital for DVT or experienced DVT during their hospitalization. Of 266 DVT patients, 73 (27%) received enoxaparin. Sixty-four (88%) patients receiving enoxaparin met practice guideline criteria. Nine patients (12%) who did not meet criteria also received the drug. Major bleeding occurred in 3 patients (4%) receiving enoxaparin; one patient had a life-threatening hemorrhage. Two of the three patients with major bleeding had contraindications to enoxaparin use. Only 45% of our DVT patients were appropriate candidates for outpatient enoxaparin therapy. We conclude that in tertiary-care hospitals with acutely ill patients, most DVT patients will not be candidates for outpatient therapy with enoxaparin. Limitations to enoxaparin use are not widely appreciated.

Outpatient treatment of acute pyelonephritis in pregnancy after 24 weeks

Objective: To compare outpatient to inpatient management of acute pyelonephritis in pregnancy beyond 24 weeks’ gestation. Methods: Ninety-two gravidas past 24 weeks’ gestation, randomized to outpatient or inpatient therapy, received two 1-g doses of intramuscular ceftriaxone at 24-hour intervals while hospitalized, then were discharged and reevaluated within 48–72 hours or remained hospitalized until afebrile for 48 hours. Subjects received oral cephalexin after initial treatment. Urine cultures were done on admission and 5–14 days after therapy. Surveillance continued until delivery. We anticipated that 15% of outpatients and 0.01% of inpatients would require changes in antibiotic therapy. Results: Twenty-one percent of women evaluated were excluded. Thirteen of 46 (28%) outpatients’ hospitalization exceeded 24 hours. Six outpatients (13.0%) and one inpatient did not respond to initial therapy and were treatment failures (relative risk [RR] 1.82, 95% confidence interval [CI] 1.00, 3.31). Within 2 weeks of initial therapy, seven of 81 (8.6%) subjects had positive urine cultures, four outpatients versus three inpatients ( P > .999). Eleven of 84 (13.1%) deliveries for which birth data were available occurred preterm (six of 41 outpatients versus five of 43 inpatients) (RR 1.14, 95% CI 0.61, 2.11). Conclusion: There were no significant differences in clinical responses or birth outcomes of inpatients or outpatients treated for acute pyelonephritis after 24 weeks’ gestation if they completed their assigned protocols. Thirty percent of outpatients were unable to, and most women with acute pyelonephritis in the third trimester were not candidates for outpatient therapy.

Continuation of antibiotic therapy for serious bacterial infections outside of the hospital.

Many children hospitalized with serious bacterial infections are candidates for either home oral antibiotic therapy or outpatient parenteral antibiotic therapy. Outpatient antibiotic therapy offers the potential for excellent medical treatment, reduced costs, and improved quality of life for ill children. However, cost considerations must not override good medical judgment. Certain children simply are not candidates for outpatient therapy because of the seriousness of their infection, poor compliance, lack of intravenous access, or poor social situation. In addition, although the few published studies to date all show that outpatient antibiotic therapy is effective, there is further need for properly designed clinical trials to evaluate the efficacy and safety of outpatient antibiotic therapy for serious bacterial infections in children.

Care of patients with deep venous thrombosis in an academic medical center: Limitations and lessons

The primary goal of our study was to review the quality of care in patients with deep vein thrombosis,, with emphasis on identifying recurrent and remedial problems. Secondary goals were (1) to evaluate the use of the vascular laboratory and (2) to characterize our patient population with deep vein thrombosis and to identify a subset of patients with uncomplicated deep vein thrombosis who might be candidates for outpatient therapy in the future. A retrospective review was performed for all patients with deep vein thrombosis diagnosed with duplex scanning who were treated as inpatients from January 1993 through March 1993. Fifty-four (16%) of 306 duplex scans were positive; 50 patients were treated as inpatients. Forty percent of patients had uncomplicated deep vein thrombosis that was potentially treatable on an outpatient basis. Mean time to obtain a therapeutic partial thromboplastin time was 22 hours (range 4 to 54 hours). Ten (20%) patients had inferior vena cava filters placed. The in-hospital mortality rate was 4%. Management problems occurred in 18 (36%) patients and included difficulty titrating anticoagulation, (10) physician failure to provide treatment after diagnosis, (five) and inappropriate use or complication of inferior vena cava filter placement (three). Venous duplex examination is liberally but appropriately used. The primary remediable problem resulting in suboptimal management is difficulty titrating anticoagulation; inappropriate placement of inferior vena cava filters and physician failure to provide treatment also occur. In the future a substantial number of patients may be suitable for outpatient therapy.