Duration Of Intravenous Antibiotic Therapy Research Articles

Assessment of an intervention aimed at early discontinuation of intravenous antimicrobial therapy in a Brazilian University hospital

Many interventions demonstrate success in adapting the duration of intravenous antibiotic therapy, but few studies have been conducted in developing countries. The aim of this study was to evaluate the effectiveness of an intervention in the induction of early discontinuation of intravenous antimicrobial therapy and/or its switch to oral therapy. The study employed a before–after intervention design that consisted of displaying a message in the computerized prescription on the third day and suspension of the prescription on the fifth day of intravenous antimicrobial therapy. A total of 465 patients were followed during the control period (CP) and 440 in the intervention period (IP). The intravenous therapy was switched to oral therapy for 11 (2.4%) patients during the CP and 25 (5.7%) in the IP (p=0.011), and was discontinued for 82 (17.6%) patients during the CP and 106 (24.1%) in the IP (p=0.017). During the IP there was a significant increase of patients who had their antimicrobial treatment discontinued before the seventh day of intravenous treatment, 37.40% (49/131) in the IP and 16.13% (15/93) in the CP (p=0.0005). The duration of intravenous antimicrobial therapy decreased by one day, but it was not significant (p=0.136). It is concluded that the proposed intervention is effective in promoting the early discontinuation of antimicrobial treatment and/or switch to oral therapy. As long as a computerized system for prescription already exists, it is easy and inexpensive to be implemented, especially in hospitals in developing countries.

Utility of Serum Procalcitonin in Skin and Soft Tissue Infections

Background Procalcitonin (PCT) has been studied as a biomarker to assist in the diagnosis and treatment of severe bacterial infections, mostly in the context of respiratory tract infections and severe sepsis, where it has been shown to reduce antimicrobial use without worsening clinical outcomes. The utility of PCT in guiding duration of antibiotic therapy in skin and soft tissue infections (SSTIs) has not been established. Our aim was to evaluate the relationship between the duration of intravenous antibiotic therapy for SSTIs and serum PCT; as well as the relationship between PCT and conventional markers of inflammation. Methods Serum PCT, leukocyte count, C-reactive protein and blood cultures laboratory, and body temperature were examined in 39 consecutive patients with SSTIs requiring inpatient intravenous antibiotic treatment. Results Thirty-nine consecutive inpatients presenting with SSTIs were evaluated. Procalcitonin values on admission correlated with duration of intravenous antibiotic therapy (Pearson correlation, 0.475; P = 0.002) and length of hospital stay (Pearson correlation, 0.534; P = 0.001). Peak serum PCT values also correlate with peak leukocyte count (Pearson correlation, 0.529; P = 0.001), peak C-reactive protein during hospitalization (Spearman correlation, 0.457; P = 0.003), and presence of Systemic Inflammatory Response Syndrome criteria on admission (P = 0.030). Conclusions Procalcitonin correlates with duration of intravenous antibiotic therapy in SSTIs; it may be a valuable adjunct in the initial diagnosis and management of antibiotic therapy in these infections.

Dermo-hypodermites à streptocoque du groupe B chez les nourrissons de moins de 3 mois : étude rétrospective dans deux centres hospitaliers

Very few studies describe group B streptococcal dermo-hypodermitis in newborns. To describe the incidence, clinical characteristics, and course of group B streptococcal dermo-hypodermitis in infants less than 3 months old. Infants under 3 months of age, hospitalized for group B streptococcal dermo-hypodermitis at Robert Debré University Hospital, Paris, France, and at Orsay Hospital, Orsay, France, between January 2002 and August 2013, were included in a retrospective study. Five infants were included in this study. All the infections occurred late. Dermo-hypodermitis accounted for 7% of the overall late-onset group B streptococcal infections during the same period. Four patients were male and had a risk factor of maternal-fetal infection (prematurity/hypotrophy). Four patients had specific clinical signs of dermo-hypodermitis with septic shock features on admission. One patient had meningitis and associated parotitis. Group B Streptococcus was isolated from blood culture of all patients. Serotype III Streptococcus was identified in four cases. The duration of intravenous antibiotic therapy varied from 7 to 23 days and the total duration of antibiotic therapy was between 14 and 44 days. The progression was favorable for all the infants, with no recurrence. Dermo-hypodermitis in infants under 3 months of age is rare but could be an early indicator of group B streptococcal bacteremia and/or sepsis. Early diagnosis of this severe complication and appropriate antibiotic therapy are critical.

Surgical and Medical Treatments of Empyema in Pediatric Patients

Background: Empyema in pediatric, if not treated adequately, would be an aggressive disease with many complications. Complete treatment of empyema includes broad antibiotics administration during the first week of the disease. However, in some cases, organized fibrinous tissue prevents antibiotic penetration and surgical intervention is required. Objectives: The aim of this study was to compare the duration of admission, duration of intravenous antibiotic therapy, time to response to treatment, and outcomes of medical and surgical interventions. Patients and Methods: In a retrospective, observational study, 60 patients with empyema were included; 35 were treated medically (medical group) and 25 surgically (surgical group). Results: Age and sex were not significantly different between the two groups. Only one of the patients in the medical group and one in the surgical group had immune deficiency. Coughing was presented in 25 patients in medical group and in 17 patients in surgical group as a symptom. Hospitalization days of were significantly lower in the medical group (12.4 ± 5.5) compared with the surgical group (20.4 ± 5.2) (P = 0.041). Duration of intravenous antibiotic therapy was not significantly lower in the medical group compared with the surgical group (P = 0.085). Time to response to treatment (from the admission day to the clinical improvement) was significantly lower in the medical group compared with the surgical one (P = 0.024). Mortality was 0% in both groups. Conclusions: If medical treatment gets started early in the course of empyema, prognosis would be excellent. Besides, there was no significant difference in short- and long-term outcomes between medical or surgical interventions.

A tailored implementation strategy to reduce the duration of intravenous antibiotic treatment in community-acquired pneumonia: a controlled before-and-after study.

We previously showed that 40 % of clinically stable patients hospitalised for community-acquired pneumonia (CAP) are not switched to oral therapy in a timely fashion because of physicians' barriers. We aimed to decrease this proportion by implementing a novel protocol. In a multi-centre controlled before-and-after study, we evaluated the effect of an implementation strategy tailored to previously identified barriers to an early switch. In three Dutch hospitals, a protocol dictating a timely switch strategy was implemented using educational sessions, pocket reminders and active involvement of nursing staff. Primary outcomes were the proportion of patients switched timely and the duration of intravenous antibiotic therapy. Length of hospital stay (LOS), patient outcome, education effects 6 months after implementation and implementation costs were secondary outcomes. Statistical analysis was performed using mixed-effects models. Prior to implementation, 146 patients were included and, after implementation, 213 patients were included. The case mix was comparable. The implementation did not change the proportion of patients switched on time (66 %). The median duration of intravenous antibiotic administration decreased from 4 days [interquartile range (IQR) 2-5] to 3 days (IQR 2-4), a decrease of 21 % [95 % confidence interval (CI) 11 %; 30 %) in the multi-variable analysis. LOS and patient outcome were comparable before and after implementation. Forty-three percent (56/129) of physicians attended the educational sessions. After 6 months, 24 % (10/42) of the interviewed attendees remembered the protocol's main message. Cumulative implementation costs were <euro>5,798 (<euro>20/reduced intravenous treatment day). An implementation strategy tailored to previously identified barriers reduced the duration of intravenous antibiotic administration in hospitalised CAP patients by 1 day, at minimal cost.

Presentation and Management of Pyogenic Liver Abscess in Surgery Department: About 34 Cases

AIM: To describe the clinical features, imaging findings, bacteriologic profile, etiology, treatment and outcome in patients presenting pyogenic liver abscess in a Tunisian hospital. METHODES: We report, in a retrospective study, 34 cases of pyogenic liver abscess that were hospitalized between January, 1st 2004 and December, 31st 2013. RESULTS: Thirty-four cases (19 males, 15 females) were found. The mean age was 64 years. The most significant clinical features of pyogenic liver abscess were upper abdominal pain with high grade fever and hepatomegaly. Thirty-one patients were investigated by CT scan, which showed a positive diagnosis in 100% of cases, 82.4% of liver abscesses were found in the right lobe of liver and were solitary in 79.4% of cases. The most causative germs, were isolated in pus culture, were Escherichia coli and Klebsiella. The most common etiologies were biliary and cryptogenic origin; portal pyemia and hematogenous origin were also found. All of patient had received intravenous antibiotic therapy (cephalosporin or fluoroquinolones combination with metronidazole and aminoglycoside) but only two patients were healed by this regime. The mean duration of intravenous antibiotic therapy was 15.5 days. The percutaneous drainage was performed in 50% (n=17) of cases and was successfully in about 70% of cases. Surgery was performed in 58.82% (n=20) of cases. Six patients had only surgical drainage of abscess and the other 14 patients had cholecystectomy with drainage of abscess.The mean length of hospital stay was 19.7 days. The outcome was generally favorable with the exception of one death from septic shock. CONCLUSION: PLA is a rare condition but has undergone a huge change. It affects the subjects increasingly older. Bacteriologically, there is an emergence of Klebsiella in favor of Escherichia coli. Its treatment became less chirurgical thanks to the development of percutaneous drainage. Its outcome is generally favorable.

Thoracic and abdominal lymphatic pump techniques inhibit the growth of S. pneumoniae bacteria in the lungs of rats.

Osteopathic physicians utilize manual medicine techniques called lymphatic pump techniques (LPT) to improve lymphatic flow and enhance immunity. Clinical studies report that LPT enhances antibody responses to bacterial vaccines, shortens duration of cough in patients with respiratory disease, and shortens the duration of intravenous antibiotic therapy and hospital stay in patients with pneumonia. The purpose of this study was to identify if thoracic LPT (Th-LPT) or abdominal LPT (Ab-LPT) would reduce Streptococcus pneumoniae colony-forming units (CFU) in the lungs of rats with acute pneumonia. Rats were nasally infected with S. pneumoniae and received either control, sham, Ab-LPT, or Th-LPT once daily for 3 consecutive days. On day 4 post-infection, lungs were removed and bacteria were enumerated. Three daily applications of either Ab-LPT or Th-LPT were able to significantly (p<0.05) reduce the numbers of pulmonary bacteria compared to control and sham. There were no significant differences in the percentage or concentration of leukocytes in blood between groups, suggesting neither Ab-LPT nor Th-LPT release leukocytes into blood circulation. Our data demonstrate that LPT may protect against pneumonia by inhibiting bacterial growth in the lung; however, the mechanism of protection is unclear. Once these mechanisms are understood, LPT can be optimally applied to patients with pneumonia, which may substantially reduce morbidity, mortality, and frequency of hospitalization.

THU0434 Pyogenic Arthritis: Clinical and Epidemiological Features of 101 Cases at a University Hospital.

ObjectivesTo describe the clinical characteristics, treatment and outcome of patients diagnosed with pyogenic septic arthritis.MethodsDesign: retrospective (1984-2012). Location: University hospital. Referial area: 800,000 inhabitants. The medical records of patients with...

Acupuncture for Dyspnea on Exertion in Chronic Obstructive Pulmonary Disease: No Blindness

should not be used to modify clinical practice. However, although mortality is objective and important, most patients withCAPdonotdie.BecausenewinterventionsforCAPare likely to result in only small changes in mortality, large sample sizes are required to detect clinically important changes. Therefore, it has been suggested that mortality is an insensitive measure of quality of care or treatment failure in CAP. 3 In our article, 1 we clearly pointed out that our study was not powered to detect a survival difference. Nevertheless, we found that only 4 of 200 patients (2%) in the 3-step group and 2 of 201 patients (1%) in the usual care group died. Importantly, no patient died during the 30-day follow-upperiodafterdischarge.However,itshouldbenoted that patients receiving usual care were more likely to experience adverse drug reactions, mainly phlebitis, probably related to the longer duration of intravenous antibiotic therapy in this group. Webelievethatapplyingthe3-stepcriticalpathway(early mobilizationanduseofobjectivecriteriaforswitchingtooral antibiotics and for deciding on hospital discharge) to the selected population analyzed is safe and effective and may allowcostsavings.Inthisregard,themostrecentInfectiousDiseasesSocietyofAmerica/AmericanThoracicSocietyConsensus

Short parenteral antibiotic treatment for adult septic arthritis after successful drainage

To assess the risk factors for recurrence of septic arthritis with an emphasis on the duration of antibiotic treatment, to gather data for a prospective study on an optimized antibiotic treatment in adults with septic arthritis. This was a retrospective single-center study conducted for the period 1996-2008. A total of 169 episodes of septic arthritis in 157 adult patients (median age 63 years; 65 females) were included. In 21 episodes (21/169, 12%), arthritis recurred after the end of antibiotic treatment. Multivariate analysis showed that Gram-negative infection (odds ratio (OR) 5.9, 95% confidence interval (CI) 1.4-25.3), immune suppression (OR 5.3, 95% CI 1.3-22.0), and lack of surgical intervention were associated with recurrence. The size of the infected joint, the number of surgical drainages (OR 1.3, 95% CI 1.0-1.7), arthrotomy vs. arthroscopic drainage (OR 0.5, 95% CI 0.2-1.8), duration of antibiotic therapy (OR 1.0, 95% CI 0.95-1.05), and duration of intravenous antibiotic therapy (OR 1.0, 95% CI 1.0-1.0) were not. Seven days of intravenous therapy had the same success rate as 8-21 days (OR 0.4, 95% CI 0.1-1.7) and >21 days (OR 1.1, 95% CI 0.4-3.1). Fourteen days or less of total antibiotic treatment had the same outcome as 15-28 days (OR 0.4, 95% CI 0.1-2.3) or >28 days (OR 0.4, 95% CI 0.1-1.6). In this retrospective study of adults with septic arthritis, the duration of antibiotic therapy, or an early switch from intravenous to oral administration, did not statistically influence the risk of recurrence. Due to study limitations, the data cannot be used directly for antibiotic therapy recommendations for septic arthritis. Prospective randomized trials are warranted to optimize the antibiotic treatment of septic arthritis.

Effect of a 3-Step Critical Pathway to Reduce Duration of Intravenous Antibiotic Therapy and Length of Stay in Community-Acquired Pneumonia

The length of hospital stay (LOS) for community-acquired pneumonia (CAP) varies considerably, even though this factor has a major impact on the cost of care. We aimed to determine whether the use of a 3-step critical pathway is safe and effective in reducing duration of intravenous antibiotic therapy and length of stay in hospitalized patients with CAP. We randomly assigned 401 adults who required hospitalization for CAP to follow a 3-step critical pathway including early mobilization and use of objective criteria for switching to oral antibiotic therapy and for deciding on hospital discharge or usual care. The primary end point was LOS. Secondary end points were the duration of intravenous antibiotic therapy, adverse drug reactions, need for readmission, overall case-fatality rate, and patients' satisfaction. Median LOS was 3.9 days in the 3-step group and 6.0 days in the usual care group (difference, -2.1 days; 95% CI, -2.7 to -1.7; P < .001). Median duration of intravenous antibiotic therapy was 2.0 days in the 3-step group and 4.0 days in the usual care group (difference, -2.0 days; 95% CI, -2.0 to -1.0; P < .001). More patients assigned to usual care experienced adverse drug reactions (4.5% vs 15.9% [difference, -11.4 percentage points; 95% CI, -17.2 to -5.6 percentage points; P < .001]). No significant differences were observed regarding subsequent readmissions, case fatality rate, and patients' satisfaction with care. The use of a 3-step critical pathway was safe and effective in reducing the duration of intravenous antibiotic therapy and LOS for CAP and did not adversely affect patient outcomes. Such a strategy will help optimize the process of care of hospitalized patients with CAP, and hospital costs would be reduced. isrctn.org Identifier: ISRCTN17875607.

Parotidite bactérienne aiguë chez les nourrissons de moins de 3 mois : étude rétrospective dans un centre hospitalier universitaire

Acute bacterial parotitis is a rare infectious disease in infants under 3 months of age.To describe the clinical characteristics and the course of acute bacterial parotitis in infants less than 3 months old.Infants under 3 months of age, hospitalized at Robert Debré university hospital, Paris, France, between January 2005 and December 2009 for acute bacterial parotitis, were included in a retrospective study.Five infants less than 3 months of age were included in this study, for a frequency of 2.5/1000 hospitalizations in this age group. All were born at term, 4 of 5 were male. Three of the 5 patients had specific clinical signs of parotitis on admission. One patient had septic shock on admission. The ultrasound confirmed the parotitis in all cases. No parotid abscess was demonstrated on imaging. All patients had at least one abnormal inflammatory biological test (WBC, CRP, PCT). Bacteria were identified in 4 of 5 cases: Staphylococcus aureus was isolated in the pus culture of the Stenon duct in 2 patients and a group B Streptococcus was isolated from blood culture of 2 other patients. The duration of intravenous antibiotic therapy varied from 4 to 13 days, and the total duration of antibiotic therapy was between 10 and 16 days. No surgical procedures were needed.Acute bacterial parotitis in infants under 3 months of age might be associated with localized infections due to S. aureus, but also with a more severe clinical presentation due to group B streptococcus infection. Early diagnosis and appropriate antibiotic therapy might prevent the progression to serious complications.

Baseline factors predicting the duration of intravenous antibiotic therapy for cellulitis in an outpatient setting

Baseline factors predicting the duration of intravenous antibiotic therapy for cellulitis in an outpatient setting

Duration of antibiotic therapy in hospitalised patients with community-acquired pneumonia

Recent guidelines suggest that duration of antibiotic therapy for hospitalized patients with community-acquired pneumonia (CAP) can be reduced by individualising treatment based on patient's clinical response. However, the degree of application of this principle in clinical practice is unknown. Duration of therapy was analysed in patients identified from the Community-Acquired Pneumonia Organization database and evaluated with respect to severity of the disease on admission and time to clinical stability (TCS). Among the 2,003 patients enrolled, mean duration of total antibiotic therapy was 11 days. Neither the pneumonia severity index (r(2) = 0.005) nor the CRB-65 (r(2) = 0.004) scores were related to total duration of therapy. Duration of intravenous antibiotic therapy was related to TCS (r(2) = 0.198). Conversely, TCS was not related to duration of either oral (r(2) = 0.014) or total (r(2) = 0.02) antibiotic therapy. Neither TCS nor other characteristics were found to be significantly associated with duration of total therapy by logistic regression analysis (r(2)<0.09). The individualised approach suggested by recent guidelines has not been adopted in current clinical practice. Duration of therapy is not influenced by either the severity of disease at the time of hospitalisation or the clinical response to therapy.

Medical vs surgical treatment for the native joint in septic arthritis: a 6-year, single UK academic centre experience

Medical treatment (serial closed-needle aspiration) and surgical treatment (arthroscopy/arthrotomy combined with joint washout) are well-recognized methods to treat septic arthritis (SA) of native joints. We compared the outcome of proven SA based on the method of treatment. We reviewed case notes of adult patients who were admitted to our institution from January 2001 to December 2006 with proven SA (Newman Grade A organism isolated from the joint). Thirty-two episodes were treated medically and 19 surgically (4 with arthrotomy, 15 with arthroscopy) in the study period. All had mono-articular SA. No significant difference in the age, symptom duration before treatment and duration of intravenous antibiotic therapy was present between the two groups. Medical treatment resulted in complete recovery in more patients (69 vs 53%, P = 0.24) but longer period of hospitalization [median (interquartile range), 16.5 (14-19) vs 15 (11-17), P = 0.34], although the difference between the groups was not significant. More surgically treated patients had deterioration in functional status at the time of discharge from the hospital (29 vs 44%, P = 0.27), but the difference between the groups was not statistically significant. Surgically treated patients required significantly more sessions of physiotherapy (mean +/- S.D., 7 +/- 2 vs 10 +/- 3, P = 0.002). Mortality was similar (one in each group). Results from this study show that for the native joint SA, surgical treatment was not superior to the medical treatment and, therefore, highlight the need for careful case selection for surgical intervention.

Infections rétro- et parapharyngées : vers une harmonisation des pratiques

To analyze the changes in the management of retropharyngeal and parapharyngeal infections and propose a decisional algorithm for their diagnosis and treatment.A retrospective survey was carried out in a tertiary care pediatric hospital between January 2001 and December 2005. All children aged less than 15 years and affected by a retro- or parapharyngeal infection were included. Clinical, biological, and radiological data, medical and surgical treatment, and complications were extracted from the review of medical charts. The results of the surgical findings were correlated with a cervical computed tomographic scan (CT scan).Thirty-one patients were included, 64.5% during the last 2 years of the study period. All children presented fever and a stiff neck. The pharyngeal examination revealed a retropharyngeal bulge in a quarter of the population and an upper respiratory tract infection was concomitant in 68% of cases. A CT scan was carried out in 29 of 31 children (93.5%), with the radiological diagnosis of an abscess in 16 children (55.2%), presuppurative adenitis in 8 children (27.6%), and cellulitis in 5 children (17.2%). The CT scan was performed within 0.75 days of admission in 2001 and 2.3 days in 2005. All children were treated with intravenous antibiotic therapy: an association of amoxicillin/clavulanic acid and an aminoglycoside in most cases. The mean duration of intravenous antibiotic therapy was 5.2 days. Seventeen patients (93.5%) underwent surgical drainage and purulent material was found in 82.3% of cases. The accuracy of the CT scan, confirmed by surgical finding of a purulent material, was 71.4% in correctly identifying an abscess. The mean duration of surgical treatment after admission increased from 1.7 days in 2001 to 3.3 days in 2005. The number of patients who underwent surgery was divided by a factor of 3 in the second period of the study. Two groups were compared: group A (n=12) treated with antibiotic therapy and group B (n=17) treated with antibiotics and surgical drainage. No significant difference was found between the two groups considering the duration of parenteral and oral antibiotic therapy, the standardization of cervical mobility, the mean time for apyrexia, and the length of hospitalization. There was one recurrence in group B 1 month later, and one case of sepsis in group A. None of the patients with retropharyngeal infection died.Without clinical evidence of severe sepsis, parenteral antibiotic therapy is recommended as the first-line treatment for children over 6 months of age presenting with retropharyngeal and parapharyngeal infections. If the clinical and/or biological conditions do not improve within 48-72h, a CT scan is indicated to assess the extent of infection and exclude complications. The decision to initiate surgical drainage depends on the patient's clinical status and the accessibility of the abscess.

Acute septic arthritis revisited: a prospective study in 93 patients correlating C-reactive protein levels with duration of intravenous antibiotic therapy, clinical and radiological outcomes

Septic arthritis is the most dreaded affection of the joints in children. Early diagnosis, urgent arthrotomy and intravenous antibiotic therapy, however, are essential factors in treatment of septic arthritis to prevent devastating complications. However, the optimal duration of intravenous antibiotic therapy for acute septic arthritis after surgical drainage is not well defined. We performed a prospective study in 93 patients with age less than 5 years who presented with acute septic arthritis and treated with arthrotomy and sequential antibiotic therapy based on determination of serial quantitative CRP levels correlating radiological and clinical outcome. Majority of the subjects (84%) had CRP values more than or equal to 96 mg/dl at the time of presentation. More than half of the subjects had CRP values reverted to normal by the seventh day of treatment. By the 21st day of treatment, all the subjects had CRP values at baseline levels. “The clinical and radiological outcome was excellent in 85% of the cases where the CRP normalized by 7 days compared to 25% where the CRP had not normalized by 21 days.” The difference was found to be statistically significant. We conclude from our study that CRP levels decreases consistently during the antibiotic therapy and patients in whom CRP values return to normal earlier have good clinical and radiological outcomes. We also conclude that intravenous antibiotics should be stopped and switched over to oral therapy once CRP levels return to normal in cases of acute septic arthritis.

Septic Arthritis After Arthroscopic Anterior Cruciate Ligament Reconstruction: A Retrospective Analysis of Incidence, Presentation, Treatment, and Cause

The purpose of this report is to summarize our experience in the diagnosis and management of septic arthritis after anterior cruciate ligament (ACL) reconstruction. A retrospective review was conducted of all the arthroscopic ACL reconstructions performed at our institution between 1997 and 2007. Postoperative septic arthritis occurred in 21 of 4,068 patients. The incidence, cause, presentation, laboratory results, and treatment of all infected patients were analyzed. The incidence of septic arthritis after ACL reconstruction was 0.52%. The most common symptoms of the infected patients were fever, swelling, severe pain, tenderness, and restricted motion. The erythrocyte sedimentation rate, C-reactive protein level, and fibrinogen level were markedly elevated. Microbiology showed that coagulase-negative Staphylococcus was the most common bacterium. Both conservative and operative treatments were effective, and no patient had the ACL graft removed. However, the conservative group had a longer recovery time and duration of intravenous antibiotic therapy. Septic arthritis after arthroscopic ACL reconstruction is a rare but potentially devastating complication. The correct diagnosis relies on clinical evaluation, laboratory tests, synovial fluid analysis, and bacterial culture. With early diagnosis and prompt treatment, the infection can be successfully eradicated. Our proposed treatment protocol is arthroscopic debridement and irrigation as quickly as possible, with retention of the ACL graft when it is still functional. Level IV, therapeutic case series.

Staphylococcal pyomyositis in a temperate region: epidemiology and modern management

To describe all cases of staphylococcal pyomyositis in the Geelong region of Victoria over 110 months, to estimate the incidence of this disease, and to describe the clinical outcomes and identify any predisposing factors. A prospective case series identified by clinical features (local pain and fever) and magnetic resonance imaging (MRI) findings (hyperintense signal on T2-weighted scan), among patients presenting to Geelong Hospital, Victoria between 1 April 1998 and 1 June 2007. Estimation of incidence, clinical course and identification of predisposing factors. We estimate an annual incidence of 0.5 cases per 100 000 person-years, and propose a recent history of vigorous exercise (six of 11 patients) and underlying skin condition (five of 11 patients) as possible predisposing factors. MRI showed eight patients had osteomyelitis and one had septic arthritis. All patients had bacteraemia and one had mitral valve endocarditis. The duration of intravenous antibiotic therapy varied between 4 and 12 weeks, and all patients were completely cured. Pyomyositis should be considered in patients presenting with local pain, fever, muscle tenderness, and a recent history of vigorous exercise or underlying skin condition. MRI may guide non-surgical management.

Impact of an Institution‐Specific Hospital‐Acquired Pneumonia Protocol on the Appropriateness of Antibiotic Therapy and Patient Outcomes

To evaluate the impact of a hospital-acquired pneumonia (HAP) protocol on appropriateness of empiric antibiotic therapy, antibiotic deescalation, antibiotic duration, patient mortality, and length of stay. Before- and after-study of protocol implementation. A 450-bed, academic medical center. One hundred consecutive patients with proven or suspected HAP. Implementation of an HAP protocol that was based on the 2005 American Thoracic Society-Infectious Diseases Society of America guidelines and included extensive education of clinicians and monitoring by pharmacists. Before protocol implementation, 50 patients with HAP were evaluated against protocol criteria. After protocol implementation, a second cohort of 50 patients with HAP was evaluated. Compared with the preprotocol group, implementation of the protocol led to an increase in both the proportion of patients who received appropriate empiric antibiotic coverage (17 [34%] vs 31 [62%] patients, p=0.005) and appropriate antibiotic deescalation (21 [42%] vs 36 [72%] patients, p=0.002) according to protocol recommendations but did not affect the appropriateness of empiric antibiotic therapy based on final lung culture data (34 [68%] vs 41 [82%] patients, p=0.11). Compared with the preprotocol group, use of the protocol decreased the duration of intravenous antibiotic therapy (median [range] 9 [2-21] vs 7 [1-16] days, p=0.024), was associated with a trend for a shorter duration of stay in the intensive care unit (median [range] 19 [2-57] vs 11 [3-76] days, p=0.065), and did not significantly affect mortality (5 [10%] vs 8 [16%] patients, p=0.37). Pharmacists performed 59 interventions to support the protocol in 29 patients in the postprotocol group, of which 48% were accepted. Implementation of an HAP protocol improved appropriate empiric antibiotic use and decreased the duration of antibiotic therapy without adversely affecting patient outcomes.