Intravenous Antibiotics In Patients Research Articles

Using Behavioral Insights to Strengthen Strategies for Change. Practical Applications for Quality Improvement in Healthcare.

For over 30 years, quality improvement (QI) methods have been used as a means of increasing the quality and safety of healthcare services, but with mixed success. One explanation highlighted in the literature for this outcome is the overemphasis on technical elements of change, and a failure to fully appreciate the human side of change. Behavioral insights (BI) is an approach that utilizes knowledge and tools from a broad range of scientific disciplines, such as neuroscience and behavioral psychology, to support behavior change. The aim of this paper is to explore the possibility of supplementing QI methods with tools and understanding from BI. We outline a practical case that involved applying aspects BI methods into a QI program aimed at reducing the use of intravenous antibiotics in patients accessing services at a busy university hospital in Copenhagen, Denmark. We exemplify how to use BI tools to guide the analysis of staff behaviors during standard clinical processes and develop targeted interventions aimed at increasing actions and behaviors more aligned to best clinical practice. Outcomes suggest that it is possible to combine the models and methods from BI and QI in a way that is helpful in focusing attention on the human side of change when developing strategies for change. Potential psychological barriers identified from the analysis included the following: 'default inertia,' 'decision complexity,' 'risk aversion,' and biases related to confidence, confirmation, and omission. Future quality improvement projects could benefit from integrating models and tools from BI to guide and support behavior change.

Efficacy and safety of adjunctive nebulized colistin sulfate for multidrug-resistant Gram-negative bacteria pneumonia: a retrospective comparative cohort study.

The incidence of multidrug-resistant Gram-negative bacteria (MDR-GNB) pneumonia has increased in the last decade. If antibiotics are given only through intravenous, the antibiotic concentrations in lung tissue will be insufficient. Recently, nebulized antibiotics have shown effectiveness as an adjunctive therapy with intravenous antibiotics for resistant strains. Therefore, the goal of this study was to assess the efficacy and safety of adjunctive nebulized colistin sulfate in combination with intravenous antibiotics in patients with MDR-GNB pneumonia. A total of 203 patients who were infected with MDR-GNB pneumonia were selected. Based on whether patients received nebulized colistin sulfate, patients were divided into 2 groups: the NCIA group (nebulized colistin sulfate in combination with intravenous antibiotics) and the IA group (intravenous antibiotics without nebulized colistin sulfate). After propensity score matching (PSM) analysis, we compared the efficacy in terms of favorable clinical outcomes, the bacteria detection rate, days of hospital stay, days of intensive care unit (ICU) stay, days of mechanical ventilation (MV), antipyretic time, days of antibiotic therapy, and 28-day all-cause mortality. Safety was also compared between groups. A total of 116 patients met the criteria for evaluation, with 46 patients in the NCIA group and 70 patients in the IA group. After PSM, 31 patients were selected from each group. There were significant differences in favorable clinical outcomes on days 7 (67.7% vs. 32.3%, P=0.005) and 14 (71% vs. 41.9%, P=0.045) and the bacteria detection rate on days 7, 14, and the last day. There were also significant differences in days of hospital stay (17 vs. 23 days, P=0.01), antipyretic time (0.5 vs. 7.5 days, P=0.037), and days of antibiotic therapy (14 vs. 23 days, P=0.002). However, there were no significant differences in days of ICU stay, days of MV, and 28-day all-cause mortality. For nephrotoxicity, the NCIA group did not increase the risk of acute kidney injury (16.1% vs. 9.7%, P=0.707), only one patient (3.2%) in the NCIA group developed airway hyperresponsiveness (P=1.000). For MDR-GNB pneumonia, nebulized colistin sulfate as an adjuvant supportive treatment for intravenous antibiotics maybe can improve clinical efficacy and has high safety.

Adherence to National Antimicrobial Guidelines in Hospitalized Geriatric Patients with Community-Acquired Pneumonia: A Prospective Observational study in a Malaysian Hospital

The evaluation of disease progression and onsite therapeutic care choices for community-acquired pneumonia (CAP) patients is vital for their well-being and the optimum utilization of healthcare resources. The current study was conducted to assess physicians’ adherence to clinical practice standards and antibiotic prescribing behavior for the treatment of CAP in older people. A prospective study that included 121 consecutive patients admitted for CAP was conducted at Kulim Hospital, Kedah, from March 2020 to August 2020. Medical records including demographic data, comorbidity, physical examination, laboratory or radiologic findings, and drugs used for the treatment of CAP were accessed from bed head tickets (BHT). The mean age for patients was 73.5 ± 6.2 years, 73 (60.3%) and 48 (39.6%) were males and females, respectively. Amoxicillin/clavulanate (19.8%) was the most prescribed antibiotic for non-severe pneumonia followed by ampicillin sodium/sulbactam sodium (6.6%), while in patients with severe CAP beta-lactam + beta lactamase inhibitors (BLIs) with a combination of macrolide were the most common antibiotics prescribed either in patients with (21.4%) or without co-morbidities (8.2%). The average length of stay in the hospital with severe pneumonia was 6–7 days for 23.9% of patients and < 5 days for 21.4% of patients. The duration of intravenous antibiotics in patients with severe pneumonia was 6–7 days for 32.2% of patients. The present findings revealed the adherence of antibiotic prescribing practices to the Malaysian National Antimicrobial Guideline 2019 for CAP therapy among geriatric patients and adherence to the CAP criteria for hospital admissions.

The Effect of Adjunctive Antibiotic Oral Therapy on the Recurrence of Infective Endocarditis After Valve Surgeries

Adjunctive oral antibiotics following intravenous antibiotics are administered after valve surgery in some patients with active infective endocarditis (IE); however, little is known about their efficacy. Therefore, we evaluated the effect of adjunctive antibiotic oral therapy after IE surgeries. Between 2009 and 2017, 585 patients underwent valve surgery for left-sided active IE at 14 hospitals. Patients who died during hospitalization or transferred with intravenous antibiotics were excluded. Of the remaining 460 patients, 239 were treated with oral antibiotics at discharge (group O) and 221 did not take the oral antibiotic (group N). The primary outcome was all-cause mortality. Secondary outcomes were the recurrence of IE and a subset analysis of it. The 2 groups had similar background, postoperative inflammatory responses, and an almost similar duration of postoperative intravenous antibiotics. The overall survival rates at 1 and 5 years were 96% and 88% in group O and 92% and 84% in group N, respectively (P = 0.425). The rates of freedom from the recurrence of endocarditis at 1 and 5 years were 98% and 94% in group O and 97% and 93% in group N, respectively (P = 0.309). In chronic hemodialysis patients, the rates of freedom from the recurrence were significantly higher in group O than in group N (1 year: 100% vs 87.5%; 5 years: 95% vs 69%, P = 0.022). Adjunctive oral antibiotics following intravenous antibiotics in patients with active IE after valve surgery did not affect the overall survival and recurrence of IE, except in chronic hemodialysis patients.

Time-to-use of Intravenous Antibiotics in Patients with Sepsis in whom Activation of the Sepsis Fast Track Protocol was Facilitated by the National Early Warning Score

Time-to-use of Intravenous Antibiotics in Patients with Sepsis in whom Activation of the Sepsis Fast Track Protocol was Facilitated by the National Early Warning Score

Short-course antibiotic regimen compared to conventional antibiotic treatment for gram-positive cocci infective endocarditis: randomized clinical trial (SATIE)

BackgroundMost serious complications of infective endocarditis (IE) appear in the so-called “critical phase” of the disease, which represents the first days after diagnosis. The majority of patients overcoming the acute phase has a favorable outcome, yet they remain hospitalized for a long period of time mainly to complete antibiotic therapy. The major hypothesis of this trial is that in patients with clinically stable IE and adequate response to antibiotic treatment, without signs of persistent infection, periannular complications or metastatic foci, a shorter antibiotic time period would be as efficient and safe as the classic 4 to 6 weeks antibiotic regimen.MethodsMulticenter, prospective, randomized, controlled open-label, phase IV clinical trial with a non-inferiority design to evaluate the efficacy of a short course (2 weeks) of parenteral antibiotic therapy compared with conventional antibiotic therapy (4–6 weeks).Sample: patients with IE caused by gram-positive cocci, having received at least 10 days of conventional antibiotic treatment, and at least 7 days after surgery when indicated, without clinical, analytical, microbiological or echocardiographic signs of persistent infection. Estimated sample size: 298 patients. Intervention: Control group: standard duration antibiotic therapy, (4 to 6 weeks) according to ESC guidelines recommendations. Experimental group: short-course antibiotic therapy for 2 weeks. The incidence of the primary composite endpoint of all-cause mortality, unplanned cardiac surgery, symptomatic embolisms and relapses within 6 months after the inclusion in the study will be prospectively registered and compared.ConclusionsSATIE will investigate whether a two weeks short-course of intravenous antibiotics in patients with IE caused by gram-positive cocci, without signs of persistent infection, is not inferior in safety and efficacy to conventional antibiotic treatment (4–6 weeks).Trial registrationClinicalTrials.gov Identifier: NCT04222257 (January 7, 2020).EudraCT 2019–003358-10.

Oral vs Intravenous Antibiotics for Patients With Klebsiella pneumoniae Liver Abscess: A Randomized, Controlled Noninferiority Study.

Klebsiella pneumoniae liver abscess (KLA) is emerging worldwide due to hypermucoviscous strains with a propensity for metastatic infection. Treatment includes drainage and prolonged intravenous antibiotics. We aimed to determine whether oral antibiotics were noninferior to continued intravenous antibiotics for KLA. This noninferiority, parallel group, randomized, clinical trial recruited hospitalized adults with liver abscess and K. pneumoniae isolated from blood or abscess fluid who had received ≤7 days of effective antibiotics at 3 sites in Singapore. Patients were randomized 1:1 to oral (ciprofloxacin) or intravenous (ceftriaxone) antibiotics for 28 days. If day 28 clinical response criteria were not met, further oral antibiotics were prescribed until clinical response was met. The primary endpoint was clinical cure assessed at week 12 and included a composite of absence of fever in the preceding week, C-reactive protein <20 mg/L, and reduction in abscess size. A noninferiority margin of 12% was used. Between November 2013 and October 2017, 152 patients (mean age, 58.7 years; 25.7% women) were recruited, following a median 5 days of effective intravenous antibiotics. A total of 106 (69.7%) underwent abscess drainage; 71/74 (95.9%) randomized to oral antibiotics met the primary endpoint compared with 72/78 (92.3%) randomized to intravenous antibiotics (risk difference, 3.6%; 2-sided 95% confidence interval, -4.9% to 12.8%). Effects were consistent in the per-protocol population. Nonfatal serious adverse events occurred in 12/72 (16.7%) in the oral group and 13/77 (16.9%) in the intravenous group. Oral antibiotics were noninferior to intravenous antibiotics for the early treatment of KLA. NCT01723150.

Management of Hospital In The Home (HITH) Peripherally Inserted Central Catheters: A Retrospective Cohort Study

Worldwide, there has been a shift in health care delivery, with an increasing emphasis on avoiding hospital admissions and providing treatment such as intravenous antibiotics for patients at home, using peripherally inserted central catheters (PICCs). However, there is inadequate data to demonstrate if rates of PICC failure are similar for hospital inpatients, currently understood to be between 7% and 36%, than those cared for at home. The objective of this study was to identify prevalence, dwell time, and complications associated with PICCs in the home setting. This single-center, retrospective cohort study of adults treated by the “Hospital in the Home” (HITH) program in Queensland, was conducted between June 1, 2017 and June 15, 2018. Clinical data were collected for patient and PICC characteristics. Variables were described as frequencies and proportions, means and standard deviations, or medians and interquartile ranges. In total, 304 patients treated by HITH during this timeframe, and 164 (54%) patients with 181 PICCs were included in this study. These patients were predominately male (n = 105, 64%), with a mean age of 54 years. The most common reason for admission was a wound infection and/or bone infection (n = 120, 33%). Most PICCs were single lumen (n = 120; 67%), inserted in the basilic vein (n = 137; 80%) by nurses (n = 122; 67%). Peripherally inserted central catheter failure occurred in 10% (n = 19); the most common complications were dislodgement (n = 9; 5%) and thrombosis (n = 4; 2%). There were no confirmed catheter-related blood stream infections. Peripherally inserted central catheter failure rates are similar between hospitalized inpatients and those cared for at home.

Does Utilisation of Hospital in the Home Services Reduce the Length of Admission for Patients With Infective Endocarditis

Background: Infective endocarditis (IE) is a common pathology requiring admission to hospital. The length of stay in these patients can often be prolonged due to the need for prolonged courses of intravenous antibiotics. This can be associated with poor outcomes for the patient due to medical complications of prolonged hospital stay as well as increase the costs to the healthcare system. One way of reducing length of stay is utilising hospital in the home (HITH) services for administration of intravenous antibiotics in patients who are otherwise stable and can be discharged home safely, but still require completion of several weeks of antibiotics. The aim of this audit was to assess in what percentage of patients HITH services were utilised and whether this led to a reduction in length of stay. Methods: A retrospective analysis of patients with a diagnosis of infective endocarditis over a 19-month period (July 2016-January 2018) at our institution was performed. Data collected: Utilisation of HITH, length of stay, number of readmissions. Results: A total of 130 patients had a diagnosis of infective endocarditis. Of these 21 (16.1%) patients had a stay >30 days (range 1–62) and 44 patients were readmitted to hospital with 27.3% having no more than 1 readmission. 42 patients (32.3%) were discharged to HITH. The median (and mean ± SD) LOS for the HITH vs non-HITH patients were 16 (19.5 ± 13.4) vs 14 (17.0 ± 12.7) days respectively. Conclusions: Outcomes following IE are complex. Further investigation of the patient benefit, health service utilisation and barriers of HITH for IE is warranted

Administration of intravenous antibiotics in patients with open fractures is dependent on emergency room triaging.

BackgroundRecent literature has demonstrated that emergent administration of antibiotics is perhaps more critical than even emergent debridement. Most recent studies recommend patients receive antibiotics no later than 1 hour after injury to prevent infection. The objective of this study is to evaluate the time to antibiotic administration after patients with open fractures arrive to a trauma center depending on triaging team.MethodsA retrospective study at a level 1 Trauma center from January 2013 to March 2015 where 117 patients with open fractures were evaluated. Patients who presented with open fractures of the extremities or pelvis were considered. Subjects were identified using Current Procedural Terminology (CPT) codes. Patients aged 18 and older were analyzed for Gustilo type, antibiotics administered in the emergency room (ER), presence of an antibiotic allergy, post-operative antibiotic regimen and number of debridements, among others. Additionally, whether a patient was triaged by ER doctors or trauma surgeons (and made a trauma activation) was evaluated. Outcome measurements included time to intravenous (IV) antibiotic administration and time to surgical debridement.ResultsPatients received IV cefazolin a median of 17 minutes after arrival. Eighty-five patients who were made trauma activations received cefazolin 14 minutes after arrival while 24 non-trauma patients received cefazolin 53 minutes after arrival (p = <0.0001). The median time to gentamicin administration for all patients was 180 minutes. Patients not upgraded to a trauma received gentamicin 263 minutes after arrival, while patients upgraded received gentamicin 176 minutes after arrival. There was no statistically significant difference between the timing to cefazolin or gentamicin based on Gustilo type.ConclusionsOverall, patients that arrive at our institution with open fractures receive IV cefazolin significantly faster when trauma surgeons evaluate the patient. Additionally, delays in gentamicin administration are demonstrated in both triaging groups. This is due to the fact that cefazolin is stocked in the hospital ER, while gentamicin is commonly not due to weight-based dosing requirements precluding a standard dose. Improvements can be made to antibiotic administration of non-trauma patients and those requiring gentamicin via improved education and awareness of open fractures.

Introducing outpatient parenteral antimicrobial therapy in a children's hospital.

Outpatient parenteral antimicrobial therapy (OPAT) offers an alternative to inpatient care for delivering intravenous antibiotics in patients' homes or in a day care clinic setting. It was first introduced in North America in the 1970s and has evolved over the years, starting with the adult population and now moving to the paediatric population ( Chapman 2013 ). OPAT has the potential to offer excellent, patient-centred, high-quality care to treat a wide variety of infectious conditions in patients who are medically stable and do not need hospitalisation. For children and young people OPAT has the potential for families to resume their normal lives: returning to work, school and home. Paediatric OPAT (P-OPAT) is being implemented across the UK, with five centres now established. This article reports on the implementation of P-OPAT at Sheffield Children's NHS Foundation Trust (Sheffield Children's) in June 2016, highlighting the challenges and successes.

A nurse-led protocol improves the time to first dose intravenous antibiotics in septic patients post chemotherapy.

Neutropenic sepsis is a time-dependent emergency with early interventions shown to improve outcomes. Broad spectrum intravenous antibiotic administration is the initial therapy in patients with suspected neutropenic sepsis. Compliance with early antibiotic administration in febrile neutropenia patients is poor. Innovations have been trialled to improve the time to first dose intravenous antibiotics in patients with suspected neutropenic sepsis. Consideration of extending first dose intravenous antibiotic prescribing to trained nursing staff may improve performance in this key standard. A retrospective analysis was performed at a specialist oncology hospital in the North West of England from January 1st 2015 to January 31st 2016. The nurses on the Medical Admissions Unit (MAU) have been given the responsibility of assessing patients presenting with fever post chemotherapy including prescribing and administering the first dose of intravenous antibiotics with the aim of improving the speed of this intervention. During the study period, 697 patients presented to the MAU with suspected sepsis post chemotherapy. Six hundred seventy-two (96.4%) patients received their first dose of intravenous antibiotics within 60min of presentation to the MAU. Of this group, 323 (48.1%) were administered antibiotics within 15min of arrival. Of the 25 (3.6%) patients who did not receive antibiotics within 1h, root cause analysis revealed the reason in 23 (92%) patients was an inability to ascertain intravenous access. Nurse-led protocols are an effective, safe, and sustainable method for achieving early antibiotic administration in patients with suspected febrile neutropenia. This is a key component of ensuring improved outcomes for this cohort of patients.

Nonoperative Management of a Multi-Regional Epidural Abscess with Neurological Dysfunction.

Spinal epidural abscesses are uncommon, but their incidence is increasing. They represent a collection of purulent material in the epidural space and most commonly occur in the lumbar spine, where they remain localised. Abscesses that affect all three spinal levels (holospinal or multiregional abscesses) are extremely rare, with only a few cases published in the literature. Epidural abscesses are particularly high risk infections as progressive neurological dysfunction can occur rapidly; early diagnosis and treatment is therefore essential to avoid long term neurological complications and reduce potential mortality. Given the uncommon nature of this condition, the treatment remains controversial with no definitive guidance on conservative versus surgical management. The literature mostly recommends surgical decompression along with intravenous antibiotics in patients with neurological abnormalities. We describe a case of a 77-year-old patient presenting with a delayed diagnosis of a multi-regional epidural abscess with associated upper motor neurone signs. The patient was successfully treated nonoperatively with a course of antibiotics resulting in complete radiological resolution of the abscess and full neurological recovery.

Adverse Drug Reactions of Long-term Intravenous Antibiotics in Patients with Pyogenic Spondylitis.

ObjectiveThe purpose of this study was to investigate the incidence, cause, and influence of the adverse drug reactions (ADRs) associated with long-term intravenous antibiotics in patients with pyogenic spondylitis (PS).MethodsWe retrospectively reviewed the medical records of 84 patients with PS who underwent intravenous antibiotic therapy in our hospital from January 2001 to December 2012. ADRs were categorized to drug eruption, acute renal failure (ARF), hematologic toxicity, toxic hepatitis, pseudomembranous colitis (PMC), drug fever, and neuronal toxicity. Incidence and onset time of each ADR after antibiotic therapy were analyzed with the incidence of ADRs according to types of antibiotics.ResultsADRs occurred in 38 of the 84 patients (incidence: 45.2%). The use of antibiotics was longer in the patients with ADRs (62.7 days) than in the patients without ADRs (44.3 day). The incidence of drug eruption, ARF, hematologic toxicity, toxic hepatitis, PMC, drug fever, and neuronal toxicity were 22.6, 11.9, 11.9, 10.7, 7.1, 3.6%, and 1.2%, respectively. The duration of antibiotics administration was related to the occurrence of PMC (p=0.001). ADRs were more common in patients treated by glycopeptides including vacomycin and teicoplanin.ConclusionThe incidence of ADRs due to long-term intravenous antibiotics was as high as 45.2% in patients with PS. Therefore, we speculate that the possibility of delayed ADRs should be considered after long-term use of the antibiotics. Furthermore, close observation is mandatory to identify and treat ADRs promptly, even though PS revealed the improvement after antibiotic therapy.

Dynamic vascular changes following intravenous antibiotics in patients with cystic fibrosis

BackgroundAdults with cystic fibrosis (CF) have altered large artery haemodynamics which is associated with a persisting systemic inflammatory state. We hypothesized that a short-term intervention favorably influencing the inflammatory status may modify their haemodynamic state. MethodsAdult patients with CF were studied immediately preceding and following 2weeks of intravenous antibiotics. Large artery haemodynamics, principally heart rate-adjusted augmentation index (AIx) were obtained. Blood pressure (BP), spirometry and CRP were also measured. ResultsComplete data was available for 15 patients; mean (SD) age 28 (6)years. CRP was reduced while FEV1% predicted improved. Following treatment AIx was lower: 10.9 (10.9)% to 8.1 (10.9)% (p<0.05) while BP was similar and a trend toward lower heart rate (p=0.06). Change in AIx was related to baseline FEV1% predicted (r=0.77) and BMI (r=0.71) (both P<0.01). ConclusionThe abnormal central haemodynamics evident in adults with CF is modulated with a short intervention of intravenous antibiotics.

The efficacy of trovafloxacin versus ceftriaxone in the treatment of experimental brain abscess/cerebritis in the rat

Current estimates of the mortality associated with brain abscesses range from 0–24%, with neurological sequellae in 30–55% of survivors. Although the incidence of brain abscess appears to be increasing, likely due to an increase in the population of immunosuppressed patients, the condition is still sufficiently uncommon to make human clinical trials of therapy problematic. An animal model to study the efficacy of new treatment regimens, specifically, new antimicrobial agents is therefore necessary. This study uses a well-defined experimental paradigm as an inexpensive method of inducing and studying the efficacy of antibiotics in brain abscess. The rat model of brain abscess/cerebritis developed at this institution was used to determine the relative efficacy of trovafloxacin as compared to ceftriaxone in animals infected with Staphylococcus aureus. S. aureus (≈10 5 CFU in 1 microliter) was injected with a Hamilton syringe, very slowly, over the course of 70 minutes after a two mm burr hole was created with a spherical carbide drill just posterior to the coronal suture and four mm lateral to the midline. Eighteen hours later treatment was begun; every 8 hours the rats were dosed with subcutaneous ceftriaxone ( n = 10), trovafloxacin ( n = 11) or 0.9% sterile pyogen-free saline ( n = 10). After four days of treatment the brains were removed and sectioned with a scalpel. The entire injected hemisphere was homogenized and quantitative cultures performed. The mean ± SEM log 10 colony forming units/ml S. aureus recovered from homogenized brain were as follows: controls 6.10 ± 0.28; ceftriaxone 3.43 ± 0.33; trovafloxacin 3.65 ± 0.3. There was no significant difference in bacterial clearance between ceftriaxone versus trovafloxacin (p = 0.39). Trovafloxacin or other quinolones may provide a viable alternative to intravenous antibiotics in patients with brain abscess/cerebritis.

Why is high-tech healthcare at home purchasing underdeveloped and what could be done to improve it?

Executive Letter (95)5 initiated a change of health policy preventing general practitioners (GPs) from prescribing packages of "high-tech healthcare at home" (HTHC). From 1 April 1995, district health authorities were required to establish contracts to purchase such care. Several reasons were behind this policy change including the belief that contracting would improve service quality by encouraging competition between potential suppliers, securing better value for money, and establishing service specifications and monitoring mechanisms. Our survey of 98 health authorities, however, highlighted that contracting for home total parenteral nutrition, intravenous antibiotics for patients with cystic fibrosis, intravenous chemotherapy and continuous ambulatory peritoneal dialysis is largely undeveloped. The majority of districts contracted with historic providers and authorities freely admitted that they did not know whether they were obtaining value for money or a service of adequate quality. Only three districts had developed a strategy for purchasing HTHC as required by the Executive Letter, and only 17 had plans to re-examine their approach. Contracting for HTHC presents practical problems, including the complexity of the process and the significant time demands for efficient and effective contracting. Phase two of this research sought to produce a "guide to good practice" for health authorities wishing to re-examine and improve their purchasing. We conducted case study analyses in districts that had made effective progress and those that had encountered difficulties, drawing upon lessons learned. We reported our findings to the NHS Executive and supplemented this with a "toolbox" that included sample documents covering areas such as tendering, monitoring mechanisms, service specifications and different purchasing approaches.

Improving the quality of pneumonia care that patients experience

PurposeAlthough many hospitals have reported attempts to reduce length of stay for patients hospitalized with community-acquired pneumonia, few have included efforts to educate patients to prepare them for earlier discharges. We aimed to improve patients’ knowledge about pneumonia and their experiences with inpatient care as part of a multifaceted intervention that included attempts to reduce unnecessary time on intravenous antibiotics and length of hospital stay. MethodsWe developed guidelines for the appropriate duration of intravenous antibiotics in patients with community-acquired pneumonia and collected baseline data retrospectively on patients discharged from October 1996 through April 1997. We surveyed these patients to assess knowledge and experience with care. Beginning in July 1997, we conducted a series of physician and nurse educational interventions (lectures, feedback of performance data, one-on-one education by peers). Patients received education about pneumonia from their nurses and a specially developed educational brochure. Following the interventions, we collected clinical and survey data on patients with pneumonia discharged from October 1997 through April 1998. ResultsAmong patients who responded to the survey (163 in the preintervention period; 114 in the postintervention period), fewer reported that no one went out of the way to help them (preintervention, 37% [n = 60]; postintervention, 6% [n = 7]; P = 0.001), more reported that they received all the information they needed to recover (75% [n = 122] vs. 94% [n = 107], P = 0.02), and more reported that they were told about danger signals of relapse (46% [n = 75] vs. 60% [n = 68], P = 0.03). Mean (± SD) time on intravenous antibiotics decreased from 5.0 ± 3.7 days to 4.3 ± 3.3 days (P = 0.04). ConclusionThe interventions improved patients’ knowledge and experiences with care, while decreasing time on intravenous antibiotics.

The incidence and significance of fevers during treatment with antithymocyte globulin for aplastic anaemia

Antithymocyte globulin (ATG) is a foreign protein used widely to treat aplastic anaemia (AA). Febrile reactions occurring during its administration may be impossible to distinguish clinically from fever due to sepsis, and are therefore routinely treated with intravenous antibiotics after collection of blood cultures. A statistically highly significant difference was found in positive blood cultures between 39 AA patients who developed fever during ATG therapy, and 38 febrile neutropenic patients with acute leukaemia. suggesting that most fevers developing during ATG treatment are not due to infection. It may therefore be reasonable to consider early discontinuation of intravenous antibiotics in patients who are clinically stable and have no proven sepsis.

Childhood osteomyelitis and septic arthritis.

The diagnosis, treatment, and monitoring of septic arthritis or osteomyelitis in children has become more streamlined in recent years. C-reactive protein appears to be a better laboratory study than sedimentation rate in the diagnosis of bone or joint infection and in monitoring a patient's clinical response to antibiotics. Oral antibiotics may be rapidly substituted for intravenous antibiotics in patients who have a identifiable sensitive organism, who show rapid clinical improvement, and who show rapid normalization of C-reactive protein. The physician must remain alert for resistant organisms, highly virulent organisms (post-varicella streptococcal infections) and rare organisms.