Parenteral Antimicrobial Use Research Articles

Challenges in the diagnosis and management of skin diseases in alpacas, goats, pigs, and sheep.

The primary aim of this article is to provide an overview of several selected skin conditions in livestock species. Topics include ectoparasites in alpacas, antler velvet in reindeer, immune-mediated disease in goats, ectoparasites in pigs, Culicoides allergic dermatitis and parapox infection in sheep. When dealing with skin disease in livestock, it is important to collect a detailed history and undertake a thorough clinical examination to include the axilla, groin, limbs and feet. While the diagnosis will often be anticipated from the history and presentation, it is important to consider a differential diagnosis list and appropriate diagnostic testing before embarking on a poly-pharmacy approach to "rule out" causes of disease. This is particularly important where morbidity is high and the livestock of perceived high value to the keeper/owner, such as goats and small-breed pigs, or when the skin condition is long standing/chronic. Ideally, the management plan should sequentially clarify the role of microbial infection and then ectoparasites before considering less common allergic and autoimmune conditions. Skin cytology is an invaluable in-house diagnostic method that can support the findings of culture. Taking skin samples for histopathology and possibly culture may prove valuable once other diagnostic methods have been explored. Given the need to protect the use of parenteral antimicrobials, topical antimicrobial therapies can be deployed successfully. The repeated use of macrocyclic lactones (avermectins) must be balanced in terms of the risks of promoting anthelmintic resistance versus controlling or eradicating the ectoparasites that have, ideally, been specifically identified.

Effects of population age structure on parenteral antimicrobial use estimations

Antimicrobial use (AMU) is conventionally reported as unadjusted defined daily doses (DDDs) or population-adjusted DDDs per 1000 inhabitants per day (DID). DID is frequently used to monitor national AMU trends, this metric does not intrinsically take temporal changes in population age structure into account. We examined the effects of population age structure on DID estimates of parenteral AMU in Japan, and predicted future trends in DDDs based on population projections. Parenteral AMU data from 2013 to 2018 were acquired from a national claims database. We assessed temporal trends in parenteral AMU by age group (children aged < 15 years, working-age persons aged 15–64 years, and older persons aged ≥ 65 years) using both DID and DDDs. In addition, we modeled DDD predictions based on age-specific population projections from 2019 to 2030. DID values for older persons were 8.08–10.15 times and 5.43–5.63 times higher than in children and working-age persons, respectively. DID was stable, but DDDs increased in older persons. The prediction models showed that DDDs will continue to increase until 2030 if DID remains steady or decreases. DID estimates were skewed by the older population. More rigorous antimicrobial stewardship efforts targeting geriatric care are needed to counter the aging-associated increase in AMU.

The Use of Topical Antibiotics Based on the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) Open Data in 2017

The national action plan on antimicrobial resistance (AMR) in Japan emphasizes the importance of understanding antimicrobial use (AMU). Some studies have been conducted on oral and parenteral AMU in Japan. However, there are few studies on the use of topical antimicrobials, such as in dermatology and ophthalmology. Therefore, the purpose of this study was to investigate the use of topical AMU in Japan. Data on AMU in dermatology and ophthalmology were obtained from the 2017 National Database of Health Insurance Claims and Specific Health Checkups of Japan Open Data. The number of dermatological products used was 58,396,530 in 2017. The proportions of betamethasone/gentamicin and gentamicin used were 50.5% and 16.7%, respectively, whereas that of the ingredient quantity in gentamicin was 7.8%. It has been suggested that topical AMU should be evaluated based on the number of products being used. The number of ophthalmological products used was 24,655,653 in 2017, and the proportion of quinolones used was 95.9%. The high prescription rate of quinolones may cause an increase in quinolone resistance in the ophthalmologic field. Topical AMU, which is a potential "blind spot" in the measures against AMR, needs to be continuously monitored, together with systemic AMU.

The effects of Japan’s National Action Plan on Antimicrobial Resistance on antimicrobial use

The aim of this study was to estimate the effects of Japan’s National Action Plan on Antimicrobial Resistance 2016–2020 (NAP) on antimicrobial use (AMU). Monthly AMU from January 2013 to December 2019 was calculated using sales data, and time-series charts of AMU were then created for the total antimicrobials and target drug categories shown in the NAP (oral cephalosporins, oral fluoroquinolones, oral macrolides, and parenteral antimicrobials). Twelve-month predictions were generated to evaluate AMU in 2020. The publication of the NAP was associated with an AMU reduction in total antimicrobials, cephalosporins, fluoroquinolones, and macrolides. Parenteral AMU showed an upward trend, although it was not significantly associated with the intervention effect. AMU reductions of 15.0% for total antimicrobials, 26.3% for cephalosporins, 23.5% for fluoroquinolones, and 24.6% for macrolides were predicted for 2020 relative to 2013. However, there was a predicted increase of 17.4% for parenteral AMU. While Japan’s NAP has contributed to the reduction in national AMU over the past 5 years, sustained action is still needed to further improve antimicrobial stewardship and promote countermeasures to antimicrobial resistance.

Benefits of a Pediatric Antimicrobial Stewardship Program in Antimicrobial Use and Quality of Prescriptions in a Referral Children's Hospital

To evaluate the results of the first 24months of a postprescription review with feedback-based antimicrobial stewardship program in a European referral children's hospital. We performed a pre-post study comparing antimicrobial use between the control (2015-2016) and the intervention periods (2017-2018) expressed in days of therapy/100days present. Quality of prescriptions was evaluated by quarterly cross-sectional point-prevalence surveys. Length of stay, readmission rates, in-hospital mortality rates, cost of systemic antimicrobial agents, and antimicrobial resistance rates were included as complementary outcomes. Total antimicrobial use and antibacterial use significantly decreased during the intervention period (P=.002 and P=.001 respectively), and total antifungal use remained stable. A significant decline in parenteral antimicrobial use was also observed (P<.001). In 8 quarterly point-prevalence surveys (938 prescriptions evaluated), the mean prevalence of use of any antimicrobial among inpatients was 39%. An increasing trend in the rate of optimal prescriptions was observed after the first point-prevalence survey (P=.0898). Nonoptimal prescriptions were more common in surgical than in medical departments, in antibacterial prescriptions with prophylactic intention, and in empirical more than in targeted treatments. No significant differences were observed in terms of mortality or readmission rates. Only minor changes in antimicrobial resistance rates were noted. Our antimicrobial stewardship program safely decreased antimicrobial use and expenditure, and a trend toward improvement in quality of prescription was also observed.

A register-based study on associations between vaccination, antimicrobial use and productivity in conventional Danish finisher pig herds during 2011 to 2014

Reduction of antimicrobial use (AMU) in pigs is a priority to counteract development of antimicrobial resistance in animal and human pathogens. However, there is concern that Danish pig producers complying with official AMU restrictions might experience reduced herd health and productivity in the future, if alternative strategies are not available. Vaccination has been suggested as a strategy to prevent disease and minimise the need for antimicrobial treatments. The aim of this register-based study was to assess the associations between data on vaccination, productivity and AMU in Danish finisher herds over a 4-year period following initiation of the Yellow Card, which is a restrictive AMU control scheme. For each of the years 2011 to 2014, sow herds were grouped according to purchase patterns regarding Porcine Circovirus Type 2 (PCV2) (use/no use). For the sow herds (N = 179–433), additional information of purchases of vaccines against Mycoplasma hyopneumoniae (MYC), Actinobacillus pleuropneumoniae (APP), Porcine Reproductive and Respiratory Syndrome virus (PRRS) and Lawsonia intracellularis (LAW) was included. By use of movement data, finisher herds receiving pigs from the sow herds were tracked and included in the analyses. Finisher herds (N = 40–62) with register data on productivity (i.e. average daily weight gain, feed conversion rate, mortality and lean meat percentage) and data on prescriptions of antimicrobials measured in Animal Daily Doses/100 finishers/day as well as the proportion of parenteral AMU treatments out of all treatments (AMU-ratio) were included. Univariable combinations were tested for statistically significant associations (P < 0.05) and included in multivariable linear mixed-effects model for each of the six outcome variables representing productivity (N=4) or AMU (N=2). Herd number was included as a random effect to account for the herds appearing more than once. The variables representing PCV2, enrolment in the Danish Specific Pathogen Free (SPF) system, year, herd type and herd size were included as potential confounders. Vaccination against PRRS and higher AMU for finishers were associated with increased lean meat percentage, potentially due to disease outbreaks resulting in reduced growth of the pigs and lower carcass weight at slaughter in herds with PRRS. None of the other types of vaccines was associated with any of the productivity outcomes. Vaccination against PCV2, PRRS and APP were associated with higher levels of AMU, and vaccination against LAW with a higher AMU-ratio. This may be explained as some farmers preferring to take action soon after observing disease problems. No association was found between vaccination against MYC and AMU. Herds enrolled in SPF had significantly higher average daily weight gain than non-SPF herds.

Regional Variation of Antimicrobial Use in Japan from 2013-2016, as Estimated by the Sales Data.

The National Action Plan on Antimicrobial Resistance in Japan aims to achieve a 50% reduction in the use of broad-spectrum oral antimicrobials (cephalosporins, macrolides, and quinolones) from 2013 to 2020. Based on the national sales data for antimicrobials, we estimated the regional antimicrobial use (AMU) from 2013-2016 and evaluated the differences in the use of broad-spectrum oral antimicrobials among three regions in which differences had been identified previously. The AMU was standardized based on the defined daily dose (DDD) and described as the DDDs/1,000 inhabitants/day (DID). Annual combined total oral and parenteral AMU during 2013-2016 was 14.9, 14.5, 14.7, and 14.6 DID, respectively. The change in mean ± standard deviation in the total AMU at the prefectural level was - 0.2 ± 0.8 DID. Among the 47 prefectures, decreasing trends were observed in 34, while in the remaining 13 prefectures increasing trends were recorded. In 2016, no significant differences in the mean usage of oral cephalosporins among the three regions were observed. The mean usage of oral macrolides in the eastern (4.1 DID) was significantly lower than that in the central region (4.7 DID) (p = 0.009) and the western (4.8 DID) (p = 0.002). The mean usage of oral quinolones in the western (3.2 DID) was significantly higher than that in the eastern (2.3 DID) (p ＜ 0.001) and central (2.7 DID) (p = 0.001) regions. To determine appropriate targets for the implementation of antimicrobial stewardship for reducting the use of broad-spectrum oral antimicrobials, further studies are required to identify the reasons underlying these differences.

The first report of Japanese antimicrobial use measured by national database based on health insurance claims data (2011\u20132013): comparison with sales data, and trend analysis stratified by antimicrobial category and age group

PurposeOur objective was to evaluate the utility of the national database (NDB) based on health insurance claims data for antimicrobial use (AMU) surveillance in medical institutions in Japan.MethodsThe population-weighted total AMU expressed as defined daily doses (DDDs) per 1000 inhabitants per day (DID) was measured by the NDB. The data were compared with our previous study measured by the sales data. Trend analysis of DID from 2011 to 2013 and subgroup analysis stratified by antimicrobial category and age group were performed.ResultsThere was a significant linear correlation between the AMUs measured by the sales data and the NDB. Total oral and parenteral AMUs (expressed in DID) were 1.04-fold from 12.654 in 2011 to 13.202 in 2013 and 1.13-fold from 0.734 to 0.829, respectively. Percentage of oral form among total AMU was high with more than 94% during the study period. AMU in the children group (0–14 years) decreased from 2011 to 2013 regardless of dosage form, although the working age group (15–64 years) and elderly group (65 and above years) increased. Oral AMU in the working age group was approximately two-thirds of those in the other age groups. In contrast, parenteral AMU in the elderly group was extremely high compared to the other age groups.ConclusionsThe trend of AMU stratified by antimicrobial category and age group were successfully measured using the NDB, which can be a tool to monitor outcome indices for the national action plan on antimicrobial resistance.

Use of parenteral antimicrobials in very small hospitals in inner Brazil: patterns, determinants, and opportunities for interventions in developing countries

Much of healthcare in developing countries takes place in small hospitals. Little is known about the use of antimicrobials in those settings. We studied the 60-day use of parenteral antimicrobials in 48 hospitals with up to 50 beds in inner Brazil. The overall use was 242.0 defined daily doses per 100 admissions, and broad-spectrum agents accounted for 26.8%. The existence of local guidelines, educational measures and restrictive policies for antimicrobial prescriptions, as well as infection control and microbiology resources, were significantly associated with lesser use. Those findings point to possible interventions aimed at preventing antimicrobial over-use in developing countries.

Age-specific Distribution of Antimicrobial Use Surveillance using National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB Japan) 2011–2013

BackgroundAntimicrobial use (AMU) surveillance is one of the key actions in the Japanese national plan on antimicrobial resistance (AMR). National database of health insurance claims and specific health checkups of Japan (NDB), which archives e-claim big data, is one candidate for their data source, since universal healthcare system is established in Japan and e-claim data covers almost all citizens. However, no study has been performed using NDB for assessing AMU. Our objective was to analyze the quantities and patterns of total systemic antibiotic prescriptions using NDB and to evaluate its utility.MethodsThe data were analyzed in accordance with the Anatomical Therapeutic Chemical (ATC) classification using defined daily dose (DDD) as a measurement unit, as recommended by the WHO Collaborating Centre for Drug Statistics Methodology. The population-weighted total consumption was normalized and expressed as defined daily doses (DDDs) per 1000 inhabitants per day (DID). Trend analysis of DID from 2011 to 2013 and subgroup analysis stratified by age group (0–14, 15–64, 65 and above years old), and ATC classification were performed.ResultsThe DID value of oral antimicrobial use in 2013 was 13.2, which was a 1.04-fold increase in comparison with that in 2011. The DID value of parenteral antimicrobial use in 2013 was 0.83, which was a 1.13-fold increase in comparison with that in 2011. The DID value of each antibiotics category calculated using the NDB was comparable to that calculated using sales data in our previous study (J Glob Antimicrob Resist.7:19–23, 2016), suggesting that the NDB is useful for analyzing the quantities and patterns of total systemic antibiotic prescription. AMU in those under 15 years old decreased from 2011 to 2013 regardless of dosage form, although those in the other age groups increased. While third-generation cephalosphorins were the most frequently used oral antibiotic subgroups in those under 15 years old, macrolides were the most frequently used oral antibiotic subgroups in the other age groups.ConclusionThis is the first report evaluating age-specific distribution of AMU in Japan from 2011 to 2013 using the NDB. These results demonstrated the utility of AMU surveillance using the NDB as a tool and benchmark to assess the AMR action plan.Disclosures All authors: No reported disclosures.

Reducing Antimicrobial Use in an Academic Pediatric Institution: Evaluation of the Effectiveness of a Prospective Audit With Real-Time Feedback

Antimicrobial use is decreasing across freestanding children's hospitals, predominantly in institutions with antimicrobial stewardship programs (ASPs) in place. A highly effective ASP should effect a greater decrease in use than predicted by existing trends. Antimicrobial stewardship programs depend on clinician adherence to program recommendations, but little is known about factors associated with adherence. Parenteral antimicrobial-use data for our institution and 43 additional freestanding children's hospitals were obtained and normalized for patient census. Segmental linear regression was used to compare rates of change of parenteral antimicrobial use before and after ASP implementation. Time-series models were developed to predict use in the absence of intervention. The odds of adherence to ASP recommendations were determined based on provider characteristics and recommendation type. In the 38 months before ASP implementation, parenteral antimicrobial use was decreasing at our hospital by 3.7%/year, similar to the 3.4%/year found across children's hospitals. The rate of change after implementation of the ASP at our hospital was 11.1%/year, compared to 5.6%/year for other hospitals over the same period. Of 643 interventions, teams adhered with recommendations in 495 cases (77.0%). According to adjusted analysis, primary service was not associated with adherence (P = .356). There was an association between adherence and the role of the clinician receiving a recommendation (P = .009) and the recommendation type (P = .009). Understanding factors associated with adherence to ASP recommendations can help those who administer such programs to strategize interventions for maximizing efficacy. Our findings reveal the value of a formal ASP in reducing use when controlling for secular trends.

Antimicrobial Use in Outpatient Hemodialysis Units

To quantify and characterize overall antimicrobial use, including appropriateness of indication, among patients receiving chronic hemodialysis. Retrospective and prospective observational study. Two outpatient hemodialysis units. All patients receiving chronic hemodialysis. The rate of parenteral antimicrobial use (number of doses per 100 patient-months) was calculated retrospectively from September 2008 through July 2011. Indication and appropriateness of antimicrobial doses were characterized prospectively from August 2010 through July 2011. Inappropriate administration was defined as occasions when criteria for infection based on national guidelines were not met, failure to choose a more narrow-spectrum antimicrobial on the basis of culture data, or occasions when indications for surgical prophylaxis were not met. Over the 35-month retrospective study period, the rate of parenteral antimicrobial use was 32.9 doses per 100 patient-months. Vancomycin was the most commonly prescribed antimicrobial, followed by cefazolin and third- or fourth-generation cephalosporins. Over the 12-month prospective study, 1,003 antimicrobial doses were prescribed. Among the 926 (92.3%) doses for which an indication for administration was available, 276 (29.8%) were classified as inappropriate. Of these, a total of 146 (52.9%) did not meet criteria for infection, 74 (26.8%) represented failure to choose a more narrow-spectrum antimicrobial, and 56 (20.3%) did not meet criteria for surgical prophylaxis. The most common inappropriately prescribed antimicrobials were vancomycin and third- or fourth- generation cephalosporins. Parenteral antimicrobial use was extensive, and as much as one-third was categorized as inappropriate. The findings of this study provide novel information toward minimizing inappropriate antimicrobial use.

Parenteral versus Oral Administration of Systemic Antimicrobials in European Nursing Homes

Residents in long-term care facilities are predisposed to healthcare-associated infections that are likely caused by antimicrobial-resistant micro-organisms. Long-term care facilities are increasingly able to offer parenteral antimicrobial treatment but there are few data on the use and appropriateness of such treatment in this setting. Information on the use of parenteral antimicrobials and associated factors in long-term care facilities is necessary to assess the risks and benefits of this treatment and to support the development of antimicrobial policies aimed at minimizing the emergence and spread of antimicrobial resistance. The aim of this study was to describe the extent of parenteral and oral antimicrobial use in participating European nursing homes (NHs) and to analyse the resident characteristics and determinants associated with route of antimicrobial administration. Data on resident characteristics and antimicrobials were collected by means of a point-prevalence survey. Logistic regression was used to analyse the data. Based on data from 21 European countries for 2046 antimicrobial prescriptions, an average of 9.0% (range by country: 0.0-66.7%) of treatment was administered parenterally. Multivariate analysis showed that residents receiving parenteral antimicrobials had greater morbidity, such as increased risk of having a urinary catheter (p < 0.001), a vascular catheter (p < 0.001), impaired mobility (p = 0.007) and disorientation (p = 0.005). Residents receiving parenteral antimicrobials also had been admitted more recently into the NH (p = 0.007). Empirical treatment of respiratory tract infections (RTIs) accounted for the majority of parenteral antimicrobials, while prophylaxis of urinary tract infection (UTI) was the most common indication for oral antimicrobials. Beta-lactam antibacterials (cephalosporins and aminopenicillins) were the predominant classes used. Our study showed that risk and care-load factors (i.e. the presence of a urinary or vascular catheter, impaired mobility, disorientation and relatively short length of stay) were associated with parenteral administration of antimicrobials in NHs. Furthermore, both the indication and the class of antimicrobial agent used were associated with administration route. For empirical treatment of RTIs, antimicrobials were most often administered parenterally.

The effect of intravenous-to-oral switch guidelines on the use of parenteral antimicrobials in medical wards.

The effect of an intravenous (i.v.)-to-oral switch policy on antibiotic prescribing in general medical wards was examined. Three audits, each of 2 months' duration, were carried out to examine the duration of i.v. therapy and length of patient stay. The first audit (S1) was performed before the introduction of switch guidelines, the second (S2) after guidelines had been placed in patient case-notes and the third (S3) after the guidelines had been introduced into the drug charts. The duration of i.v. therapy was significantly shorter in the S3 group (mean = 3.7 days) than in the S2 or S1 groups (mean 4.4 and 4.35 days, respectively) (P < 0.05). There was no significant difference in the length of patient stay between the three audit periods but the stay was significantly shorter in 81 switched patients (mean duration = 8.9 days) than in matched controls (mean duration = 12.6 days) (P = 0.01). Fewer patients with respiratory infection were treated for > 24 h with i.v. antimicrobials in the S3 audit period (75/549) than in the S2 (85/372) and S1 audits (83/326) (P < 0.01). The introduction of switch guidelines to drug charts reduces the length of i.v. therapy. Switched patients spend less time in hospital than their matched controls.

The costs of burn care: an analysis with an emphasis on the use of parenteral antimicrobials.

Because infection is a common cause of morbidity and mortality in patients with burns and intensive antibiotic therapy is often required, the focus of this study was to describe the patterns of use and costs of parenteral antibiotics in a burn unit. The study also evaluated the overall economics of burn care in our population. Forty-one percent of the study group received parenteral antimicrobial agents; the specific agents, indications, and costs are described. The costs of parenteral antibiotics made up a negligible 1.2% of hospital costs and only 12.4% of pharmacy costs. This study revealed the continued hospital losses related to the reimbursement system used by diagnosis-related groups for patients with Medicare. If all patients studied (n = 61) were reimbursed under diagnosis-related groups the unit would have experienced an annual loss of approximately 1.2 million dollars. If specialized burn care facilities are to remain, it may be necessary to reevaluate the appropriateness of the diagnosis-related group reimbursement system for burn-related injury. This is especially important if all third-party reimbursement sources consider conversion to this system of compensation.

Intervention to Discontinue Parenteral Antimicrobial Therapy in Hospitalized Patients with Urinary Tract Infection, Skin and Soft Tissue Infection, or No Evident Infection

AbstractObjectives:In a previous study, we found that unsolicited recommendations to physicians of medically stable patients with pneumonia to suspend parenteral antimicrobials shortened hospital length of stay (LOS) significantly. In this study, we made similar recommendations to physicians treating patients with different indications for parenteral antimicrobials, to examine the effect on LOS.Methods:A nurse-interventionist presented randomly assigned physicians with nonconfrontational suggestions to discontinue parenteral antimicrobials by substituting comparable oral antimicrobials or stopping treatment. Patients were being treated for urinary tract infection, skin infection, or no evident infection. Blinded observers evaluated in-hospital and 30-day postdischarge patient courses. Methodologies were identical to the previous study.Results:There were 70 physician-patient episodes (49 intervened episodes, 21 control episodes). In 44 episodes (90%), compliant physicians discontinued parenteral antimicrobials. Compared to a median postrandomization LOS of 2.5 days (range, 0 to 40.5) for 21 patients of control physicians, the corresponding LOS for 44 patients of compliant physicians was two days (range, 0 to 8; P= 1.0), and for five patients of noncompliant physicians, five days (range, 3 to 11; P= 0.04).The combined occurrence of all adverse events detected in this and the previous study was 11% for patients of control physicians, compared to 14% for patients of compliant physicians (P= 0.2), and 19% for patients of noncompliant physicians (P&lt;0.05).Conclusions:For patients of compliant physicians hospitalized with urinary tract infection, skin and soft tissue infection, or no evident infection, cessation of parenteral antimicrobials did not significantly shorten LOS, due to brief LOS of patients of control physicians. Patients of noncompliant physicians experienced more adverse events and prolonged LOS. The appropriateness of routine continuous use of parenteral antimicrobials in medically stable inpatients is questioned.

Comparative Clinical, Microbiologic, and Economic Audit of the Use of Oral Ciprofloxacin and Parenteral Antimicrobials

To examine the use of oral ciprofloxacin and parenteral antimicrobials in the treatment of acute infection (respiratory tract, urinary tract, blood) in hospitalized patients, with particular reference to severity of infection, outcome, and associated economic implications of each treatment. A prospective, multicenter comparative audit was conducted in the UK over an 18-month period. The audit was undertaken by clinical pharmacists who reviewed the antimicrobial treatment of patients with infective episodes, who were receiving or could have received oral therapy. Clinical pharmacists who collated the data all are employed in teaching hospitals. Patients were identified for analysis by their type of infection, severity of illness, antimicrobial prescribed, route of administration, and response to therapy. Additionally, data on costs of the antimicrobials prescribed and the supplementary costs of drug administration were calculated. Four hundred eighty-five patients were enrolled for analysis; 208 of the patients had respiratory tract infection, 112 had urinary tract infection, 138 had septicemia, and 27 had mixed infections. Sepsis scores were applied to 152 patients receiving oral ciprofloxacin and 333 patients receiving parenteral antimicrobials and yielded mean scores of 5.9 (SD 3.1, range 1-13) and 8.7 (SD 4.2, range 1-22), respectively. Of 485 patients, 188 were paired according to sepsis score results and route of administration. Resolution occurred in 133 patients (79 receiving oral and 54 receiving parenteral therapy), further therapy was required in 49 (11 oral and 38 parenteral), and treatment was withdrawn in 6 (4 oral and 2 parenteral). Microbiologic assessment yielded positive results in 227 patients (47 percent). Drug acquisition costs (based on 1 UK pound = 1.80 US $) per course of treatment were $47.23 (SD $38.32, range 5.40-218.70) for the oral group and $173.70 (SD 209.77, range 2.11-1021.40) for the parenteral group. Overall costs for treatment courses were $74.00 (SD $52.81, range 8.10-309.17) and $305.59 (SD $304.70, range 14.69-1345.00) for the two groups, respectively (p < 0.001). This study suggest that, in patients with moderate infective episodes, oral ciprofloxacin may reduce overall treatment costs compared with the use of parenteral antimicrobial agents.