Antibiotic optimization. An evaluation of patient safety and economic outcomes

BACKGROUND: Although numerous reports have described interventions designed to influence antibiotic utilization, to our knowledge none have been evaluated in a randomized study. METHODS: Adult inpatients receiving 1 or more of 10 designated parenteral antibiotics for 3 or more days during a 3-month period were randomized to an intervention (n = 141) and a control (n = 111) group using an unblocked, computer-generated random number table. Obstetric patients and those seen in infectious disease consultation were excluded. The intervention group received antibiotic-related suggestions from a team consisting of an infectious disease fellow and a clinical pharmacist. Both groups were evaluated for clinical and microbiological outcomes as well as antibiotic utilization via prospective chart reviews and analysis of the hospital's administrative database. RESULTS: Sixty-two (49%) of the intervention group patients received a total of 74 suggestions. Sixty-three (84%) of these suggestions were implemented; the majority involved changes in antibiotic choice, dosing regimen, or route of administration. Per patient antibiotic charges were nearly $400 less in the intervention group vs controls (P = .05). Almost all the savings were related to lower intravenous antibiotic charges. Clinical and microbiological response, antibiotic-associated toxic effects, in-hospital mortality, and readmission rates were similar for both groups. Multiple linear regression analysis identified randomization to the intervention group and female sex as the sole predictors of lower antibiotic charges. There was a trend toward a shorter length of stay for the intervention group (20 vs 24.7 days, P = .11). CONCLUSIONS: This is the first randomized study to evaluate whether antibiotic choices can be influenced in a cost-effective fashion without sacrificing patient safety. We demonstrate that 50% of patients initially treated with expensive parenteral antibiotics can have their regimens refined after 3 days of therapy and that these modifications result in good clinical outcomes with a substantial reduction in antibiotic expense.     

The perioperative nurse's role in assisted-fertility procedures

Infertility is the inability to achieve pregnancy within a stipulated period of time (ie, one year) or the repeated failure to carry a pregnancy to term. Advances in assistive reproductive technology have enabled many couples to overcome infertility, but health care providers need to remember that these couples require much support. This article addresses the perioperative nurse's responsibilities during assisted-fertility procedures that are performed in the OR (eg, transvaginal oocyte retrieval, gamete intrafallopian transfer, zygote intrafallopian transfer.     

Critical controls for juice safety

Operations for ischemic heart disease complicated by the appearance of postinfarction left ventricular aneurysm were fulfilled on 94 patients. The modified operation after V. Dor used in 55 patients allowed fulfilling interventions on the damaged parts of the interventricular septum excluding the application of foreign patches. Intrahospital lethality was 7.6%.     

Nurse to patient ratios and patient outcomes

The findings of this study suggest that currently available data could be used to monitor changes and trends in nurse to patient ratios. A link was discovered between nurse staffing levels and patient readmission rates that has not been addressed in the literature, although this would require further investigation.     

Evaluation of variances in patient outcomes

New knowledge and understanding about improving the quality and reducing the costs of care will come from careful scrutiny of the variations in the outcomes of nursing interventions. Nurses need to systematically identify and measure outcomes, understanding the probabilistic nature of these patient responses to the care received. Using a formative evaluation process, nurses should measure degrees of patient outcomes over time to ascertain the effects of nursing care and analyze the variances in these observed outcomes from what was expected. Critical pathways are valuable tools for guiding evaluations of nursing care along a timeline and can lead to improvements in nursing care.     

RN first assistants expand their perioperative role

Aureobasidium pullulans, a yeast-like microorganism was found to produce mannobiose permease and xylobiose permease, transporting beta-1,4-mannobiose or beta-1,4-xylobiose into the cells from extracellular media. Both permeases are induced by the same inducers as the corresponding hemicellulolytic enzyme systems. Mannobiose permease is induced by beta-1,4-mannobiose or is formed in the cells growing on mannan (inducers of beta-mannanolytic enzymes) and xylobiose permease is induced by d-xylose, beta-1,4-xylobiose or during the growth on xylan (inducers of xylanolytic enzymes). The permeases are energy dependent, synthesized de novo and their activities are inhibited by d-glucose. Since mannobiose permease transports beta-1,4-mannobiose, xylobiose permease appears to be less specific and transports beta-1,4-mannobiose, beta-1,4-xylobiose and methyl beta-d-xylopyranoside. Methyl beta-d-mannopyranoside or methyl beta-d-xylopyranoside serve as less efficient inducers of the corresponding permeases than beta-1,4-mannobiose or beta-1, 4-xylobiose.     

Nurse staffing and patient outcomes

This pilot study examined prospectively blood serum concentrations of fluvoxamine, side effects and therapeutic response after a fixed dosage of 100 mg fluvoxamine/day for 14 days. Twenty male and female patients who met the DSM-IV criteria of a major depression received 50 mg fluvoxamine b.i.d. for two weeks. On days 7 and 14 side effects and therapeutic response were registered and serum concentrations of fluvoxamine were determined. A Receiver Operating Characteristic (ROC) curve was constructed to determine a possible relationship between serum concentrations and clinical effects. The serum concentrations of fluvoxamine were highly variable, even when dosages were corrected for body weight, ranging between 23 to 227 microg/l. No relationship between serum concentrations and side effects was detectable. On the other hand, ROC analysis, conducted on day 14, revealed a significant upper concentration threshold of 85 microg/l (p < 0.01) with no responder above this threshold. The results of this pilot study should be regarded as a hint at the possible therapeutic benefits of lower fluvoxamine serum concentrations by means of lower fluvoxamine dosages. Furthermore, this indicates for the first time that therapeutic drug monitoring might be useful for patients under antidepressant therapy with fluvoxamine.     

Audit of patient outcomes after herniorrhaphy

The efficacy of a surgical procedure is a measure of outcome when performed by specialists. The monotonous excellence of countless cohort studies bears witness to the efficacy of numerous techniques of herniorrhaphy. Effectiveness, however, is of far greater relevance to health care commissioners than efficacy. Audit is an instrument of effectiveness and can be further developed to study cost-effectiveness where outcomes do not differ greatly.     

Critical ovarian hyperstimulation syndrome in a coasted in-vitro fertilization patient

We report an instance of critical ovarian hyperstimulation syndrome in a highly responsive in-vitro fertilization patient despite the preventive measure of a 4 day 'coast' interval during which no gonadotrophins were administered while gonadotrophin-releasing hormone agonist therapy continued until serum oestradiol concentrations fell below 3000 pg/ml.     

Revising nursing documentation to meet patient outcomes

Often, complex documentation forms place unnecessary burdens on nurses. A change in one hospital's patient care forms contributes to positive outcomes. With the revised documentation, nurses spend more time caring for patients while still meeting the Joint Commission on Accreditation of Healthcare Organizations' requirements.     

Prophylactic perioperative treatment in a patient with colon carcinoma complicated by polycythemia vera

A patient with colon carcinoma complicated by polycythemia vera (PV) who underwent a partial colectomy concomitant with prophylactic perioperative treatment resulting in successful outcome is herein described. Seven weeks after the cessation of the latest exacerbation of PV, a partial colectomy was performed. In order to prevent the development of disseminated intravascular coagulation and thrombotic complications, the following perioperative treatment was performed: administration of gabexate mesilate (2,000 mg/day), fresh frozen plasma (300 ml/day), heparin (5,000 IU/day) for 7 days and anti-thrombin-III for 4 days, and a potent antibiotic therapy for 12 days and graded elastic bandages around the bilateral lower extremities for 14 days. As a result, an uneventful postoperative course was achieved. The present case suggests that these treatments are useful in the perioperative management of PV patients.     

Critical care management of the heart failure patient in the home

As part of a program to determine the underlying factors responsible for genotoxicity and perhaps lung cancer risk in Chinese women, we qualitatively identified the volatile components emitted during the heating of cooking oils to 265 degrees C. 1,3-Butadiene, benzene, and a series of aldehydes, olefins, and saturated hydrocarbons were elucidated in vapors from Chinese rapeseed oil. On a relative basis, the intensity of 1,3-butadiene vapors from this were 15.7-, 6.3-, and 1.4-fold greater than in the vapors from peanut, soybean, and Canola oils, respectively. Thus, the Chinese rapeseed oil yielded a higher emission rate of 1,3-butadiene than the other three oils investigated. The benzene formation rate followed a similar trend, i.e., its intensity in Chinese rapeseed oil was 14-, 6.6-, and 1.7-fold greater than in vapors from peanut, soybean, and Canola oils, respectively.     

Predictors of patient outcomes following interactions with nurses

A research and theory-based model was used to identify outcome predictors of hospitalized patients' perceptions of caring and support by nurses. The model tested the effects of cogent personal characteristics of patients (general level of self-esteem and need for control while hospitalized) on their perceptions of humanistic caring and support from nurses and, in turn, considered the effect of these variables on situational appraisal, coping strategies, psychological distress, and coping effectiveness. The 120 hospitalized adult patients indicated that the moderate amount of humanistic caring they received was beneficial. Several factors influenced caring ratings. Higher positive ratings were received from younger patients; however, people with low self-esteem and those desiring more control over their care or reporting a high degree of pain tended to perceive more threat and psychological distress as a results of their encounters with nurses. Following positive caring experiences with nurses, patients with higher self-esteem levels reported effective coping. Overall, positive caring experiences, along with coping strategies and decreased psychological distress levels, explained 40% of the variance of hospitalized patients' ability to cope effectively following their encounters with nurses.     

Epidural anesthesia and analgesia in the perioperative treatment of a patient with Kartagener syndrome

Kartagener's syndrome is an inherited disease characterized by a triad of symptoms--bronchiectasis, situs inversus and sinusitis--and is classified as an immotile cilia syndrome. Patients may experience specific airway problems when undergoing anesthesia for surgical procedures. We report the case of a woman with Kartagener's syndrome who underwent surgery under epidural anesthesia with postoperative epidural analgesia, both techniques proving successful.