Impact of a new guideline for central venous catheter care on sepsis in total parenteral nutrition: experience in Ramathibodi Hospital.

BACKGROUND: Total parenteral nutrition (TPN) is the essential treatment for hospitalized patients in whom normal enteral nutrition is inadequate or not feasible. However, TPN-related sepsis is the most serious and fatal complication of the treatment and the catheter is the most common cause of infection. Therefore, the Nutrition Support team in Ramathibodi Hospital has developed a new guideline for central venous catheter care for TPN patients and has used it for at least a year. OBJECTIVE: Survey the current incidence of TPN-related sepsis in the hospital, the predisposing factors of the TPN-related sepsis, and the pathogenic organisms of the sepsis. MATERIAL AND METHOD: Between July 1999 and February 2000, 52 TPN treatments (catheter count) in 40 surgical and medical patients were prospectively recruited. Microbiological studies were done in all cases of TPN-related sepsis. RESULTS: The incidence of TPN-related sepsis was 15% per catheter or 12.64/1000 catheter-days. Although no statistically significant predisposing factors were found for the sepsis, some factors such as postoperative TPN and short interval (< or = 2 days) for TPN line change (OR = 3.33, 95% CI = 0.33-30.34) showed a higher risk for TPN-related sepsis. The most common pathogenic organisms were Coagulase-negative staphylococci, Candida albicans, and gram-negative bacteria. The organisms were found from hemoculture in septic patients and were well correlated with those found in the catheter line. Thus, the significant pathogenic role of Coagulase-negative staphylococci emphasizes the importance of aseptic technique during catheterization. CONCLUSION: The Ramathibodi guideline rendered support for a good policy to improve and standardize the TPN treatment. Along with a practical guideline, the well-trained and highly responsible personnel would also be crucial to avoid the infectious complications.

Comparison of essential trace elements in blood of patients receiving Ramathibodi Standard Parenteral Nutrition with Ramatrace or a commercial formular.

OBJECTIVE: Commercially intravenous trace element product is very expensive compared to Ramatrace. Therefore, the present research was designed to compare the levels of zinc, copper chromium and manganese in the blood of patients receiving Ramathibodi Standard Parenteral Nutrition (STD) containing the Ramatrace or the commercial product. MATERIAL AND METHOD: Two groups of patients receiving STD were recruited. Group 1 (19 males and 11 females) received Ramatrace and Group 2 (19 males and 11 females) received a commercial product. Blood samples on day 0, day 3 and day 10 were measured for zinc, copper chromium and manganese levels by atomic absorption spectrophotometer (model 3100, Perkin Elmer). RESULTS: The present results showed that levels of zinc, copper, chromium and manganese were not significantly different between the two groups. On day 0, day 3 and day 10, the levels of zinc, copper and manganese in the blood of both groups were significantly increased (p < 0.05). Blood chromium levels of Group 1 were significantly increased from day 0 (0.14 +/- 0.02 microg/dL) to day 3 (0.23 +/- 0.02 microg/dL) but there was no significant difference between day 3 and day 10. In Group 2, the blood levels of chromium from day 0 to day 10 were significantly increased. CONCLUSION: In patients receiving STD, Ramatrace could improve the levels of zinc, copper, chromium and manganese as well as the commercial product. This may be one way to reduce the cost of treatment.

Effect of diabetes drug counseling by pharmacist, diabetic disease booklet and special medication containers on glycemic control of type 2 diabetes mellitus: a randomized controlled trial.

BACKGROUND: type 2 diabetes mellitus continues to increase in prevalence worldwide. Many factors have been cited as contributing to compliance, such as family and social support, education, number of tablets per dose, frequency of administration and health care provider communication. Toward these goals, the present study was developed to measure the effect offactors on glycemic control such as diabetes education by pharmacists, a diabetes disease booklet and special medication containers. MATERIAL AND METHOD: A total of 360 volunteers with type 2 DM patients were recruited, participants were simple randomized to control 180 and intervention 180 patients. Which intervention categorized to 4 groups; all intervention groups received diabetes drug counseling by a pharmacist, one group received plus a diabetes booklet, one received plus special medical containers and the last group received all of them. The interventions were done at the 1st time of visit. Both the control and intervention groups were monitored for fasting plasma glucose and HbA1c at 0, 3, 6 months and glycemic level in both groups was compared. RESULTS: After 3 months, mean fasting plasma glucose and HbA1c decreased wiih the intervention group vs. control group (152.36 +/- 39.73 to 131.52 +/- 35.22 mg%) and (150.16 +/- 41.78 to 153.98 +/- 47.95 mg%) respectively; (p < 0.001). HbA1c level 8.16 +/- 1.44 to 7.72 +/- 1.26 vs 8.01 +/- 1.51 to 8.38 +/- 1.46 respectively; (p < 0.001). After 6 months, mean fasting plasma glucose and HbA1c decreased with the intervention group vs. control group (152.36 +/- 39.73 to 145.20 +/- 46.07 mg%) and (150.16 +/- 41.78 to 159.16 +/- 54.90 mg%) respectively; (p < 0.013). HbA1c level 8.16 +/- 1.44 to 7.91 +/- 1.27 vs. 8.01 +/- 1.51 to 8.80 +/- 1.36 respectively; (p < 0.001). The most favorable glycemic outcome was the group that received all of the interventions; mean FPG was reduced from 147.46 +/- 36.07 to 125.38 +/- 31.12 mg% (p < 0.000) in 1nd visit (3 months later) and still reducing effect on the 2nd visit (6 month later) mean FPG from 147.46 +/- 36.07 to 130.21 +/- 33.96 mg% (p < 0.016) also the same way in HbA 1c level. The group that received only drug counseling by pharmacist had no significant reduction in FPG and HbA1c. (p > 0.05). CONCLUSION: Drug counseling by a pharmacist has little beneficial effect on diabetes management outcome compared to the diabetes booklet and special drug container. To improve glycemic control of type 2 DM is to integrate self-management in daily life, wide a variety of education, drug taken behavior and health care provider available communication produce improvement in patient management and is somewhat better when used in combination.

Pharmacokinetics of ofloxacin in drug-resistant tuberculosis.

The pharmacokinetics of ofloxacin were investigated in 11 drug-resistant pulmonary tuberculosis (TB) patients with a mean age (SD) of 38.09 (11.97) years. All patients received ofloxacin 10 mg/kg once daily combined with other active anti-TB drugs. Following an 8-h overnight fast, serum samples were drawn prior to and from 0.25 up to 24 hours after dosing. Serum ofloxacin concentrations were determined by high performance liquid chromatography (HPLC) assay. Pharmacokinetics of ofloxacin were well described by a linear, 2-compartment open model with first-order absorption and first-order elimination. Mean +/- SD of Cmax was 9.61 +/- 2.17 microg/ml occurred at 1.68 +/- 1.21 hours. Means +/- SD of AUC(0-24) and AUC(0-infinity) were 70.57 +/- 26.40 and 82.45 +/- 43.64 microg x h/ml, respectively. Ofloxacin distributed widely with a mean +/- SD of Vss/F of 1.37 +/- 0.24 L/kg. Mean +/- SD of CL/F was 8.19 +/- 2.53 L/h, whereas mean +/- SD of T(1/2beta) and mean residence time were 8.03 +/- 3.37 and 10.77 +/- 4.55 hours, respectively. The free Cmax/MIC of Mycobacterium tuberculosis of 7.7-15.4:1 was estimated. These suggested that ofloxacin 10 mg/kg once daily combined with other active anti-TB drugs provides sufficient Cmax/MIC ratio and long T(1/2beta) which supported its use in drug-resistant TB.