Financial impact of a home intravenous antibiotic program on a medicare managed care program.

This study quantitates cost savings achieved by a home intravenous antibiotic (HIVA) program in a Medicare managed health care program. In 1998, 66 treatment courses of HIVA therapy were administered for a total of 1542 patient-days of therapy. The calculated cost of HIVA therapy included the actual costs of drugs, supplies, nursing and therapists' salaries, and laboratory studies. Savings were calculated based on the average daily direct variable cost (DDVC) for hospital acute unit or skilled nursing facility (SNF) care associated with the patient's discharge diagnosis-related-group. The number of days on HIVA therapy was assumed to equal the number of days in the hospital acute unit or hospital-based SNF. The average cost per day of HIVA therapy was $122, whereas average DDVC of hospital acute unit care was $798, and the average DDVC of SNF care was $541. In 1 year, the HIVA program saved our health care system $646,000-$834,000, which demonstrates that HIVA programs are powerful tools to reduce costs in Medicare managed health care programs.

Comparison of the amplified Mycobacterium tuberculosis (MTB) direct test, Amplicor MTB PCR, and IS6110-PCR for detection of MTB in respiratory specimens.

Several nucleic acid amplification techniques (NAAT) have been developed for rapid and direct detection of Mycobacterium tuberculosis (MTB) from clinical specimens. This study compared the performances of the Gen-Probe Amplified MTB Direct Test (AMDT), Roche Amplicor MTB PCR test, and an IS6110-PCR assay with acid-fast smear and culture in the detection of MTB from 428 respiratory specimens from 259 patients. Patients' charts were reviewed for clinical correlation. Of 98 specimens that were clinically positive for MTB, acid-fast smear was positive in 50% of cases, culture in 93%, IS6110-PCR in 83%, AMDT in 84%, and Amplicor MTB PCR in 80%. Of 337 specimens that were negative for MTB, 117 (35%) were positive for nontuberculous mycobacteria. Specificities were as follows: smear, 89%; culture, 100%; IS6110-PCR, 99%; AMDT, 98%; and Amplicor MTB PCR, 96%. The accuracies of the tests were 80%, 98%, 96%, and 92%, respectively. MTB culture-positive specimens that were smear-negative were detected by AMDT and IS6110-PCR in 77% of cases and by Amplicor MTB PCR in 70%. NAAT was less sensitive than was culture for detection of MTB, but all these techniques had acceptable accuracy and were completed within hours. NAAT may be useful for rapid screening of respiratory specimens to distinguish MTB from nontuberculous mycobacteria infection in order to isolate patients.

Epizootic of Mycobacterium bovis in a zoologic park.

An epizootic of Mycobacterium bovis in a zoologic park resulted in the death of 4 southern white rhinoceroses and 2 colobus monkeys. Zoo personnel were detected that had positive intradermal tuberculin skin test results after exposure to mycobacterial-infected animals. On the basis of DNA fingerprinting, all 3 mycobacterial isolates (from 1 rhinoceros and 2 monkeys) were determined to be genetically similar and probably originated from the same source. The 3 animals (1 rhinoceros and 2 colobus monkeys) that had confirmed infections lived in separate, but adjacent, areas. Aerosolization of bacteria during routine cleaning was believed to have contributed to the unusual distance between infected animals. Tuberculosis has reemerged as a major disease problem in human and veterinary medicine.

Dermatologic manifestations of nontuberculous mycobacterial diseases.

Various nontuberculous mycobacteria can cause infection of skin and soft tissues. These organisms are also known as atypical mycobacteria, anonymous mycobacteria, and mycobacteria other than tuberculosis. These organisms are much more common causes of cutaneous infection than Mycobacterium tuberculosis. Infections caused by nontuberculous mycobacteria are frequently misdiagnosed because clinicians fail to include them in the differential diagnosis of chronic skin infection.

Rhinoceros' rhinorrhea: cause of an outbreak of infection due to airborne Mycobacterium bovis in zookeepers.

Seven of 24 zookeepers exposed to a Southern white rhinoceros infected with Mycobacterium bovis were presumably infected via aerosols generated in the cleaning of the barn for the rhinoceros. All demonstrated conversion by the intermediate-strength purified-protein-derivative skin test, but none had clinical illness. In certain occupational settings like zoos and abattoirs, exposure to M. bovis may be an occupational hazard, and routine periodic tuberculin screening should be performed.

Improvement in 'stat' laboratory turnaround time. A model continuous quality improvement project.

BACKGROUND: Continuous quality improvement is being advocated as the process that, if adopted, would improve the efficiency, productiveness, and quality of medical institutions, thereby helping to solve the health care crisis our country is facing. To determine if these techniques could be effective in a tertiary-care multispecialty group practice, a model project was undertaken. The model project chosen was to determine if we could improve the turnaround time for "stat" laboratory examinations performed in our large outpatient facility. METHODS: A 10-member team consisting of everyone involved in the process of laboratory testing was empowered to evaluate the present process and make appropriate changes. With traditional techniques of quality improvement, the process was assessed, data were collected and statistically analyzed, changes were introduced, and data were recollected and analyzed. RESULTS: After intervention, the preanalytic delays were reduced by 76% and the postanalytic delays by 88%. Waiting time for patients was reduced by an average of 62%. By instituting the changes suggested, the institution saved $225,000 on a one-time basis and $40,000 to $50,000 on a recurring basis. CONCLUSION: Adoption of quality improvement techniques appears to be a desirable management paradigm that should be explored by all medical institutions interested in maximizing the quality of care offered while at the same time minimizing its cost.

Kaposi's sarcoma with a non-Hodgkin's lymphoma. Its association in a male homosexual with human T-cell lymphotropic virus type III infection.

Combined tumor syndromes, specifically reticuloendothelial malignancies and Kaposi's sarcoma, have long been recognized. With the recognition of the acquired immunodeficiency syndrome (AIDS), several patients with concurrent non-Hodgkin's lymphoma and Kaposi's sarcoma have been reported at high risk for developing AIDS. The present Centers for Disease Control definition of AIDS excludes these patients on the assumption that one tumor is affecting the cellular immunity, allowing for the development of the second malignancy. In evaluating such a patient who had serologic evidence of human T-cell lymphotropic virus type III infection, the probable cause of AIDS, we have reviewed reports of patients with similar concurrent malignancies before and since the onset of the AIDS epidemic. We conclude that patients in high-risk groups for AIDS who develop similar combined tumor syndromes should be classified as having AIDS.

Overview of bacterial infections of the skin and soft tissue and clinical experience with ticarcillin plus clavulanate potassium in their treatment.

The etiology, diagnosis, and treatment of skin and soft tissue infections are discussed, and the results of clinical experience with ticarcillin plus clavulanate potassium in these diseases at one clinic are reported. In a randomized and controlled clinical trial, the safety and effectiveness of ticarcillin plus clavulanate potassium and cefazolin were compared in the treatment of soft tissue infections in 20 patients. The 12 patients in the group treated with ticarcillin plus clavulanate potassium included 10 men and two women, with a mean age of 61 years; the eight patients in the group treated with cefazolin were five men and three women, with a mean age of 63.8 years. Ticarcillin plus clavulanate potassium was administered for four to 26 days (mean 12.5 days), and cefazolin for four to 20 days (mean 12 days). There were 29 evaluable pathogens in the group receiving ticarcillin plus clavulanate potassium and 22 in the group receiving cefazolin. Of the 29 pathogens in the former group, 22 were eradicated; three reinfections or superinfections occurred but were ultimately eradicated, and four pathogens persisted. Eighteen of the 22 pathogens in the cefazolin-treated group were eliminated and the other four persisted. Clinically, six of the 12 patients in the ticarcillin plus clavulanate potassium-treated group had cures, four showed improvement, and two failed to show a response. In the cefazolin-treated group, five of the eight patients had cures, one showed improvement, and two failed to show a response.

Studies in homosexual patients with and without lymphadenopathy. Relationships to the acquired immune deficiency syndrome.

We studied the immunologic function of 19 sexually active homosexual men, ten of whom had persistent lymphadenopathy. Analysis of mononuclear cell populations distinguished homosexuals from heterosexual controls since, as a group, homosexuals had increased percentages of natural killer cells (Leu 7+), decreased helper-inducer T lymphocytes (OKT-4+), increased suppressor/cytotoxic (OKT-8+) T lymphocytes, low OKT-4:OKT-8 ratios, and depressed mitogenic responses. Homosexuals without lymphadenopathy were distinguishable from controls by increased percentages of Ia+ cells, decreased OKT-4+ cells, and decreased OKT-4:OKT-8 ratios. Four had positive findings simultaneously for hepatitis B surface antigen (HBsAg) and surface antibody, and five had positive findings for HBsAg alone. Homosexuals with lymphadenopathy were distinguishable from controls by increased percentages of Leu 7+ cells, increased total lymphocyte numbers per cubic millimeter, decreased percentages of both OKT-4+ and OKT-8+ cells, abnormal OKT-4:OKT-8 ratios, and depressed mitogenic responses. Only histories of larger numbers of sexually acquired diseases, higher numbers of OKT-8+ cells per cubic millimeter, and lower mitogenic responses in homosexuals with lymphadenopathy distinguished this group from homosexuals without lymphadenopathy. Furthermore, none of the nine patients tested in this group was HBsAg positive. We conclude that homosexuals without lymphadenopathy are distinguishable from those with lymphadenopathy by both immunologic and serologic abnormalities.

Clinical usefulness of amikacin and doxycycline in the treatment of infection due to Mycobacterium fortuitum and Mycobacterium chelonei.

The antimicrobial agents amikacin and doxycycline, which are not conventionally considered for use in treatment of mycobacterial infections, inhibit growth of Mycobacterium fortuitum and Mycobacterium chelonei in vitro. Ten patients were treated with these drugs alone or in combination with some surgical procedure. Seven of the 10 patients were definitely cured by the therapy. Only one definite treatment failure occurred. Patients with infections due to M. fortuitum or M. chelonei that are susceptible in vitro to these drugs appear to benefit from chemotherapy.

Disk diffusion testing of susceptibility of Mycobacterium fortuitum and Mycobacterium chelonei to antibacterial agents.

Although recent studies have suggested that some antibacterial agents have good activity against the rapidly growing mycobacteria Mycobacterium fortuitum and Mycobacterium chelonei, an easily applicable method for susceptibility testing of clinical isolates is not yet available. We evaluated a disk diffusion method with Mueller-Hinton agar and 48-h readings with 59 strains of M. fortuitum and 11 strains of M. chelonei and compared the results to agar dilution susceptibilities for nine antimicrobial agents. All isolates were susceptible to 16 micrograms of amikacin or kanamycin per ml with minimum zone diameters of 14 and 18 mm, respectively. Amikacin inhibited 100% of isolates of M. fortuitum at 2 micrograms/ml, whereas 10 of 11 (91%) of M. chelonei strains had minimum inhibitory concentrations of 4.0 micrograms/ml or greater. Doxycycline and minocycline had almost identical activities, inhibiting 44% of strains at 4.0 micrograms/ml, and both allowed easy differentiation between susceptible and resistant strains by disk diffusion. Although most isolates of M. chelonei grew better on 7H10 agar, this media gave two- to eight-fold higher minimum inhibitory concentrations than were obtained with Mueller-Hinton agar. Disk diffusion susceptibility testing appears to be a simple and reliable means of predicting susceptibility results for M. fortuitum and most isolates of M. chelonei by the agar dilution method.

Problems in diagnosis and therapy of Mycobacterium fortuitum infections.

Mycobacterium fortuitum was isolated 11 times from 8 patients during a 6-year period. Six of the isolates were from sputum; one was from aspiration of a lymph node, and 4 were from wound cultures. The isolation from sputum was believed not to be associated with pulmonary infection in all 6 instances. The difficulty in diagnosis and therapy of infections with Mycobacterium fortuitum is illustrated by these cases and by others from the literature. Amikacin and doxycycline may offer some therapeutic benefit for patients with Mycobacterium fortuitum infections.

Subacute thyroiditis with increased serum alkaline phosphatase.

Three patients had subacute thyroiditis and elevated serum alkaline phosphatase, presumably related to the thyroiditis. Concomitant elevation of the serum gamma-glutamyl transferase suggested that the alkaline phosphatase was of hepatic origin. The elevation of the serum alkaline phosphatase could not be definitely related to the degree or duration of elevation of the serum thyroxine. The combination of elevated serum alkaline phosphatase with the systemic symptoms of subacute thyroiditis may obscure the diagnosis, especially if patients have little or no neck pain.

In vitro susceptiiblity of Mycobacterium fortuitum and Mycobacterium chelonei to amikacin.

Infections due to Runyon group IV atypical mycobacteria, Mycobacterium fortuitum and Mycobacterium chelonei, in humans have been difficult to treat in the past because of the organisms' resistance to all of the conventional antimycobacterial drugs. Determinations of minimal inhibitory concentrations (MICs) by the agar dilution method suggest that amikacin may be useful in the treatment of infections due to M. fortuitum and M. chelonei. Further support for the efficacy of antimicrobial agents with good in vitro activity in the treatment of infections with M. fortuitum and M. chelonei will depend on correlation of future clinical experience with standardized data on the MICs for these organisms.

In vitro susceptibility of Nocardia asteroides to amikacin.

By drug dilution tests in agar, it has been shown that each of 27 strains of Nocardia asteroides was inhibited by 1 mug or less of amikacin per ml of medium.