A tailored implementation strategy to reduce the duration of intravenous antibiotic treatment in community-acquired pneumonia: a controlled before-and-after study.

We previously showed that 40 % of clinically stable patients hospitalised for community-acquired pneumonia (CAP) are not switched to oral therapy in a timely fashion because of physicians' barriers. We aimed to decrease this proportion by implementing a novel protocol. In a multi-centre controlled before-and-after study, we evaluated the effect of an implementation strategy tailored to previously identified barriers to an early switch. In three Dutch hospitals, a protocol dictating a timely switch strategy was implemented using educational sessions, pocket reminders and active involvement of nursing staff. Primary outcomes were the proportion of patients switched timely and the duration of intravenous antibiotic therapy. Length of hospital stay (LOS), patient outcome, education effects 6 months after implementation and implementation costs were secondary outcomes. Statistical analysis was performed using mixed-effects models. Prior to implementation, 146 patients were included and, after implementation, 213 patients were included. The case mix was comparable. The implementation did not change the proportion of patients switched on time (66 %). The median duration of intravenous antibiotic administration decreased from 4 days [interquartile range (IQR) 2-5] to 3 days (IQR 2-4), a decrease of 21 % [95 % confidence interval (CI) 11 %; 30 %) in the multi-variable analysis. LOS and patient outcome were comparable before and after implementation. Forty-three percent (56/129) of physicians attended the educational sessions. After 6 months, 24 % (10/42) of the interviewed attendees remembered the protocol's main message. Cumulative implementation costs were 5,798 (20/reduced intravenous treatment day). An implementation strategy tailored to previously identified barriers reduced the duration of intravenous antibiotic administration in hospitalised CAP patients by 1 day, at minimal cost.

Diagnostic, therapeutic and economic consequences of a positive urinary antigen test for Legionella spp. in patients admitted with community-acquired pneumonia: a 7-year retrospective evaluation.

AIMS: A positive urinary antigen test for Legionella spp. (Legionella urinary antigen test; LUAT) allows an early switch from empiric to targeted treatment (TT) in hospitalised, community-acquired pneumonia (CAP) patients. We aimed to evaluate the diagnostic, therapeutic and economic consequences of this frequently used test 7 years after its implementation. METHODS: We retrospectively evaluated LUATs performed between 2005 and 2011 in two teaching hospitals. All tests performed in hospitalised CAP patients were used in the economic evaluation and positive tests were included in the treatment evaluation. Data on patient characteristics, admission and outcome were retrieved from the patients' files. The number of days gained by making a rapid aetiological diagnosis, the number of days TT could be provided and their costs were calculated. RESULTS: Of 4485 LUATs, 2504 (56%) were performed for CAP including 55 (1%) positive tests (€1041/positive test). In 26 (60%) of the 43 included positive tests, LUAT was the only test showing Legionella spp. Subsequently, earlier TT was possible in the remaining cases during 209 cumulative admission days (€274/TT day). LUAT led to detection of Legionella spp. 13 days earlier per case (€203/day) as compared with culture/serology alone. CONCLUSIONS: Timely LUAT use in accordance with current guidelines allows early detection and treatment of CAP caused by Legionella spp. at considerable expense.

Positive urinary antigen tests for Streptococcus pneumoniae in community-acquired pneumonia: a 7-year retrospective evaluation of health care cost and treatment consequences.

A positive pneumococcal urinary antigen test (PUAT) for Streptococcus pneumoniae allows an early switch from empiric to targeted treatment in hospitalised community-acquired pneumonia (CAP) patients. The economic and treatment consequences of this widespread implemented test are, however, unknown. We retrospectively evaluated all tests performed since its introduction in two teaching hospitals. Data on patient characteristics, treatment, admission and outcome were retrieved from the electronic patient files. Test benefits were expressed as the number of days that targeted therapy (i.e. penicillin) was administered to hospitalised CAP patients due to a positive PUAT. This calculation was based on the timing of the PUAT and the initiation of targeted therapy. Subsequently, we performed two direct cost analyses from a hospital perspective, first including tests performed for CAP only, and second including costs of all (excessive) tests. Between 2005 and 2012, 3,479 PUATs were performed, of which 1,907 (55 %) were for CAP. A total of 1,638 PUATs (86 %) were negative and 269 (14 %) were positive. Fifty-two (19 %) positive tests were excluded. In 75 (35 %) of the 217 remaining positive tests, a positive PUAT led to targeted treatment during 293 cumulative admission days. Testing costs for CAP only were €131 per targeted treatment day. These costs were €257 if local protocol dictated PUAT use for all CAP cases, as opposed to €72 if the test was reserved for severe cases only. When including all tests, PUAT costs were €254 per targeted treatment day. Therefore, improving the selective use of the PUAT in hospitalised CAP patients may lead to increased (cost-)efficiency.

Freezing vibrational energy flow: a fitness function for interchangeable computational and experimental control.

We develop a fitness functional for freezing molecular energy flow that relies only on experimental observables. The functional allows us to implement a modular control algorithm where simulation data and experimental data can be used interchangeably. This interchangeability could be useful as a spectroscopic tool and for reactive control because the controllability of the experimental system and its model can be compared directly. The fitness functional performs as well as functionals based on complete knowledge of the wave function. We compare our simulation results with an analytical theory of control, and find good agreement between the simulated and predicted times over which the system can be controlled.

Woringer-Kolopp disease (pagetoid reticulosis).

We report the clinical, histopathological, and ultrastructural features of a case of Woringer-Kolopp disease, review the literature, and discuss the relationship of the condition to mycosis fungoides. At the present time it is best to regard Woringer-Kolopp disease as a form of cutaneous T-cell lymphoma that may remain localized for many years or may eventually be associated with widespread mycosis fungoides.

Abrasive cleansing in the management of acne vulgaris.

The comparative effectiveness of an abrasive cleaner and the same cleansing agent without the abrasive granules was evaluated using a bilateral paired comparison method in 44 patients with acne vulgaris. Lesion counts and an appraisal of the severity of disease were made every two weeks for a total of eight weeks. An equal reduction in both the number and severity of acne lesions was seen with each test product. Substantial differences between the adverse effects of these two products were not observed.

Treatment of psoriasis with amcinonide 0.1 percent and fluocinonide 0.05 percent ointments. A comparative double-blind study.

Fifty psoriatic patients enrolled in a three week, double-blind, randomized, parallel study were treated either with amcinonide ointment 0.1 percent twice a day or fluocinonide ointment 0.05 percent three times a day. After Week 1 of treatment, no statistically significant differences appeared between the two groups with regard to improvement in signs and symptoms of psoriasis. After Week 3, improvement in all efficacy parameters, except erythema, and in Total Scores in both groups was greater than 50 percent as compared to baseline evaluations. There were no statistically significant differences between the treatment groups. Only one patient in each group reported an adverse experience that could have been drug-related. Amcinonide ointment used twice a day and fluocinonide ointment used three times a day were judged comparable with regard to safety and clinical efficacy. Amcinonide may be considered to have some advantage over fluocinonide because its twice a day treatment schedule makes it more convenient for patients to use.