All-inclusive concurrent antibiotic usage review: a way to reduce misuse without formal controls.

During an 11-week period, all antibiotic usage on a 113-bed medical teaching service was reviewed concurrently in weekly sessions between house staff and a review team. Recommendations for change, based on accepted criteria, were communicated by the house officer to the attending physician. In one-half of the patients no change was suggested; in one-third, a recommended change was made; and in only one-sixth was a recommendation not followed. Cost savings were conservatively estimated to approach $10,000 in this pilot study; this extrapolates to almost $300,000 per year for the 714-bed medical center, or more than 18% of the antibiotic expenditures. This program achieves its objective in a nonthreatening, noncontrolling manner, provides continuing education, and contributes to improved patient care.

Acceptability and cost savings of selective sputum microbiology in a community teaching hospital.

Our experience in introducing selective sputum microbiology into a clinical laboratory was recorded prospectively and analyzed. Based on low-power microscopy with determination of ratios of polymorphonuclear to squamous cells, 32% of specimens were discarded as unfit for culture. Speedy processing and prompt telephone calls afforded opportunities to replace these with better specimens, but only 29% of rejected specimens were resubmitted. Interpretive readings of smears for microorganisms yielded meaningful yielded meaningful information to clinicians and correctly predicted culture results in 73.8% of acceptable specimens. Technological time was similar to that required to process the same number of specimens in the usual way, but rejection of unsatisfactory specimens led to a 22% saving in supplies. Clinicians readily accepted the new system. Where nurses are responsible for specimen collection, they must be informed of the rationale for selective culture and the unreliability of gross visual inspection in evaluating sputum.

Unpredictable response of Pseudomonas aeruginosa to synergistic antibiotic combinations in vitro.

The combined activity of ticarcillin and each of three aminoglycosides, gentamicin, tobramycin, and amikacin, was studied with 45 clinical isolates of Pseudomonas aeruginosa. All strains individually were susceptible to each of these agents. Comparison of the results revealed highly variable interaction, both from strain to strain and from one aminoglycoside to another against the same strain. Against 11 strains, none of three antibiotic pairs tested was synergistic by conventional criteria; against the remaining 34, three, any two, or any one pair among those tested was synergistic. The minimal inhibitory concentrations of individual drugs gave no indication of the degree of synergism to be expected. We conclude that generalizations about the behavior of this organism vis-à-vis penicillin-aminoglycoside combinations in vitro are subject to many exceptions. Furthermore, no test using a particular antibiotic combination is reliable as a screen for other combinations. If this experience is duplicated in vivo, combination testing may be as important for the choice of combination therapy as individual susceptibility testing is for the choice of individual antibiotics.

Misinformation from sputum cultures without microscopic examination.

Only 13 of 38 hospital laboratories surveyed include a Gram stain routinely in microbiological sputum examination. In a prospective three-hospital study, 60% of over 1,200 "sputum" specimens consisted predominantly of saliva, as judged by cell composition. Compared with the results of cultures in which microorganisms presumptively identified on sputum smears were specifically sought ("directed cultures"), cultures of the same specimens processed in the routine manner missed pneumococci 61%, haemophili 23%, and yeasts 44% of the time. The findings were similar in all three hospitals despite differences in administration, staffing, primary culture media, and workload. Unless microscopic examination is routinely included, half of all microbiological information rendered on sputum specimens is meaningless and subject to dangerous misapplication. Furthermore, culture must be guided by microscopic findings, or respiratory pathogens will frequently be missed. Finally, when routine culture and smear disagree, the culture cannot be assumed to be correct. Microscopic examination should be mandatory in sputum microbiology, both for specimen evaluation and as a guide to what to look for in culture.

Brucella suis infection in Philadelphia. A survey of hog fever and asymptomatic brucellosis.

Examination of hospital and public health records revealed 19 cases of brucellosis diagnosed in Philadelphia between 1968 and 1972. A serologic survey at Philadelphia's largest hog-processing plant, however, indicated infection in 39% of workers. If extrapolated industry-wide, the total would be several hundred in Philadelphia. The infection is usually unrecognized or asymptomatic, since men were active in physically demanding jobs with agglutinin titers in excess of 1:5000. Overt illness, usually first diagnosed after weeks of incapacity, responded readily to tetracycline therapy. Although clinical manifestations are nonspecific, attention to occupational history should quickly lead to the diagnosis. It is emphasized that any hog-processing plant, wherever located, is potentially a reservoir of brucellosis. Prolonged morbidity and loss of production time might be avoided if physicians were more alert to this infection. Agglutinins in possibly significant titers were also found in a small fraction of persons without identifiable exposure.

Herpes simplex encephalitis in Hodgkins disease. Isolation of drug-sensitive virus from brain following unsuccessful treatment with idoxuridine.

Herpes simplex encephalitis developed in a patient with Hodgkin's disease under therapy. Despite treatment with idoxuridine in a total dose of 280 mg/kg intravenously, he died without showing any clinical response. At autopsy, there was no gross or microscopic evidence of Hodgkin's disease, and virus isolated from the brain postmortem was inhibited in vitro by idoxuridine 0.5 mug/ml. Failure of idoxuridine to affect the course of infection by a drug-sensitive virus may be due to poor tissue penetration, although the role of the Hodgkin's disease cannot be discounted.

Carbenicillin in the first nine months of unrestricted use. A chapter in the natural history of an antibiotic.

During the first nine months following its release for general use, carbenicillin was administered to forty-two patients in Hahnemann Hospital. Thirty-nine available records of patients receiving the drug for other than urinary infection were reviewed. Among children, all but one had mucoviscidosis: most were given acceptable therapeutic regimens; survival rate was 80%, and their physicians were favorably impressed. Among adults, underlying disease was usually life threatening; most were inadequately treated; survival rate was 31%, and their physicians were not favorably impressed. The multiplicity of variables precludes objective evaluation of the drug under the circumstances of its use, but one that could have been avoided was the inconsistency of the therapeutic regimen, which in adult patients was too often insufficient. As used, therefore, carbenicillin has not provided the benefits predicted from its earlier controlled evaluation, and the large expenditure of money, particularly by adult patients, has been largely wasted.