[Behavioral approach to facilitate appropriate use of antibiotics].

Many hospitals have infection control education programs to facilitate the appropriate use of antimicrobial agents. Even with these efforts, however, it is not rare to encounter irregular prescriptions. In order to solve this discrepancy between knowledge and actual behavior, we chose an alternative approach to improve the decision making process. Recent advances in information technology have made it possible to not only instantly integrate various bacterial examination results using a computer, but to simultaneously carry out the statistical analyses at a much lower cost. We employed a client-server system to accomplish these tasks in Kagawa University Hospital. By connecting CCD camera-equipped microscopes to the system directly, image uploading has become a single-clicking job. Various microbial examination data were automatically transferred to the system once they became available in analytical devices such as BacT/ALERT 3D, VITEK, and an MIC analyzer. These data were presented to hospital doctors in well-designed web windows without delay. By removing psychological barriers to access laboratory examination data, statistics, and relevant information, more doctors seemed to independently follow scientific processes to choose antimicrobial agents. The daily behavior of hospital doctors has also been influenced by the system, e. g., pasting the microscopic images onto clinical records, or starting Gram staining in their own wards. These subtle but fundamental changes will eventually alter the way they make prescription decisions. The computer system was also useful for the infection control team to monitor and detect nosocomial infections, which has become essential to carry out its daily activities.

Peritoneal pharmacokinetics of cefepime in laparotomy patients with inflammatory bowel disease, and dosage considerations for surgical intra-abdominal infections based on pharmacodynamic assessment.

This study aimed to examine the peritoneal pharmacokinetics of cefepime and to assess its pharmacodynamic exposure in peritoneal fluid (PF). Cefepime (1 g) was administered to eight patients with inflammatory bowel disease before abdominal surgery. Venous blood and PF samples were obtained at the end of the 0.5-h infusion and at 1, 2, 3, 4, 5, and 6 h thereafter. Drug concentrations in plasma and PF were determined, analyzed pharmacokinetically, and used for a Monte Carlo simulation with minimum inhibitory concentration (MIC) data. Cefepime penetrated well into PF, with a maximum drug concentration in a PF/plasma ratio of 0.59 +/- 0.15 (mean +/- SD, n = 8), and an area under the concentration-time curve ratio of 0.90 +/- 0.10. The probabilities of attaining the bacteriostatic and bactericidal targets (40% and 70% of the time above the MIC, respectively) in PF were > or =85% against Escherichia coli, Klebsiella species, and Enterobacter cloacae with 0.5 g every 12 h, 1 g every 12 h, 1 g every 8 h, and 2 g every 12 h. However, 1 g every 8 h or 2 g every 12 h was required for bacteriostatic and bactericidal probabilities > or =85% against Pseudomonas aeruginosa. These conventional regimens did not achieve a high probability against Bacteroides species. These results should help to give us a better understanding of the peritoneal pharmacokinetics of cefepime while also helping to choose the appropriate dosage to prevent surgical intra-abdominal infections on the basis of the pharmacodynamic assessment.

[Status of achievement of the aseptic preparation method for total parenteral nutrition expected by physicians and nurses].

In most medical institutions, although total parenteral nutrition (TPN) should be prepared by pharmacists in sterile condition, nurses actually perform this procedure in hospital wards. The currently growing belief is that pharmacists should prepare all preparations for injection using aseptic technique. Therefore, we conducted a survey on how physicians and nurses feel about methods of preparation of TPN and other agents for injection. The results demonstrated that physicians and nurses desired pharmacists to prepare all agents for injection according to prescriptions using aseptic technique, under pharmacological control and on a 24-hours basis. Based on these results, we examined a method to realize this expectation to the extent possible in our hospital and applied it when aseptic TPN preparations were extended to include relatively stable patients requiring TPN in all hospital wards. The number of TPN preparations increased steadily. The mean number of aseptic TPN preparations after stabilization of this method was 1214 a month. A total of 48% of all TPN solutions required were prepared in aseptic condition, with an average of 4.4 vials of agents mixed per prescription. For TPN base solution, 71% of a double--bag preparation consisting of electrolytes, saccharides, and amino acids was used. It was prepared in the wards most often for the reason, "described as an unscheduled prescription". The cost of consumables required for aseptic preparations was approximately 1.7 times the insurance coverage for addition of aseptic preparations. The physicians and nurses supported the method used by the pharmacists. To ensure complete aseptic preparation of injections by pharmacists, additional pharmacists, a review on their working system, more insurance points, and a broader range of insurance coverage may be required.

[Surveillance of reasonable period of antibiotic administration to compromised hosts].

For the purpose of prevention of hospital-acquired infection caused by antibiotic-resistant bacteria, we examined a method to establish an appropriate time period for the administration of antibiotics to compromised hosts. Using these antibiotics we monitored patients who received instruction about the drug regimen in the Blood and Respiratory Diseases Department ward. We monitored a) third-generation cephalospolins, b) Imipenem/Cilastatin, and c) antibiotics used against methicillin-resistant Staphylococcus aureus. When the antibiotics were administered over 14 days, pharmacists notified physicians of the current duration of administration using a confirmation form, and confirmed their future administration schedule. We examined the antibiotic usage regimen of all the patients in this ward before and after the confirmation form was adopted. Patients given the same antibiotics within 14 days significantly increased in percentage from 82% to 91% after the confirmation form was adopted (p < 0.05). The median duration of antibiotic administration decreased from 7 days to 5 days. The case with antibiotic administration for the longest duration was a patient with leukemia who received vancomycin for 116 days after adoption of the confirmation form. This patient died 4 days after his antibiotic was changed. Only 16% of the patients administered antibiotics in this ward were monitored for the duration of antibiotic administration after adoption of the confirmation form. When the pharmacists positively provided physicians with information on some patients concerning the prolongation of antibiotics administration, the number of patients administered antibiotics for less than 14 days significantly increased throughout this ward without interfering with the treatment of patients who required long-term administration of antibiotics.