Central venous catheter-related biofilm infections: An up-to-date focus on meticillin-resistant Staphylococcus aureus.

Central venous catheters are indispensable for the long-term treatment of seriously and chronically ill patients, but their use is often associated with a variety of complications; indeed, 90% of primary bloodstream infections are related to patients having a catheter. In studies performed in France, Germany and Italy, meticillin-resistant Staphylococcus aureus (MRSA) accounted for >50% of all S. aureus isolates obtained in catheter-related bloodstream infections (CRBSIs). These infections have a serious impact on long-term disability of the patient, a substantial additional financial burden for health systems, and high costs for patients. Decreasing the rate of CRBSIs requires a multidisciplinary approach, including behavioural and educational interventions and the insertion of the correct type of catheter. Although vancomycin remains the cornerstone of empirical therapy for CRBSIs caused by MRSA, combination of different antimicrobials and new approaches are indispensable to enhance the eradication of S. aureus biofilms and to manage the patient appropriately.

Diagnosis and management of skin and soft-tissue infections (SSTI): a literature review and consensus statement on behalf of the Italian Society of Infectious Diseases and International Society of Chemotherapy.

Skin and soft-tissue infections (SSTIs) are among the most common bacterial infections, posing considerable diagnostic and therapeutic challenges and resulting in significant morbidity and mortality among patients as well as increased healthcare costs. eight members of the SSTI working group of the Italian Society of infectious Diseases prepared a draft of the statements, grading the quality of each piece of evidence after a careful review of the current literature using MEDLINE database and their own clinical experience. Statements were graded for their strength and quality using a system based on the one adopted by the Infectious Diseases Society of America (IDSA). The manuscript was successively reviewed by seven members of the SSTI working group of the international Society of Chemotherapy, and ultimately re-formulated by all e xperts. the microbiological and clinical aspects together with diagnostic features were considered for uncomplicated and complicated SSTIs. Antimicrobial therapy was considered as well -both empirical and targeted to methicillin-resistant Staphylococcus aureus (MRSA) and/or other main pathogens.

Comparison of therapeutic interchange with standard educational tools for influencing fluoroquinolone prescribing.

The abilities of therapeutic interchange (TI) and standard educational tools (SET) to change prescribing habits were compared. We evaluated the replacement of ciprofloxacin with levofloxacin in a four-hospital health system during a 14-month study period. Two hospitals used TI and two SET. The demographics, sites of infection, and severity of illness were analyzed for 554 patients treated at SET hospitals and 1323 patients treated at TI hospitals during a total of 2040 hospitalizations over a 14-month period. In TI hospitals, 97% of patients received levofloxacin, whereas 43% received levofloxacin in SET hospitals (p < 0.001). Clinical outcomes were not significantly different for the two groups, although more patients in the SET hospitals received combination antimicrobial therapy. Differences in savings per patient were significant between TI hospitals ($60) and SET hospitals ($37) (p < 0.001). The total annualized savings for all four hospitals was $156,444. TI was more effective than SET in facilitating changes in prescribing patterns in a health care system and resulted in significant cost savings to hospitals and payers.

Intravenous-to-oral transition therapy in community-acquired pneumonia: the INOVA Health System experience.

Economic pressures on the delivery of health care have necessitated a focus on reducing costs and resource utilization while maintaining or improving the quality of care. A growing consensus holds that switching from intravenous to oral therapy is a cost-effective and clinically sound approach for a significantly large group of patients with community-acquired pneumonia (CAP). Drug utilization studies within the INOVA Health System revealed that levofloxacin is a cost-effective alternative to ciprofloxacin in infectious disease and that use of risk prediction criteria can reduce inappropriate hospitalizations for CAP, thereby reducing costs. In addition, the INOVA experience demonstrates that the strategy used to implement new antibiotic regimens such as switch-therapy regimens is an important factor in cost reduction: a therapeutic interchange mandate is more successful than standard educational techniques in changing treatment patterns.

Comparative safety of filgrastim versus sargramostim in patients receiving myelosuppressive chemotherapy.

STUDY OBJECTIVE: To compare rates of adverse events with filgrastim versus sargramostim when given prophylactically to patients receiving myelosuppressive chemotherapy. DESIGN: Retrospective review with center crossover. SETTING: Ten United States outpatient chemotherapy centers. PATIENTS: Four hundred ninety patients treated for lung, breast, lymphatic system, or ovarian tumors. INTERVENTION: Prophylactic use of filgrastim or sargramostim, with dosages at investigator discretion. MEASUREMENTS AND MAIN RESULTS: The frequency and severity of adverse events and the frequency of switching to the alternative CSF were assessed. There was no difference in infectious fever. Fever unexplained by infection was more common with sargramostim (7% vs 1%, p<0.001), as were fatigue, diarrhea, injection site reactions, other dermatologic disorders, and edema (all p<0.05). Skeletal pain was more frequent with filgrastim (p=0.06). Patients treated with sargramostim switched to the alternative agent more often (p<0.001). CONCLUSION: Adverse events were less frequent with filgrastim than with sargramostim, suggesting that quality of life and treatment costs also may differ.

The role of the hospital pharmacist in cost control and antibiotic policy.

The pharmacist provides a vital role in the management of antibiotic policy. Consumers and payers demand quality care at a significantly reduced price. It is imperative that health care adapt to the times. Physicians must be involved in all phases of programmes that are viewed as cost saving. These programmes should integrate and document both clinical and financial aspects of care.

Antibiotic usage: pharmacoeconomic impact in a changing healthcare system.

There is limited experience in the healthcare field in terms of the evaluation of treatment costs. All too often, healthcare providers focus on the financial end-points (such as drug acquisition costs) as opposed to clinical end-points. This approach fails to view products from a broader perspective and tends to ignore the impact of a drug in terms of better patient compliance, fewer office visits, reduced length of hospital stay, or avoidance of hospitalisation. This article will briefly discuss the techniques used in the US to improve the utilisation of antibiotics, and describe the move towards the use of outpatient (i.e. outpatient care attached to a hospital, or in an infusion or clinic setting) or home therapy.

Benefits of outpatient parenteral antibiotic therapy: to the individual, the institution, third-party payers and society.

The cost of outpatient parenteral antibiotic therapy is outweighed by the benefits to all involved: provider, payer, patient and society. Simple comparisons of inpatient and outpatient charges are not a true measure of costs. Recent in-depth cost-benefit analyses reveal a significant saving when indirect benefits, such as increased productivity and quality of life, are included. Even so, financial issues remain to be addressed.

Nasointestinal tube placement with a pH sensor feeding tube.

Radiographic confirmation of enteral feeding tube placement is a common practice representing considerable expense and causing delay in the initiation of enteral nutrition therapy. We evaluated an enteral feeding tube with a pH sensor, which allows immediate verification of the location of the tube by assessment of the pH upon insertion. Insertion pHs were obtained for 24 intensive care unit patients requiring feeding tube placement. Placement was verified radiographically and compared with expected location on the basis of the pH profile. The radiograph and the insertion pH profile were in agreement in 87.5% (21 of 24) of the cases. Concomitant use of histamine blockers did not affect the ability of the pH sensor to detect placement accurately (Fisher's Exact Test, p 5.71) Use of these pH measurements eliminates the need for radiographic documentation of placement, provides a savings for the patient, and may be beneficial in promoting enteral feedings in critically ill patients.

Outpatient parenteral antibiotic therapy. Management of serious infections. Part I: Medical, socioeconomic, and legal issues. Costs and benefits.

The costs of outpatient parenteral antibiotic therapy are outweighed by the benefits to all involved: provider, payer, patient, and society. Simple comparisons of inpatient and outpatient charges are not a true measure of costs. Recent in-depth cost-benefit analyses reveal a significant saving when indirect benefits, such as increased productivity and quality of life, are included. Even so, financial issues remain to be addressed.

Efficacy and tolerability of imipenem-cilastatin versus ceftazidime plus tobramycin as empiric therapy of presumed bacterial infection in neutropenic cancer patients.

The efficacy and tolerability of monotherapy with imipenem-cilastatin (I-C) were compared with that of ceftazidime plus full-course therapy with an aminoglycoside (tobramycin) (C&T) in the treatment of presumed bacterial infection in neutropenic cancer patients. A total of 106 adult patients diagnosed with presumed bacterial infection and an underlying malignancy with an absolute neutrophil count (ANC) < 500/mm3 were enrolled in this open-label study. A total of 131 febrile episodes occurred. Forty-five patients in the I-C group and 41 in the C&T group, who were well matched on demographic and baseline characteristics, were evaluable for efficacy and safety. Seventy-two hours after the start of therapy, no significant between-group differences in treatment outcomes, including withdrawals or deaths, were seen. Thirty-five (78%) of 45 patients in the I-C group and 29 (71%) of the 41 in the C&T group had successful outcomes at the final evaluation. Superinfection occurred in 8 (18%) I-C patients and 3 (7%) C&T patients. Within the subgroup of patients with an initial ANC < 100/mm3, the final evaluation showed no significant differences in treatment outcome between groups. Of the 131 in the safety population 30 (46%) I-C patients and 28 (42%) C&T patients had one or more adverse experiences; drug-related adverse events occurred in 25 (38%) patients in the I-C group and 11 (17%) patients in the C&T group. The data suggest that imipenem-cilastatin should be considered for initial empiric therapy of presumed bacterial infection in neutropenic cancer patients.

Considerations in comparing intravenous and intramuscular antibiotics.

With the implementation of prospective payment (e.g. diagnosis-related groups [DRGs] and cost containment efforts, physicians and pharmacists have had to reevaluate current drug delivery systems in the search for the least costly means of administering parenteral products. The following describes a three-phase approach to fully assess relative antibiotic cost and to assess economic efficiencies of intramuscular and intravenous administration of antibiotics. Relative costs of therapy consist of acquisition cost, administration cost and total cost of self-administration. Various intravenous administration systems are described, as are considerations for intramuscular administration. Comparisons are made using intravenous and intramuscular administrations of cefazolin, gentamicin, penicillin and imipenem. Using a 'best case' scenario, the intramuscular route was found to be up to one tenth the expense of the intravenous route in certain instances. Also, the intramuscular route may facilitate early discharge and self-administration in the home. Antibiotics available for intramuscular injection should therefore be considered as an economically efficient alternative to intravenous injections, in appropriate patients.