Concurrent outbreaks with co-infection of norovirus and Clostridium difficile in a long-term-care facility.

We describe an outbreak of simultaneous Clostridium difficile and norovirus infections in a long-term-care facility. Thirty patients experienced acute gastroenteritis, and four had co-infection with identical C. difficile 027 and genotype II.4 New Orleans norovirus strains. Co-occurring infection requires improved understanding of risk factors, clinical impact, and testing strategies.

Clinical and fiscal impact of lansoprazole intolerance in veterans with gastro-oesophageal reflux disease.

BACKGROUND: Omeprazole was replaced by lansoprazole as the only proton pump inhibitor on the Veterans Affairs (VA) formulary in February 1997. We aimed to assess the clinical and fiscal impact of this conversion at two VA hospitals. METHODS: We identified lansoprazole intolerant patients using pharmacy databases. We reviewed medical records to obtain data regarding reasons for lansoprazole intolerance. The costs of the formulary change and the savings to the VA were calculated. RESULTS: A total of 3833 patients required long-term proton pump inhibitor therapy; 2224 (58%) were started on lansoprazole and 1479 (39%) were converted from omeprazole to lansoprazole. The remaining 130 (3.4%) patients were never converted from omeprazole to lansoprazole. Of the 3833 patients, 325 (8.5%) currently receive omeprazole therapy; of these, 195 out of 3703 (5.3%) patients are true lansoprazole failures; 172 of these 195 patients completed the study. Most (87%) of the lansoprazole intolerant patients received prior omeprazole. Discontinuation of lansoprazole was due to poor symptom control in 69% and/or side-effects (22%) including diarrhoea (10%), abdominal pain (5%), or hives (1%). The 1-year cost of managing lansoprazole failure in 195 patients was $61 690. However, the savings to the VA during the same time period, which totalled $321 360, more than offset the costs associated with the conversion. CONCLUSIONS: Lansoprazole intolerance requiring omeprazole conversion occurred in 5% of veterans on proton pump inhibitor therapy for chronic gastro-oesophageal reflux disease (GERD) symptoms and in 10% of patients with prior omeprazole success. The VA realized substantial cost savings in association with the formulary change.

Prescribing practice and cost of antibacterial prophylaxis for surgery at a US Veteran Affairs hospital.

This study retrospectively compared the actual drug-related cost of antibacterial prophylaxis for specific operative procedures with the theoretical costs based on recommendations published in Medical Letter on Drugs and Therapeutics, the Surgical Infection Society, and those of the chiefs of each surgical subspecialty at our institution. We identified all patients who received in intravenous bacterial for prophylaxis before a clean or clean-contaminated operation between 1st January and 30th September 1993, using the medical centre's computerised information system. The information included comprehensive surgical case histories, and pharmacy and microbiology records. Only those operations in which recommendations for surgical prophylaxis were present in all 3 guidelines were included. The outcome measures were antibacterial-related costs (drug acquisition and administration costs), the number of antibacterial doses dispensed, and choice of antibacterial agents. During the study period, 3,322 operations were performed, 2,993 of which were excluded. Thus, 329 patients undergoing operations in 6 subspecialties were included in the analysis. The actual mean cost per patient significantly exceeded the projected costs using Medical Letter Consultants' and Surgical Infection Society guidelines for all 6 subspecialties [mean excess cost per patient: $US49.04 and $US34.95, respectively (1994 values)] and institutional guidelines for 4 of the 6 subspecialties (mean excess cost per patient: $US24.36). The actual mean number of doses per patient significantly exceeded those projected using Medical Letter Consultants' and Surgical Infection Society guidelines for all 6 subspecialties (mean excess number of doses per patient: 6.0 and 4.0, respectively) and institutional guidelines for 4 of the 6 subspecialties (mean excess number of doses per patient: 2.9). The choice of antibacterial was appropriate in approximately 90% of cases. We conclude that the practice of antibacterial prophylaxis for specific operative procedures performed by 6 subspecialties is not in accordance with institutional or published guidelines, and the excess cost is primarily a result of prolonged duration of antibacterial prophylaxis.