Comparing a combination of penicillin G and gentamicin to a combination of clindamycin and amikacin as prophylactic antibiotic regimens in prevention of clean contaminated wound infections in cancer surgery.

BACKGROUND AND AIM: Appropriate antibiotic selection and timing of administration for prophylaxis are crucial to reduce the likelihood of surgical site infection (SSI) after a clean contaminated cancer surgery. Our aim is to compare the use of two prophylactic antibiotic (PA) regimens as regards efficacy, timing, and cost. PATIENTS AND METHODS: Two hundred patients with gastric, bladder, or colorectal cancer were randomized to receive preoperative PA, group A received penicillin G sodium and gentamicin and group B received clindamycin and amikacin intravenously. The demographic data of patients were collected, and they were observed for wound infections. RESULTS: Infected wounds occurred in 19 patients with a rate of 9.5%. Highest incidence of SSI was among bladder cancer patients (14.2%); p=0.044. The rate of SSI was 11% in group A, and 8% in group B, p=0.469. The cost of PA administered in group A was significantly less than that of group B (21.96±3.22LE versus 117.05±12.74LE, respectively; p<0.001). SSI tended to be higher among those who had longer time for antibiotic and incision (≥30min) than those who had shorter time interval (<30min), (13% vs. 6.5%, respectively). CONCLUSION: Both penicillin+gentamicin and clindamycin+amikacin are safe and effective for the prevention of SSI in clean contaminated operative procedures. In a resource limited hospital, a regimen including penicillin+gentamicin is a cost-effective alternative for the more expensive and broader coverage of clindamycin+amikacin. Timing of PA is effective in preventing SSIs when administered 30min before the start of surgery.

An oral carbapenem, but only now intravenous penicillin: the paradox of Japanese antimicrobials.

At present there is a profound paradox in antimicrobial use and development in Japan. A tightly held domestic pharmaceutical market with significant barriers to the importation and registration of foreign agents, has spurred domestic pharmaceutical companies to develop a vast range of antimicrobials. Many Japanese developed antimicrobials are now used globally. A negative consequence of this environment, however, is the lack of availability of several 'workhorse' narrow-spectrum agents to treat patients in Japan. Absent agents include anti-staphylococcal penicillins and until recently, intravenous benzylpenicillin. In substitution for these unavailable agents, patients are frequently administered broader spectrum antimicrobials. This change offers no additional benefit to the patient and is potentially contributing to treatment failure and high rates of antimicrobial resistance amongst key bacterial pathogens in Japan. The situation in Japan illustrates the broader global challenges faced in integrating the development of new antimicrobial agents with maintaining the supply and use of older and less profitable agents.

Oral versus i.v. antibiotics for community-acquired pneumonia in children: a cost-minimisation analysis.

Community-acquired pneumonia represents a high financial burden to healthcare providers. This manuscript seeks to estimate and compare the costs of treating children hospitalised with community-acquired pneumonia, with oral and intravenous antibiotics, thus determining which treatment is cost minimising. A cost-minimisation analysis was undertaken alongside a randomised controlled non-blinded equivalence trial. 232 children (from eight paediatric centres in England) diagnosed with pneumonia, who required admission to hospital, were randomised to receive oral amoxicillin or i.v. benzyl penicillin. The analysis considered the cost to the health service, patients and society, from pre-admission until the child was fully recovered. Oral amoxicillin and i.v. benzyl penicillin have equivalent efficacy. Children treated with i.v. antibiotics were found to have significantly longer in-patient stays (3.12 versus 1.93 days; p<0.001). i.v. treatment was found to be more expensive than oral treatment ( pound1,256 versus pound769; difference pound488; 95% CI: pound233- pound750), such that treatment of community-acquired pneumonia with oral amoxicillin would result in savings of between pound473 and pound518 per child (euro545 and euro596 per child) admitted. The findings demonstrate that oral amoxicillin is a cost-effective treatment for the majority of children admitted to hospital with pneumonia.

Randomized controlled trial on prevention of postcesarean infection using penicillin and cephalothin in Brazil.

BACKGROUND: There is a need to assess the effects of different antibiotic administration models on infectious complications among women from low-income populations who undergo cesarean delivery, and the cost benefit. DESIGN: Randomized, blinded controlled clinical trial study of a single preoperative dose of cephalothin, versus a postcesarean scheme for infection prophylaxis, versus no antibiotics. METHODS: The setting was a tertiary Brazilian center with 1,500 deliveries annually. Pregnant women (n = 600) with an indication for emergency or elective cesarean section were randomly allocated consecutively to one of three groups and treated as follows: Group 1 (n = 200), no antibiotics; Group 2 (n = 200), the standard antibiotics scheme followed at this center; Group 3 (n = 200), a single dose of intravenous cephalothin 2 g, intraoperatively. MAIN OUTCOME MEASUREMENTS: Prevalences of wound infection, puerperal and postcesarean infections, and costs of antibiotics used. RESULTS: Antibiotics reduced the incidence of puerperal infection, but did not change the percentages of wound and postcesarean infections and no use of antibiotics increased the puerperal infection risk sixfold. Cephalothin reduced the relative risk of puerperal infection by 89% (95% confidence interval: 7-87%). Penicillin reduced it by 78%, but this was not statistically significant. No deaths occurred. The costs of the two schemes were similar (almost US 1.00 dollars). CONCLUSIONS. Prophylactic cephalothin use was associated with decreased postcesarean puerperal infection and presented a cost benefit.

The efficacy of an antibiotic protocol for community-acquired pneumonia.

OBJECTIVE: To assess the efficacy of an antibiotic protocol to avoid empirical use of third-generation cephalosporins in community-acquired pneumonia (CAP). DESIGN AND SETTING: Retrospective case review of patients with CAP one year after implementing the protocol. Comparison was made with patients with CAP treated at a metropolitan tertiary referral hospital (where use of third-generation cephalosporins was common). PARTICIPANTS: 86 patients (district hospital with an antibiotic protocol) and 72 patients (metropolitan tertiary referral hospital), January - June 1999. OUTCOME MEASURES: Rate of staff adherence to the protocol; patient characteristics associated with poor protocol adherence; demographic and prognostic features of both groups at presentation; duration of intravenous therapy, time to defervescence, length of stay; inpatient mortality rates; and drug cost savings per patient treated according to the protocol. RESULTS: Overall protocol adherence rate was 60%. Patients with penicillin allergy were significantly less likely to receive treatment according to the protocol (P<0.001). At the district hospital, patients were generally older and taking more regular medications. Patients at each hospital had similar prognostic factors and demographic features at presentation. Inhospital mortality (P=0.92; 95% CI, -0.08 to 0.07), duration of fever (P=0.57) and length of stay (P=0.78) were not significantly different between patients treated empirically with penicillin and those treated empirically with third-generation cephalosporins. Treating a patient according to the protocol saved an average of $77.44 in drug costs. CONCLUSION: One year after implementation, our protocol for treating CAP is proving efficacious, although levels of adherence could improve.

Penicillin dosing for pneumococcal pneumonia.

Most textbook authors still endorse penicillin G as the specific antibiotic of choice for pneumococcal pneumonia. However, problems with early precise etiologic diagnosis of pneumonia and the emergence of drug-resistant pneumococci cause penicillin to be seldom used for this purpose today. A third explanation for the infrequent use of penicillin is lack of clear consensus dosing guidelines. Emergence of pneumococci resistant to the newer cephalosporins and concerns about overuse of vancomycin, however, have prompted renewed interest in the development of precise, rapid methods for diagnosis of pneumococcal pneumonia with the implication that penicillin might be used more frequently. We review several issues concerning penicillin dosing: intermittent vs continuous therapy, high dose vs low dose, relationship of dose to resistance, and cost-effective pharmacology. An optimum "high-dose" regimen for life-threatening pneumococcal pneumonia in a 70-kg adult consists of a 3 million unit (mu) loading dose followed by continuous infusion of 10 to 12 mu of freshly prepared drug every 12 h. The maintenance dose should be reduced in elderly patients and in patients with renal failure according to the following formula: dose (mu/24 h = 4+[creatinine clearance divided by 7]). This regimen provides a penicillin serum level of 16 to 20 microg/mL, which should suffice for all but the most highly resistant strains (minimum inhibitory concentration > or = 4 microg/mL). Newer cephalosporins and vancomycin can be reserved for patients with suspected meningitis or endocarditis or for localities in which highly resistant pneumococci are known to be prevalent.