Changes in antimicrobial agent usage resulting from interactions among clinical pharmacy, the infectious disease division, and the microbiology laboratory.

Rapid reporting of culture and susceptibility data is the first of several important steps in the successful management of infected patients. As has been said many times, rapidly reported data are of little value unless the patient directly benefits. Benefit requires better overall communication and an action plan linked to timely use of these results. In 1989 the Millard Fillmore Hospital Antibiotic Review Committee developed and implemented a prototype approach to hospital wide antimicrobial management. The formulary was revised and the drug use evaluation process modified to enhance effectiveness and to lower the cost of therapy and inventory. Clinical pharmacy antimicrobial agent management specialists were then recruited to individualize patient treatments to the isolated pathogens in conjunction with the Division of Infectious Diseases. To provide the clinical pharmacy specialists with rapid and clinically useful information, a real-time computer link was created between the pharmacy (antibiotic orders) and the microbiology laboratory (culture results). Customized software was implemented to screen all patients automatically for mismatches between pathogens and drugs, or to screen for doses inappropriate to minimum inhibitory concentration or renal function. Special attention was paid to identification of opportunities to target a more appropriate narrow-spectrum regimen after culture results became available. Changes in antimicrobial regimen or dosage were made by contacting the prescribing physician. Over 90% of the recommended changes were made, and virtually all changed regimens had satisfactory clinical outcome. Real dollar expenditures for antimicrobial agents declined by > $200,000 per year. Prior to the institution of this computerized clinical management strategy, antimicrobial purchases were rising yearly at the rate of 12%-15%. The combined efforts of clinical pharmacy, microbiology, and infectious disease personnel successfully optimized antimicrobial therapy on a hospital wide basis. Antimicrobial agent optimization improved patient outcome, and the cost savings more than covered the costs of the program personnel and software.

NaCl transport by Madin Darby canine kidney cyst epithelial cells.

The mechanism of NaCl transport across the epithelium of intact MDCK cysts grown in a collagen gel matrix was investigated. Double-barreled microelectrodes were used to measure basolateral membrane PD (Vbl), transepithelial PD (Vt), and intracellular (Cli) and intralumenal (Clcy) Cl- activities in cysts under different conditions. In a control Ringer's solution (RS), Cli (60 +/- 1 mM) and Clcy (107 +/- 2 mM) exceeded the values corresponding to electrochemical equilibrium across the basolateral membrane and epithelium, respectively. Cli was reduced by superfusing the cysts with a low Cl- RS (Cli, 20 +/- 3 mM), a low Na+ RS (Cli, 40 +/- 4 mM), or by adding amiloride to the control RS (Cli, 46 +/- 1 mM). Cli was unaffected by removal of either K+ or HCO3- from the RS or by adding furosemide or SITS to the control RS. Vbl in the control RS was -50 +/- 2 mV and was affected only by removal from the RS of K+ (Vbl, -31 +/- 3 mV) or HCO3- (Vbl, -29 +/- 4 mV) or by the addition of SITS to the control RS (Vbl, -59 +/- 5 mV). Vt in control RS was -2 +/- 0.2 mV (lumen negative), and was increased by reducing bath Na+ (Vt, -37 +/- 2 mV) but not by reducing bath Cl-. These data indicate that Cl- is secreted in a basolateral to apical direction by the cyst epithelium. Basolateral Cl- transport probably occurs mainly by an electroneutral Cl-/HCO3- exchanger. Transepithelial Na+ transport seems to occur via a paracellular route which appears to be cation selective. These experiments also support the existence, in the basolateral membrane, of a Na+/K+ ATPase, a Na+/H+ exchanger, and possibly a Na+/HCO3-/CO3(2-) transporter.

Femoral intraarterial digital angiography: an outpatient procedure.

Selective intraarterial digital angiography was performed in 50 patients with known or suspected peripheral vascular disease. Excellent anatomic detail was provided by low-volume injection of 80 mgl/ml contrast medium. The procedure was performed with a 20- to 21-gauge needle or short 3 French catheter as an outpatient procedure. No complications were observed. Thirty-five patients underwent subsequent surgical repair of abnormalities demonstrated by this direct intraarterial technique.