Trends in outpatient antibiotic use in Israel during the years 2000-2010: setting targets for an intervention.

PURPOSE: The abundant use of antibiotics (Abs) in the community plays a major role in inducing Ab resistance, but the literature concerning patterns in outpatient Ab use is limited. This study aims to lay the foundations for future policy and interventional programs to address the rise in Ab resistance by looking at long-term trends in Ab usage in Israel. METHODS: Defined daily doses per 1,000 inhabitants per day (DID) of total Ab use, consumption in different age groups, and of different Ab preparations were calculated for the years 2000, 2005, and 2010 in the eight districts of Israel. Data were collected from the pharmacy registries of "Clalit Health Services", the largest Health Maintenance Organization (HMO) in Israel, covering 4 million patients, representing 53 % of the population. Trends in use over time were analyzed. RESULTS: The overall Ab usage in Israel has remained constant in the last decade. Three significant trends were identified in this study: an increase in the consumption of expensive, broad-spectrum Abs, paralleled by a reduction in narrow-spectrum Abs; an increase in Ab consumption among the elderly, counteracted by reduced usage among children; large regional variations in the overall and specific use of Ab agents. CONCLUSIONS: Our main findings of increased broad-spectrum Ab consumption, primarily among the adult population in Israel, and a wide variability in Ab use between the regions in Israel, can focus our future studies on searching for the factors behind these trends to aid in constructing interventional methods for decreasing outpatient Ab overuse.

Variability in outpatient antimicrobial consumption in Israel.

BACKGROUND: Antibiotic consumption has an important effect on microbial resistance. Nationwide data on the comparative use of antibiotics in outpatient settings in Israel have only been partially collected and published. The aim of our study was to analyze the use of antibiotics in the outpatient setting in Israel and assess a number of influencing factors. MATERIALS AND METHODS: Defined daily doses per 1,000 inhabitants per day (DID) of total antibiotic use, consumption in different age groups, and consumption of different antibiotic groups were calculated for the years 2003-2005 in the districts of Israel. The data was collected from prescription data compiled by the pharmaceutical services of "Clalit Health Services", the largest health maintenance organization (HMO) in Israel, covering 55% of the population.Trends in use and variables associated with antibiotic consumption were analyzed. RESULTS: There was a significant decrease in antibiotic use from 2003 to 2005, ranging from 1.8 to 8.2% in the different districts. The highest consumption was noted in the youngest age groups, with more than half of all antibiotics prescribed to children < or = 18 years of age. Antibiotic consumption was significantly different between the different regions in Israel. A multivariate analysis revealed that a higher prevalence of diabetes mellitus was the only significant variable associated with antibiotic use. Variability in the use of different antibiotics was also found; for example, amoxicillin comprised 19.5-33.4% of total antibiotic consumption in the different districts, while fluoroquinolone consumption ranged from 3.2 to 7.3%. CONCLUSIONS: Outpatient antibiotic use in the population insured by "Clalit Health Services" declined between 2003 and 2005. Children had the highest consumption rates. There were large differences in antibiotic use between geographic regions, and diabetes mellitus was the only variable significantly associated with antibiotic use. We therefore conclude that most of the differences in antibiotic use are likely due to doctor preferences, local routines, and patients' attitudes and expectations.

[Israel hospital pharmaceutical services: a national survey].

Results of a 1996 survey of hospital pharmaceutical services in Israel are presented. A questionnaire was mailed to 46 pharmacy directors in Israel hospitals of which a total of 33 were returned (72%). The main services provided at hospital pharmacies are production of pharmaceuticals and inventory management. The pharmacy directors estimated that more then half of their pharmacists' time was spent on technical work that did not need their academic, professional knowledge. In Israel general hospitals there are on the average 1.23 full time pharmacist positions per 100 hospital beds and 1.09 positions for other pharmacy employees. A similar survey carried out in the United States showed an average of 7.4 pharmacists per 100 hospital beds. Pharmacists there have broad clinical roles which, in general Israeli pharmacists do not have. Computer systems are used in our pharmacies mainly for inventory management. About half of the directors did not think that the location, structure and furnishings of their pharmacy were appropriate for its role. Under current conditions, Israel hospital pharmacies are not organized to provide pharmaceutical services beyond inventory management and pharmaceutical production. Appropriate budgets and personnel are required to develop clinical pharmacy services at Israel hospitals. This would lead to improved quality of drug treatment and cost-containment and would allow pharmacists to exploit their knowledge, skills and training that under the current system, are only partially utilized.

[The clinical pharmacist in internal medicine--impact on the quality of therapeutic care].

Several studies have documented the impact of clinical pharmacy services on patient care and drug costs in hospital wards. However most hospitals in Israel do not provide such services and until recently their benefits in local health care have not been demonstrated. We therefore determined whether the activity of a pharmacist in the medical department of a medical center leads to improved quality of drug utilization and reduced costs. During the first 3 months of the clinical pharmacist's work all interventions and consultation were documented. The effect of these interventions on drug costs was calculated by the change in drug acquisition costs during the study period compared with those of preceding months, as well as in the other 5 medical departments of the hospital without clinical pharmacy services. During the study period the pharmacist joined 44 clinical rounds in which he documented 40 consultations in response to physicians' requests for drug information and 42 interventions on his own initiative. The pharmacist's recommendations were accepted in 38 of the 42 cases (90%). In 10 cases the pharmacist's initiative in improving the quality of drug therapy led to an increase in drug acquisition costs. However, the overall drug costs during the study period decreased 12.6%. During the same period drug costs in the other medical departments decreased only 2.2%. The results of this study conform with those of many other studies that show a beneficial impact of the clinical pharmacist on the quality of drug therapy and on drug costs. They indicate that the clinical pharmacist can play a crucial role in the medical department.

Drug use evaluation of ciprofloxacin: impact of educational efforts on appropriateness of use.

OBJECTIVE: To evaluate the appropriateness of ciprofloxacin use in a 550-bed general hospital before and after an educational intervention. METHOD: A drug use evaluation was carried out for 6 weeks, to examine the appropriateness of initiating therapy with ciprofloxacin, as judged by compliance with the hospital's protocols for antibiotic use. The results were distributed to all the hospital physicians, together with a review of the usage guidelines. Four months later the survey was repeated to examine the effects of this educational effort on the patterns of use. RESULTS: During the initial survey, 115 patients were treated with ciprofloxacin. During the follow-up 126 patients were treated with ciprofloxacin. The percentage of unjustified use had decreased from 31% to 13% at follow-up (P<0.005). Improvement was seen in all the hospital departments needing improvement and most significantly in the medical departments. The most frequent indication for use of the drug was urinary tract infection (86 patients (36%) in total in the two stages). The most significant improvement was in justified usage for urinary tract infections: from 65% in the initial stage to 88% in the second stage (P < 0.025). CONCLUSION: This study indicates that performing a drug use evaluation and distributing the results to the doctors concerned has a beneficial effect on the appropriateness of drug use and provides an important tool for identifying the main problems in prescribing, so that educational efforts can be focused.

"Acute" fat deposition in bowel wall submucosa: CT appearance.

OBJECTIVE: The deposition of submucosal fat in small and large bowel is known to occur in chronic processes such as inflammatory bowel disease, and has been assumed to reflect long disease duration. However, we have observed that submucosal fat deposition can occur in a short period of time. MATERIALS AND METHODS: Four patients were evaluated in whom serial CT examinations showed intramural fat deposition occurring within six months of a normal study. Confirmation of fatty deposition was made by Hounsfield unit measurement in all patients and by pathologic examination of bowel specimens in two patients. RESULTS: All four patients received cytoreductive chemotherapy for treatment of lymphoma or leukemia prior to the development of fat deposition. In all patients, serial CT examination documented the occurrence of fat-attenuation bowel wall thickening that developed in a short time period (12, 36, 67, and 186 days). Three of the four cases were initially misinterpreted as wall thickening from other causes (intussusception or colitis). Pathologic examination of bowel in the two patients with the shortest time intervals confirmed the presence of mature fat confined to the submucosa. CONCLUSION: These cases demonstrate that submucosal fat deposition in bowel wall is not limited to inflammatory bowel disease and other longstanding, chronic diseases; fatty infiltration can occur in a relatively short period of time, and is particularly likely to occur after cytoreductive therapy.

Evaluation of fat saturation technique for T2-weighted MR imaging of the spine.

The objective of this study was to evaluate the use of fat saturation for performance of T2-weighted imaging of the spine. Eighteen consecutive patients underwent MR imaging of the cervical (n = 7) or lumbar (n = 11) spine with proton density/T2-weighted sequences (TR 2200 ms, TE 30/80 ms) performed with and without fat saturation. Quantitative and qualitative analysis of images was conducted to compare tissue contrast, myelographic effect, presence of artifacts, and ability to delineate important anatomic structures on conventional and fat suppressed sequences. Images obtained with fat saturation demonstrated improved myelographic effect and increased contrast between vertebral body and disk, and between CSF and nerve roots/spinal cord. Image quality and most artifacts were equal on both sequences, though fat suppressed images had reduced image uniformity. Quantitative measurements of tissue contrast indicated improved contrast between vertebral bodies and CSF, disk, and spinal cord/nerve roots on fat saturation images.

MR imaging of bone marrow lesions: relative conspicuousness on T1-weighted, fat-suppressed T2-weighted, and STIR images.

OBJECTIVE: Fat-saturation pulse sequences offer important potential advantages for depiction of bone marrow lesions on MR images. The objectives of this study were to evaluate the relative conspicuousness of bone marrow lesions on images obtained by using two of the most widely available fat-suppression techniques, short-TI inversion recovery (STIR) and fat-saturation T2-weighted imaging, and to analyze the effect of these methods on image quality. In addition, we sought to determine if either or both of these sequences provide significant advantages relative to conventional T1-weighted spin-echo images for the evaluation of bone marrow lesions. SUBJECTS AND METHODS: T1-weighted (600/15 [TR/TE]), STIR (2500/20/160 [TR/TE/TI]), and fat-saturation T2-weighted (2500/20-70) MR images were obtained with a 1.5-T system in 34 consecutive patients with suspected bone marrow lesions. The conspicuousness of 36 lesions was evaluated subjectively by three radiologists, who also evaluated the MR images for how well they showed margination and extent of the lesion, image uniformity, motion artifacts, and overall image quality. In addition, lesion contrast on these sequences was compared quantitatively by using percentage contrast measurements. RESULTS: Lesions were qualitatively equally conspicuous with all four pulse sequences. Quantitative measurements indicated that lesions were more conspicuous on fat-saturation T2-weighted and STIR images than on T1-weighted images (p < .001). Differences between the first two sequences were not significant. Factors related to image quality, including reduction in motion artifacts and image uniformity, were generally superior on T1-weighted images. CONCLUSION: T1-weighted, fat-saturation T2-weighted, and STIR sequences all provide a high degree of sensitivity for depiction of most types of bone marrow abnormalities. Although the conspicuousness of lesions is similar on fat-saturation T2-weighted and STIR images, the former sequence has several practical advantages, including acquisition of more slices per unit time and improved tissue specificity. The combination of T1-weighted and either fat-saturation T2-weighted or STIR images is highly effective for the evaluation of bone marrow lesions.

Intraoperative pneumothorax during laparoscopic cholecystectomy: a complication of prior transdiaphragmatic surgery.

Pulmonary complications of laparoscopic surgery include subcutaneous emphysema, mediastinal emphysema, hypercarbia, and pneumothorax. Pneumothorax is a rare complication that may occur in patients with diaphragmatic defects. We report a case of intraoperative left-sided pneumothorax in a patient who had undergone an esophagogastrectomy for carcinoma 16 years previously. The mechanisms for development of this complication and its management are discussed.

CT depiction of prostatic zonal anatomy.

The objective of this study was to investigate the frequency of recognition of prostatic zonal anatomy on CT. Computed tomography in 71 patients without known prostate disease was reviewed. Differential attenuation allowed for distinction of the peripheral zone and central gland of the prostate in 24% patients. The peripheral zone was of lower attenuation than the central gland, attributable to relatively increased water content in the peripheral zone. Patients in whom zonal anatomy was evident were significantly older and had prostate glands significantly larger than those in whom the prostate appeared as a homogeneous structure. All patients in whom prostatic zonal anatomy was visualized had received intravenous contrast material injection. Development of benign prostatic hyperplasia nodules within the central gland may contribute to relative increased attenuation or increased contrast enhancement within this region of the prostate gland.

Periportal contrast enhancement on CT scans of the liver.

Periportal contrast enhancement relative to adjacent liver and portal blood has been reported on CT scans in cases of schistosomiasis and hepatic Kaposi sarcoma in AIDS patients. We observed this phenomenon in 10 (8%) of 130 consecutive, contrast-enhanced, nondynamic CT examinations of the abdomen. Thus, the occurrence is more common and less specific than previously reported. Seven of the 10 patients in our series were receiving chemotherapy for malignant disease, and three had abdominal pain with no definitive diagnosis. In four of the 10 patients, corresponding areas of periportal low attenuation or radiolucency were observed on initial dynamically enhanced scans. Periportal enhancement may be related to late diffusion of contrast material into periportal areas that were initially radiolucent. Such diffusion may occur because of endothelial insult. Periportal contrast enhancement appears to be a nonspecific finding on nondynamic contrast-enhanced CT scans of the abdomen. Periportal enhancement is important to recognize because it can mimic the appearance of portal vein thrombosis and may also be used to differentiate intrahepatic biliary dilatation from periportal radiolucency.

Postgastrostomy tube deformity on upper GI series.

Three cases are presented in which a focal concave deformity occurred along the greater curvature of the stomach on upper gastrointestinal (GI) series. These patients all had recent removal of a surgically placed gastrostomy tube from a similar location. This deformity appears to be related, at least in part, to invaginated gastric mucosa intentionally produced during surgical gastrostomy tube placement. This association and appearance should be noted as it may mimic other lesions.

The CT appearance of the giant left atrium.

The Giant Left Atrium (GLA) is a well-known, albeit rare, complication of mitral valve disease. Although traditionally diagnosed by chest X-ray or echocardiography (1, 2), when the left atrium achieves massive proportions, these modalities may be difficult to interpret or even misleading. We report, not only the first description of this entity using computer tomography (CT), but also one of the largest left atria described in the literature. We feel that CT may be reliable when making this diagnosis as well as useful in evaluation of those patients in whom the symptoms suggest some of the complications of this disease.

Opacification of ascitic fluid on delayed contrast computed tomography scans.

Ascitic fluid opacification on delayed intravenous contrast computed tomography scans was observed in eight consecutive patients imaged. This apparently common phenomenon may alter both the sensitivity and the specificity of ascitic fluid detection. It may also serve as a diagnostic aid by making nonascitic intra-abdominal fluid collections (ie, pseudocyst and cystic tumor) more apparent.

The extrapleural fat sign: CT characteristics.

Three cases of medially displaced extrapleural fat are presented. In these cases displacement is secondary to tumor, thoracic wall edema, and hematoma. When significantly displaced, and especially when distorted, the extrapleural fat may present a confusing CT picture. The recognition of this finding may aid in establishing differential diagnosis and staging.

The gastric air-fluid sign: aid in CT assessment of gastric wall thickening.

The differentiation of apparent gastric wall thickening due to incomplete gastric distention from true pathologic wall thickening can be difficult on computed tomographic (CT) scanning. We have observed a transition in gastric wall thickening that is often present at or slightly above the gastric air-fluid or air-contrast level. The apparently thickened gastric wall in the dependent portion of the stomach undergoes an abrupt change to normal thickness at or above the air-fluid level. Review of CT scans in 259 patients without known or suspected gastric pathologic conditions revealed this finding, termed the "gastric air-fluid sign," in 57 patients (22%). While not considered diagnostic, the presence of this sign may allow for a greater degree of confidence in the CT assessment of gastric wall thickening in an appropriate clinical setting.

Radiographic characteristics of colonic "mucosal bridges": sequelae of inflammatory bowel disease.

Colonic mucosal bridges are a relatively unusual entity occurring in patients with inflammatory disease of the colon. The authors describe two cases in which the pattern of multiple long, linear band-like defects may be easily misinterpreted as thickened mucosal folds, mucous strands, or foreign matter. The possibility of mucosal bridges should be considered if this radiographic pattern is demonstrated, and the patient's history is compatible with their formation.