A comparison of the safety, timing and cost-effectiveness of administering antibiotics by intravenous bolus (push) versus intravenous piggyback (slow infusion) in surgical prophylaxis.

This study was carried out to evaluate the safety, timing and cost-effectiveness of administering perioperative antimicrobial prophylaxis with cefmetazole via intravenous (IV) bolus, or 'push', compared with the more common method of IV 'piggyback' administration. A total of 60 patients were studied, 30 in each group. No major adverse reactions were noted in either group. Phlebitis did not occur with either method of administration. Loss of patency was noted in 2 patients in the IV bolus group at the time of catheter removal. While no overall difference in timing of antibiotic administration in relation to the surgical procedure was noted, 2 patients in the IV piggyback group did not receive their preoperative dose until after surgery had started. Both pharmacy preparation time and nursing administration time were shorter with the IV push method, resulting in a cost avoidance of $US0.60 per dose. Material cost avoidance, primarily due to elimination of the minibag and IV tubing with bolus administration, was $US3.25 per dose. Extrapolated cost avoidance for our institution, for both prophylaxis and treatment, is $US184 000 per year. Administration of selected antibiotics by IV push is safe, allows optimal timing of administration, minimises preparation and administration time, and is cost-effective. Hospitals and outpatient care facilities should consider this alternative method of antibiotic administration.

Itraconazole treatment of phaeohyphomycosis.

Nineteen patients with phaeohyphomycosis were treated with itraconazole. Of these, 17 were assessable for clinical outcome. Of these, two had received no prior therapy, five had failed amphotericin B therapy, four had failed ketoconazole or miconazole therapy, and five had failed both amphotericin B and azole therapy. One patient had received only prior surgical intervention. Fungi of seven different genera caused disease of the skin in nine patients, soft tissue in nine, sinuses in eight, bone in five, joints in two, and lungs in two. Itraconazole was given in dosages ranging from 50 to 600 mg/day for 1 to 48 months. Clinical improvement or remission occurred in nine patients. Two patients have had stabilization of disease. Six patients failed treatment, one had a relapse after initially successful treatment. Itraconazole appears to be highly effective in some patients with phaeohyphomycosis, including patients refractory to other antifungal agents.

Sucralfate significantly reduces ciprofloxacin concentrations in serum.

The effect of sucralfate on the bioavailability of ciprofloxacin was evaluated in eight healthy subjects utilizing a randomized, crossover design. The area under the concentration-time curve from 0 to 12 h was reduced from 8.8 to 1.1 micrograms.h/ml by sucralfate (P less than 0.005). Similarly, the maximum concentration of ciprofloxacin in serum was reduced from 2.0 to 0.2 micrograms/ml (P less than 0.005). We conclude that concurrent ingestion of sucralfate significantly reduces the concentrations in serum produced by a 500-mg dose of ciprofloxacin. On the basis of these findings, ciprofloxacin and sucralfate should not be administered concurrently.

Postinfusion phlebitis after intravenous push versus intravenous piggyback administration of antimicrobial agents.

The incidence and severity of phlebitis associated with the i.v. push method versus the i.v. piggyback method of administration of antimicrobial agents were evaluated. All patients admitted to two nursing units of an 886-bed, tertiary-care hospital from March through June 1987 who received intravenous cephalosporins or extended-spectrum penicillins were considered for inclusion in the study. The method of administration, either i.v. push or i.v. piggyback, was randomly assigned. Each patient's catheter site was evaluated every 24 hours according to standardized definitions of phlebitis and patency. Information on each patient and venipuncture site also was collected. A total of 319 catheter sites were studied in 155 patients. There was no significant difference in the incidence or severity of postinfusion phlebitis between the i.v. push and the i.v. piggyback groups (41% versus 47%). When studying only those catheter sites discontinued because of phlebitis, the time until development of phlebitis averaged 45 +/- 20.5 hours in the i.v. push group, compared with only 36.2 +/- 17.6 hours in the i.v. piggyback group; this difference was significant. The fact that the catheter sites lasted significantly longer in the i.v. push group, combined with elimination of the cost of syringe infusion pumps or i.v. tubing and minibags, suggests that use of the i.v. push method may result in substantial cost savings. Other advantages associated with the i.v. push method include time savings for nursing personnel and patients and greater ease in scheduling doses of multiple antimicrobial agents.(ABSTRACT TRUNCATED AT 250 WORDS)

Altered vancomycin dose vs. serum concentration relationship in burn patients.

Drug elimination in patients sustaining serious thermal injury may be altered, resulting in an increased clearance and shortened half-life. Nine burn and eight medical/surgical patients with normal renal function were studied prospectively. Doses were adjusted to achieve peak and trough vancomycin serum concentrations within a narrow range. No significant difference between the groups was noted in terms of demographic characteristics, creatinine clearance, or vancomycin serum concentrations. However, the difference in daily dose needed to maintain the specified serum concentrations was significantly greater for burn patients (p less than 0.02). Burn patients also had to be dosed significantly more often than medical/surgical patients to achieve peak and trough vancomycin serum concentrations within the desired range (p less than 0.02). The elimination half-life in burn patients was significantly shorter than that in control patients (p less than 0.001). Because of the unusually high dosage requirements in burn patients, along with their poor predictability, individualization of therapy with vancomycin serum concentrations is recommended to ensure a successful therapeutic outcome.

Optimal cefotaxime dosing for gram-negative bacteremia: effective trough serum bactericidal titers and drug concentrations 8 and 12 hr after 1- or 2-gm infusions.

Thirteen adult patients (47-81 yr) with gram-negative bacteremia and normal (less than or equal to 1.5 mg/dl) serum creatinines were treated with 1 or 2 gm of cefotaxime every 8 or 12 hr. The infecting organisms were Escherichia coli (9 strains), Klebsiella pneumoniae (2 strains), and one isolate of Salmonella enteritidis and Serratia marcescens. All patients recovered without any serious sequelae. The range of MICs for cefotaxime and desacetyl-cefotaxime were 0.015-0.25 micrograms/ml and 0.015-4.0 micrograms/ml, respectively. The MBC values for cefotaxime and desacetyl-cefotaxime were identical to the MIC values except for two strains. The trough levels of cefotaxime varied from 65.9 to 1.1 micrograms/ml. The serum concentration of desacetyl-cefotaxime varied from 84 to less than 1.0 microgram/ml. All corresponding trough serum inhibitory activities (SIA) were greater than or equal to 1:32. Comparisons of calculated and directly measured serum bactericidal activity (SBA) and SIA results suggest an additive and occasional synergistic benefit of the cefotaxime desacetyl metabolite. This study supports the clinical efficacy and cost-effectiveness of 8- and 12-hr dosing intervals for cefotaxime against bacteremic gram-negative strains having the usual high susceptibility (MICs, less than or equal to 0.25 micrograms/ml) to the newer cephalosporins.

Treatment of central nervous system fungal infection with ketoconazole.

Two patients with fungal infection of the central nervous system (coccidioidal meningitis and cerebral histoplasmomas) were treated with ketoconazole for 30 months. Both responded to dosages substantially less than those described previously for similar infections. Neither patient experienced any significant adverse effects from the prolonged therapy.

Toxic shock syndrome in menstruating women.

Eight adult women became severely ill with an acute, toxic erythroderma during menses. The syndrome was characterized by fever, generalized erythema, profound shock, multiple organ dysfunction, and desquamation occurring several days after the rash had faded. Gastrointestinal and cardiovascular abnormalities were present in all patients; three patients required ventilatory support; dialysis was performed on two; and one patient died. Mild relapse occurred in two patients during subsequent menses; the other patients have recovered without sequelae during follow-up of 6 to 42 months. Cervical colonization or local infection with Staphylococcus aureus is associated with this syndrome.