Antibiotic prophylaxis prior to endoscopic retrograde cholangiopancreatography in patients with obstructive jaundice: is it worth the cost?

BACKGROUND: There are few published data concerning the economic impact of antibiotic prophylaxis prior to endoscopic retrograde cholangiopancreatography in the setting of biliary obstruction. AIM: To perform decision analysis to determine the costs of prophylaxis in patients undergoing endoscopic retrograde cholangiopancreatography for obstructive jaundice. METHODS: A decision analysis model was constructed. The probability of biliary sepsis, death and endoscopic retrograde cholangiopancreatography complications was obtained from the medical literature and from a retrospective analysis of our own experience. Costs were obtained from Medicare reimbursement at our institution. The strategies evaluated were endoscopic retrograde cholangiopancreatography with and without single-dose antibiotic prophylaxis. We compared the total costs, number of episodes of cholangitis and deaths associated with each strategy. RESULTS: Based on published data and the results of our retrospective analysis, the strategy of administering single-dose prophylactic antibiotics prior to endoscopic retrograde cholangiopancreatography in patients with obstructive jaundice resulted in lower total costs, fewer episodes of cholangitis and fewer deaths compared to a strategy of not administering antibiotics. The results were sensitive to the rates of cholangitis, cost of antibiotics and the cost of treating an episode of cholangitis. CONCLUSIONS: Antibiotic prophylaxis prior to endoscopic retrograde cholangiopancreatography results in fewer cases of cholangitis and is cost saving when compared to a strategy of no prophylaxis in patients with obstructive jaundice.

Magnetic resonance imaging of the brain in bacterial endocarditis.

Computed tomographic scanning of the brain is useful but not always conclusive in delineating central nervous system involvement in patients with bacterial endocarditis. Two patients are described in whom computed tomographic findings were normal, but magnetic resonance imaging revealed evidence of multiple brain abnormalities. Magnetic resonance imaging appears to be more sensitive than computed tomography for detecting central nervous system involvement in patients with bacterial endocarditis and should be employed when computed tomographic findings are normal in a patient with endocarditis and neurologic deterioration.

Evaluating the impact of education by a clinical pharmacist on antibiotic prescribing and administration in an acute care state psychiatric hospital.

An antibiotic utilization review program was implemented by a clinical pharmacist in an acute care state psychiatric facility. Antibiotic utilization was concurrently audited in 61 antibiotic orders, written for 48 patients, in order to determine antibiotic prescribing and administration practices and problems. Interventions, consisting of educational presentations, problem-solving meetings, and distribution of written educational materials, were provided by a clinical pharmacist to improve antibiotic prescribing and administration practices. A second audit of 68 antibiotic orders written for 47 patients was concurrently audited after completion of the interventions. When prescribing problems were detected, the clinical pharmacist made recommendations to the prescribing physician. Statistically significant changes in the use of culture and sensitivity tests, appropriate dosage regimens, correct antibiotic administration, and selection of cost-effective therapy were found after all educational interventions were provided. A positive trend not resulting in statistical significance was noted for documentation of infectious disease and selection of appropriate antibiotic agents. This study demonstrates a drug utilization review role for clinical pharmacist's involvement in the acute care psychiatric facility, and illustrates one method by which clinical pharmacists can provide educational programs to improve nonpsychotropic drug prescribing and administration in this setting.