Evaluation of Acinetobacter baumannii infection and colonization, and antimicrobial treatment patterns in an urban teaching hospital.

In 1990 there was a sudden increase in the incidence of colonization and infection due to Acinetobacter baumannii (AB) in our intensive care units (ICUs). The isolates were multiply resistant to beta-lactam and aminoglycoside antibiotics, but remained susceptible to imipenem, amikacin, and ampicillin-sulbactam. We examined the frequency of infection and colonization with AB and the effects of increased imipenem and amikacin therapy on Pseudomonas aeruginosa. We also used disease-matched controls to determine the clinical and financial impacts of treating colonization. All patients with at least one AB isolate from January-December 1992 were identified retrospectively and classified as infected or colonized based on published Centers for Disease Control criteria; the control group was selected from a computerized medical records data base matching primary diagnostic codes (102 patients both groups). The 102 patients yielded 140 isolates, 124 resistant AB and 16 sensitive AB. Thirty three patients were infected, 69 colonized. Mortality correlated with APACHE II scores. Patients acquired the organism approximately 2 weeks after admission; they had a mean ICU stay of 27.35 days, compared with 5.53 days for controls. Patients with positive AB cultures required significantly more use of ventilators than those with negative AB cultures. They also had significantly longer hospital stay, more bed transfers, greater duration and number of antibiotics, and higher hospital and pharmacy charges. Unnecessary treatment for colonization with either imipenem or amikacin resulted in a substantial decrease of P. aeruginosa susceptibility to each agent. The financial impact of treating colonization was significant and is a potential area for cost avoidance. Our results emphasize the need to extubate and move patients to non-ICU beds as soon as possible to decrease the risk of nosocomial infection. It also highlights the need to avoid treating colonization, thus avoiding unnecessary antibiotic therapy.

Urokinase activity after freezing: implications for thrombolysis in intraventricular hemorrhage.

The retention of urokinase activity after frozen storage was studied. Urokinase powder was reconstituted aseptically in sterile water for injection or preservative-free 0.9% sodium chloride injection to a final concentration of 5000 IU/mL. Samples were stored in 5-mL plastic syringes at -20 or -70 degrees C for up to six months. Samples containing urokinase 25,000 IU/mL were similarly prepared by using sodium chloride injection as the diluent and were stored frozen at the same temperatures for up to 93 days. Urokinase activity was measured with a chromogenic assay at each test interval. Samples were also cultured after thawing to evaluate their potential to support microbial growth. The activity of urokinase at either concentration did not change appreciably during the study period. The method of thawing-at room temperature or in a refrigerator-had no effect on urokinase activity. No microbial growth was observed. Urokinase 5000 IU/mL did not show any changes in activity when reconstituted with sterile water for injection or 0.9% sodium chloride injection and frozen for up to six months. Urokinase 25,000 IU/mL in sodium chloride injection was also stable after 93 days of frozen storage.

Omeprazole-induced exfoliative dermatitis.

A 41-year-old man being treated for severe esophageal reflux disease developed red, exfoliative scaling on his back, trunk, and legs after taking omeprazole 20 mg twice/day for 3 months. He also had redness and extreme sloughing of the skin on his hands. Even after he discontinued omeprazole and after several courses of topical and systemic steroids, symptoms continued to occur 18 months after treatment, mostly localized to the hands. Exfoliative dermatitis is associated with many drugs, but omeprazole has been implicated only once before in the literature.

A pharmacist-initiated program of intravenous to oral antibiotic conversion.

A prospective program to convert patients from parenteral to oral antibiotics was evaluated over 12 months to determine its pharmacoeconomic impact on antibiotic acquisition and length of hospital stay. Physicians of patients meeting predetermined clinical criteria for mild and moderate infections were contacted to discuss potential oral alternative therapy. Clinical end points and economic data were followed in 242 patients (200 converted and 42 not converted but meeting criteria). No significant differences were noted between the groups with regard to demographic data, infection diagnosis, clinical outcome, or adverse effects. The average number of days of therapy for patients converted was 1.53 days shorter than that of patients who were not converted to oral therapy (p < 0.003). Cost savings for drug acquisition and length of stay were $15,149.24 and $161,071.88, respectively. The intervention program appeared to provide a cost-effective conversion from parenteral to oral antimicrobial administration without compromising patient care. It is anticipated that expansion of the program to include additional antibiotics will result in even greater cost savings for the institution.

Thromboembolic prophylaxis in moderate-risk patients undergoing elective abdominal surgery: decision and cost-effectiveness analyses.

We conducted a retrospective, literature-based decision analysis to compare the cost-effectiveness of conventional low-dose heparin, dalteparin, and intermittent pneumatic compression (IPC) as thromboembolic prophylaxis to a no-prophylaxis option in patients at moderate risk of developing thromboembolic complications after major elective abdominal surgery. The analysis was conducted through an institutional perspective. Probability and incidence rate data were summarized from the literature. Cost data were obtained from the Detroit Medical Center's cost accounting systems and from national diagnosis-related group estimates. Mortality and complications avoided were the main outcome measures on which cost-effectiveness was based. Overall costs associated with conventional low-dose heparin, dalteparin, intermittent pneumatic compression, and no prophylaxis were $84, $122, $102, and $112, respectively in the primary analysis, which included costs of labor. Corresponding cost-effectiveness ratios in terms of costs/complication-free patient were $86, $124, $103, and $118, respectively. Compared with no prophylaxis, incremental cost-effectiveness analysis in terms of cost/mortality avoided involved savings of $6087 and $3125 with conventional low-dose heparin and IPC, respectively, and expenses of $2857 with dalteparin. A secondary analysis excluding costs of labor showed similar results. The results of the study consistently showed conventional low-dose heparin to provide the most cost-effective thromboembolic prophylaxis of the methods considered in terms of reducing both morbidity and mortality in the patient population studied.

A pharmacoeconomic analysis of neuromuscular blocking agents in the operating room.

A cost-minimization analysis was performed to compare the direct costs of various neuromuscular blocking agents (NMBAs) in procedures of specific durations. Secondary objectives were to review the role of the NMBAs studied with respect to their place on our hospital formulary, and to develop a pharmacoeconomic methodology to be applied to other formulary decisions. Patients were stratified according to estimated length of surgical procedure; group 1 (55 patients) included surgeries estimated to take less than 2 hours, and group 2 (55 patients) included those estimated to be 2-4 hours long. Patients were then randomized to one of three intermediate-acting NMBAs: atracurium, vecuronium, or rocuronium. Anesthesia records were used to obtain all anesthetic agents administered in the operating room, and drug costs were calculated from hospital drug acquisition costs as of December 1994. Postanesthesia care unit (PACU) costs were estimated from patient charges and converted to costs using our hospital's cost-to-charge ratio. Costs that were common to all study treatments or unrelated to the use of NMBAs were excluded from the analysis. Two time-adjusted costs were calculated to determine the cost of neuromuscular blockade/hour and the total anesthesia drug costs/hour. In group 1 there were no statistical differences in NMBA cost/hour, anesthesia cost/hour, or PACU times or costs. In group 2, a significant difference was found in NMBA cost/case between atracurium ($54.23 +/- 41.26, mean +/- SD) and vecuronium ($31.95 +/- 15.33, p = 0.046). Atracurium was also significantly more costly than either vecuronium or recuronium/hour ($21.95 +/- 7.42 vs $14.39 +/- 7.02 and $16.07 +/- 8.15, respectively, p = 0.011) and anesthesia cost/hour ($28.77 +/- 7.43 vs $ 22.82 +/- 7.46 and $23.32 +/- 6.54, respectively, p = 0.03). There were no differences in PACU times or costs. Based on these results, vecuronium or rocuronium is preferred over atracurium in procedures with an estimated duration of 2-4 hours. In the patient population evaluated, there were no significant cost differences among the three NMBAs in surgeries with an estimated duration of less than 2 hours.