Long-Term Impact of a Smartphone App on Prescriber Adherence to Antibiotic Guidelines for Adult Patients With Community-Acquired Pneumonia: Interrupted Time-Series Study.

BACKGROUND: Mobile health platforms like smartphone apps that provide clinical guidelines are ubiquitous, yet their long-term impact on guideline adherence remains unclear. In 2016, an antibiotic guidelines app, called SCRIPT, was introduced in Auckland City Hospital, New Zealand, to provide local antibiotic guidelines to clinicians on their smartphones. OBJECTIVE: We aimed to assess whether the provision of antibiotic guidelines in a smartphone app resulted in sustained changes in antibiotic guideline adherence by prescribers. METHODS: We analyzed antibiotic guideline adherence rates during the first 24 hours of hospital admission in adults diagnosed with community-acquired pneumonia using an interrupted time-series study with 3 distinct periods post app implementation (ie, 3, 12, and 24 months). RESULTS: Adherence increased from 23% (46/200) at baseline to 31% (73/237) at 3 months and 34% (69/200) at 12 months, reducing to 31% (62/200) at 24 months post app implementation (P=.07 vs baseline). However, increased adherence was sustained in patients with pulmonary consolidation on x-ray (9/63, 14% at baseline; 23/77, 30% after 3 months; 32/92, 35% after 12 month; and 32/102, 31% after 24 months; P=.04 vs baseline). CONCLUSIONS: An antibiotic guidelines app increased overall adherence, but this was not sustained. In patients with pulmonary consolidation, the increased adherence was sustained.

Validating the Remote First Aid Self-Efficacy Scale for Use in Evaluation and Training of First Responders in Remote Contexts.

INTRODUCTION: The purpose of this study was to investigate the psychometric properties of the remote first aid self-efficacy scale (RFA SES). The RFA SES is a 30-item self-report scale developed in response to emerging evidence showing that self-efficacy is predictive of performance. METHODS: Trained alumni from Wilderness Medical Associates (WMA) training courses and less trained students from Laurentian University (LU) were recruited via email to complete an online questionnaire at 2 different periods (T1 and T2). The questionnaire included demographic questions, the 30-item RFA SES, the 10-item Connor-Davidson resilience scale (CD-RISC), and the 10-item generalized self-efficacy scale (GSES). Data analysis included assessment of the dimensionality, reliability, and validity of the scale. RESULTS: There were 448 alumni from WMA and 1106 students from LU who participated in the study. The RFA SES demonstrated a clear unidimensional structure. The mean interitem correlation was 0.75 at T1. Test-retest reliability (T1 to T2) was high for both the LU group (intraclass correlation [ICC]=0.90) and the WMA group (ICC=0.92). Moderate correlations were found between RFA SES and CD-RISC (r=0.42, P<0.001), a general measure of resilience, and the GSES (r=0.48, P<0.001), a general measure of self-efficacy. Wilderness Medical Associates participants showed higher mean scores than LU students at T1 (t [569]=16.2, P<0.001). CONCLUSIONS: The RFA SES is a unidimensional, reliable, and potentially valid scale. Further research should focus on item reduction followed by additional tests of reliability and validity.

The Impact of the Auckland Cellulitis Pathway on Length of Hospital Stay, Mortality Readmission Rate, and Antibiotic Stewardship.

BACKGROUND: The Dundee classification of cellulitis severity, previously shown to predict disease outcomes, provides an opportunity to improve the management of patients with cellulitis. METHODS: We developed and implemented a pathway to guide the management of adults with cellulitis based on their Dundee severity class, and measured its effect on patient outcomes. We compared the outcomes in patients admitted to Auckland City Hospital (ACH) between July 2014 and July 2015 (the baseline cohort) with those in patients admitted between June 2017 and June 2018 (the intervention cohort). RESULTS: The median length of stay was shorter in the intervention cohort (0.7 days, interquartile range (IQR) 0.1 to 3.0 days) than in the baseline cohort (1.8 days, IQR 0.1 to 4.4 days; P < .001). The 30-day mortality rate declined from 1.8% (19/1092) in the baseline cohort to 0.7% (10/1362; P = .02) in the intervention cohort. The 30-day cellulitis readmission rate increased from 6% in the baseline cohort to 11% (P < .001) in the intervention cohort. Adherence to the ACH cellulitis antibiotic guideline improved from 38% to 48% (P < .01) and was independently associated with reduced length of stay. CONCLUSIONS: The implementation of the Auckland cellulitis pathway, readily generalizable to other settings, improved the outcomes in patients with cellulitis, and resulted in an annual saving of approximately 1000 bed days.

Emergency care with lay responders in underserved populations: a systematic review.

OBJECTIVE: To assess the individual and community health effects of task shifting for emergency care in low-resource settings and underserved populations worldwide. METHODS: We systematically searched 13 databases and additional grey literature for studies published between 1984 and 2019. Eligible studies involved emergency care training for laypeople in underserved or low-resource populations, and any quantitative assessment of effects on the health of individuals or communities. We conducted duplicate assessments of study eligibility, data abstraction and quality. We synthesized findings in narrative and tabular format. FINDINGS: Of 19 308 papers retrieved, 34 studies met the inclusion criteria from low- and middle-income countries (21 studies) and underserved populations in high-income countries (13 studies). Targeted emergency conditions included trauma, burns, cardiac arrest, opioid poisoning, malaria, paediatric communicable diseases and malnutrition. Trainees included the general public, non-health-care professionals, volunteers and close contacts of at-risk populations, all trained through in-class, peer and multimodal education and public awareness campaigns. Important clinical and policy outcomes included improvements in community capacity to manage emergencies (14 studies), patient outcomes (13 studies) and community health (seven studies). While substantial effects were observed for programmes to address paediatric malaria, trauma and opioid poisoning, most studies reported modest effect sizes and two reported null results. Most studies were of weak (24 studies) or moderate quality (nine studies). CONCLUSION: First aid education and task shifting to laypeople for emergency care may reduce patient morbidity and mortality and build community capacity to manage health emergencies for a variety of emergency conditions in underserved and low-resource settings.

Reducing Expectations for Antibiotics in Patients With Upper Respiratory Tract Infections: A Primary Care Randomized Controlled Trial.

PURPOSE: Many family practitioners prescribe antibiotics for patients with upper respiratory tract infections (URTIs) to meet patients' expectations. We evaluated the impact of providing brief tablet-based information about antibiotic treatment of URTIs on patients' expectations for antibiotics and on family practitioners' antibiotic-prescribing behavior. METHODS: We performed a 3-arm randomized controlled trial among patients presenting with URTIs at 2 urban family practices in Auckland, New Zealand, during winter 2018. Participants were randomly allocated to view a presentation about the futility of antibiotic treatment of URTIs, the adverse effects associated with antibiotics, or the benefits of healthy diet and exercise (active control), immediately before their consultation. Before and after viewing the presentations, participants used a Likert scale to rate the strength of their belief that antibiotics are effective for treating URTIs and of their desire to be prescribed an antibiotic. Patients reported whether an antibiotic had been prescribed, and pharmacy dispensing records were reviewed to determine whether an antibiotic was dispensed. RESULTS: Participants who viewed either the futility or the adverse effects presentation had greater reductions in their expectations to receive antibiotics than the control group. The mean reduction (95% CI) was 1.1 (0.8-1.3) for the futility group, 0.7 (0.4-0.9) for the adverse effects group, and 0.1 (0-0.3) for the control group (Cohen d = 0.7; P <.001). There was no significant difference among the 3 groups with regard to antibiotic prescribing (P = .84) or dispensing (P = .43). CONCLUSIONS: A brief tablet-based waiting room intervention significantly reduced participants' expectations about receiving antibiotics for URTI immediately before their family practitioner consultation. The intervention did not influence family practitioner prescribing behavior, however.

Conceptual framework for task shifting and task sharing: an international Delphi study.

BACKGROUND: Task shifting and sharing (TS/S) involves the redistribution of health tasks within workforces and communities. Conceptual frameworks lay out the key factors, constructs, and variables involved in a given phenomenon, as well as the relationships between those factors. Though TS/S is a leading strategy to address health worker shortages and improve access to services worldwide, a conceptual framework for this approach is lacking. METHODS: We used an online Delphi process to engage an international panel of scholars with experience in knowledge synthesis concerning TS/S and develop a conceptual framework for TS/S. We invited 55 prospective panelists to participate in a series of questionnaires exploring the purpose of TS/S and the characteristics of contexts amenable to TS/S programmes. Panelist responses were analysed and integrated through an iterative process to achieve consensus on the elements included in the conceptual framework. RESULTS: The panel achieved consensus concerning the included concepts after three Delphi rounds among 15 panelists. The COATS Framework (Concepts and Opportunities to Advance Task Shifting and Task Sharing) offers a refined definition of TS/S and a general purpose statement to guide TS/S programmes. COATS describes that opportunities for health system improvement arising from TS/S programmes depending on the implementation context, and enumerates eight necessary conditions and important considerations for implementing TS/S programmes. CONCLUSION: The COATS Framework offers a conceptual model for TS/S programmes. The COATS Framework is comprehensive and adaptable, and can guide refinements in policy, programme development, evaluation, and research to improve TS/S globally.

Quality of work life of paramedics practicing community paramedicine in northern Ontario, Canada: a mixed-methods sequential explanatory study.

INTRODUCTION: This article aimed to evaluate pilot community paramedicine (CP) programs in northern Ontario from the perspectives of paramedics to gain program recommendations related to both rural and urban settings. METHODS: An online questionnaire was created and distributed to 879 paramedics with and without CP experience employed at eight emergency medical services providers in northern Ontario. An explanatory sequential design was used to analyze and synthesize the results from the quantitative survey items and the open-ended responses. RESULTS: Seventy-five (40.5%) respondents participated in a CP program, and the majority of 75 paramedics who indicated they participated in CP (n=41, 54.4%) were from rural areas. CP was generally well received by both paramedics currently practicing CP and those who were not practicing CP. The majority (86.3%) of paramedics stated paramedics should be practicing CP in the future. Paramedics identified developing professional relationships and improving health promotion as positive aspects of CP. Areas for CP program improvement included better organization and scheduling, improved training and a need for better patient tracking software. CONCLUSION: Engaging and consulting paramedics in the ongoing process of CP development and implementation is important to ensure they feel valued and are part of the change process.

Association of the Dundee severity classification with mortality, length of stay and readmission in adult inpatients with cellulitis.

Background: The Dundee classification is a simple severity assessment tool that could optimize treatment decisions and clinical outcomes in adult patients with cellulitis; however, it has not been validated in a large cohort. Objectives: To determine whether the Dundee classification reliably identified those patients with cellulitis who had a higher mortality, a longer length of hospital stay or an increased risk of readmission. Methods: We performed a retrospective study of all adults with a primary discharge diagnosis of cellulitis admitted to Auckland City Hospital from August 2013 to June 2015. We classified patients by severity using the Dundee scoring system. Results: The 30 day all-cause mortality in adult patients with a discharge diagnosis of cellulitis was 2% (29/1462) overall, and was 1% (10/806), 2% (6/271), 3% (10/353) and 9% (3/32) in Classes 1, 2, 3 and 4 of the Dundee classification, respectively (P = 0.01). Mortality was strongly associated with age >65 years (OR 9.37, 95% CI 3.00-41.23) and with heart failure (OR 6.16, 95% CI 2.73-14.23). There were significant associations between the Dundee classification and the incidence of bacteraemia, the length of hospital stay and the rate of readmission to hospital. Conclusions: The Dundee classification is a simple, reliable tool that can be easily applied in clinical settings to predict risk of mortality in order to determine which patients can be managed in the community with oral or intravenous therapy, and which require inpatient care.

The use of a poster to reduce expectations to receive antibiotics for a common cold.

Many doctors prescribe antibiotics for a cold, to meet patient's expectations. As a result, patient's education about antibiotics and antibiotic resistance forms a major component of the WHO's Global Action Plan on Antimicrobial Resistance. However, it is not known whether simple educational material can change a person's attitudes about antibiotic therapy. We designed three posters about antibiotic treatment for "cold and flu". Hospital inpatients answered a baseline survey and then were asked to look at one of three randomly selected posters. The posters highlighted the futility of antibiotic treatment for colds (futility), the risk of adverse drug reactions from antibiotics (harm), and the issue of antimicrobial resistance (resistance). Participants then completed a follow-up survey. Participants' expectations to receive antibiotics for a "bad cold" reduced significantly after viewing a poster (82/299, 27% expected antibiotics in the baseline survey compared with 13% in the follow-up survey, P < 0.01). Continuing expectation to receive antibiotics after viewing one of the posters was associated with expectation to receive antibiotics in the baseline survey and the strong belief that colds were caused by bacteria. Participants who viewed the resistance poster were more likely to continue to expect antibiotics than participants who viewed the futility poster (OR 2.46, 95%CI 1.16-5.20, P = 0.02). Following discussion of the study, viewing a poster reduced participants' expectations to receive antibiotics for a hypothetical cold. Changing patients' expectations to receive antibiotics using simple educational material about antibiotic futility could lead to significant reductions in antibiotic prescription for viral upper respiratory tract infections.

Efficacy and acceptability of treatment to eradicate nasal Staphylococcus aureus carriage among haemodialysis patients.

AIM: For patients requiring haemodialysis, the risk of Staphylococcus aureus disease is higher in those colonized and persists while the person requires haemodialysis, necessitating frequent decolonization. However, the duration of successful decolonization is not known. This study aimed to determine the duration of efficacy of decolonization in intermittent and persistent S. aureus carriers requiring haemodialysis using two decolonization strategies. METHODS: We screened 100 outpatients requiring haemodialysis for S. aureus carriage and then decolonized 14 intermittent carriers and 18 persistent carriers. Participants were invited to undertake two decolonization attempts, using systemic or topical antibiotics 12 weeks apart. Nasal swabs were taken weekly to determine the duration of successful decolonization. RESULTS: Decolonization was successful in 24/32 (75%) participants and the median duration of decolonization was 35 days (95% confidence interval (CI) 11-59). The median duration of S. aureus decolonization was significantly shorter for persistent carriers (19 days, 95% CI 13-25 days) in comparison with intermittent carriers (70 days, 95% CI 61-79 days; P < 0.01). 28/52 (54%) post-decolonization surveys indicated that they would use the treatment again, 14/52 (27%) surveys indicated that they would not use the treatment again, and 10/52 (19%) were undecided. 16/53 (30%) decolonization attempts resulted in an adverse drug reaction. CONCLUSION: Staphylococcus aureus decolonization using topical or systemic treatments was successful for many haemodialysis patients, and provided a month free of S. aureus colonization. Although decolonization treatment provided a shorter duration of success for persistent carriers in comparison with intermittent carriers, persistent carriers are likely to gain the most from effective decolonization strategies.

Staphylococcus aureus colonisation and its relationship with skin and soft tissue infection in New Zealand children.

New Zealand children suffer from high rates of skin and soft tissue infection (SSTI). Staphylococcus aureus colonisation is known to increase the risk of nosocomial infection. We aimed to determine whether S. aureus colonisation also increased the risk of community-onset SSTI. This study, performed within the Growing Up in New Zealand cohort, used interview and administrative data, and bacterial culture results from the nose, throat, and skin swabs collected at 4½ years of age. Multivariable log-binomial regression was used to derive adjusted risk ratios. S. aureus was isolated from 2225/5126 (43.4%) children. SSTI affected 1509/5126 (29.4%) children before age five. S. aureus colonisation at any site was associated with SSTI (aRR = 1.09, 95%CI 1.01-1.19), particularly in the year prior to swab collection (aRR = 1.18, 95%CI 1.02-1.37). The strongest association was between skin colonisation and SSTI within the year prior to swab collection (aRR = 1.47, 95%CI 1.14-1.84). Socioeconomic and ethnic variables remained independent determinants of SSTI. S. aureus colonisation was associated with an increased risk of community-onset SSTI. Socioeconomic and ethnic factors and eczema had independent effects on SSTI risk. Interventions which reduce the prevalence of S. aureus colonisation may be expected to reduce the incidence of community-onset SSTI.

Antibiotic consumption by New Zealand children: exposure is near universal by the age of 5 years.

Background: Increasing concerns about antibiotic resistance and microbiome disruption have stimulated interest in describing antibiotic consumption in young children. Young children are an age group for whom antibiotics are frequently prescribed. Objectives: To describe community antibiotic dispensing during the first 5 years of life in a large, socioeconomically and ethnically diverse cohort of children, and to determine how antibiotic dispensing varied between population subgroups. Methods: This study was performed within the Growing Up in New Zealand longitudinal cohort study ( www.growingup.co.nz ) with linkage to national administrative antibiotic dispensing data. Descriptive statistics and univariate and multivariable associations were determined. Results: The 5581 cohort children received 53 052 antibiotic courses, of which 54% were amoxicillin. By age 5 years, 97% of children had received one or more antibiotic courses, and each child had received a median of eight antibiotic courses (IQR 4-13). The mean incidence of antibiotic dispensing was 1.9 courses/child/year. Multivariable negative binomial regression showed that Maori and Pacific children received more antibiotic courses than European children, as did children in the most-deprived compared with the least-deprived areas. A distinct seasonal pattern was noted. Conclusions: This study provided a detailed description of antibiotic dispensing within a large and diverse child cohort. Antibiotic exposure was near universal by age 5 years. The predominance of amoxicillin use and the seasonal pattern suggest much antibiotic use may have been for self-limiting respiratory infections. There is a need for safe and effective interventions to improve antibiotic prescribing practices for New Zealand children.

Ethnic disparities in infectious disease hospitalisations in the first year of life in New Zealand.

AIM: Infectious disease (ID) hospitalisation rates are increasing in New Zealand (NZ), especially in pre-school children, and Maori and Pacific people. We aimed to identify risk factors for ID hospitalisation in infancy within a birth cohort of NZ children, and to identify differences in risk factors between ethnic groups. METHODS: We investigated an established cohort of 6846 NZ children, born in 2009-2010, with linkage to a national data set of hospitalisations. We used multivariable logistic regression to obtain odds ratios (OR) for factors associated with ID hospitalisation in the first year of life, firstly for all children, and then separately for Maori or Pacific children. RESULTS: In the whole cohort, factors associated with ID hospitalisation were Maori (OR: 1.49, 95% CI: 1.17-1.89) or Pacific (2.51; 2.00-3.15) versus European maternal ethnicity, male gender (1.32; 1.13-1.55), low birthweight (1.94, 1.39-2.66), exclusive breastfeeding for <4 months (1.22, 1.04-1.43), maternal experience of health-care racism (1.60, 1.19-2.12), household deprivation (most vs. least deprived quintile of households (1.50, 1.12-2.02)), day-care attendance (1.43, 1.12-1.81) and maternal smoking (1.55, 1.26-1.91). Factors associated with ID hospitalisation for Maori infants were high household deprivation (2.16, 1.06-5.02) and maternal smoking (1.48, 1.02-2.14); and for Pacific infants were delayed immunisation (1.72, 1.23-2.38), maternal experience of health-care racism (2.20, 1.29-3.70) and maternal smoking (1.59, 1.10-2.29). CONCLUSIONS: Maori and Pacific children in NZ experience a high burden of ID hospitalisation. Some risk factors, for example maternal smoking, are shared, while others are ethnic-specific. Interventions aimed at preventing ID hospitalisations should address both shared and ethnic-specific factors.

Rapid Emergence and Evolution of Staphylococcus aureus Clones Harboring fusC-Containing Staphylococcal Cassette Chromosome Elements.

The prevalence of fusidic acid (FA) resistance amongStaphylococcus aureusstrains in New Zealand (NZ) is among the highest reported globally, with a recent study describing a resistance rate of approximately 28%. Three FA-resistantS. aureusclones (ST5 MRSA, ST1 MSSA, and ST1 MRSA) have emerged over the past decade and now predominate in NZ, and in all three clones FA resistance is mediated by thefusCgene. In particular, ST5 MRSA has rapidly become the dominant MRSA clone in NZ, although the origin of FA-resistant ST5 MRSA has not been explored, and the genetic context offusCin FA-resistant NZ isolates is unknown. To better understand the rapid emergence of FA-resistantS. aureus, we used population-based comparative genomics to characterize a collection of FA-resistant and FA-susceptible isolates from NZ. FA-resistant NZ ST5 MRSA displayed minimal genetic diversity and represented a phylogenetically distinct clade within a global population model of clonal complex 5 (CC5)S. aureus In all lineages,fusCwas invariably located within staphylococcal cassette chromosome (SCC) elements, suggesting that SCC-mediated horizontal transfer is the primary mechanism offusCdissemination. The genotypic association offusCwithmecAhas important implications for the emergence of MRSA clones in populations with high usage of fusidic acid. In addition, we found thatfusCwas colocated with a recently described virulence factor (tirS) in dominant NZS. aureusclones, suggesting a fitness advantage. This study points to the likely molecular mechanisms responsible for the successful emergence and spread of FA-resistantS. aureus.

Assessing children's interpretations of the Aboriginal Children's Health and Well-Being Measure (ACHWM).

BACKGROUND: There are emerging opportunities to improve the health of Aboriginal children and youth. The Aboriginal Children's Health and Well-being Measure (ACHWM) was developed to enable Aboriginal communities to obtain group-level data from the perspectives of their children 8 to 18 years of age. The survey was developed in collaboration with children, based on the Medicine Wheel framework. The purpose of this study was to ensure that children and youth interpreted the ACHWM questions consistently and accurately and to establish the face validity of the survey. METHODS: Children and parents/caregivers from the Wikwemikong Unceded Indian Reserve (Canada) participated in a detailed interview process as they completed the ACHWM, in 2012. Each participant worked through their thought process verbally, to enable the interviewer to identify questions that were misinterpreted or inconsistently interpreted. Questions were revised based on feedback from the participants, and reviewed with new participants until a stable version was established. The resulting version was reviewed by health care providers and community members to further ensure cultural relevance and face validity within the community. RESULTS: A total of 18 interviews, with 9 children and 9 caregivers, were required to achieve a stable version of the survey. The children ranged in age from 8 to 18 years. Revisions were required for 19 questions. Most of these revisions were minor linguistic changes. In addition, 6 questions were deleted due to consistent problems and 4 questions were created to address gaps identified during the process. Community members confirmed the appropriateness of the measure for their community and communicated their pride in their youth's role in the development of this survey. CONCLUSIONS: The result was a 58-question version of the ACHWM that was consistently interpreted and culturally appropriate, and had face validity confirmed by experts from the community, children and their parents/caregivers. The ACHWM is ready to be assessed for relevance to other Aboriginal communities.

Urocanate as a potential signaling molecule for bacterial recognition of eukaryotic hosts.

Host recognition is the crucial first step in infectious disease pathogenesis. Recognition allows pathogenic bacteria to identify suitable niches and deploy appropriate phenotypes for successful colonization and immune evasion. However, the mechanisms underlying host recognition remain largely unknown. Mounting evidence suggests that urocanate-an intermediate of the histidine degradation pathway-accumulates in tissues, such as skin, and acts as a molecule that promotes bacterial infection via molecular interaction with the bacterial regulatory protein HutC. In Gram-negative bacteria, HutC has long been known as a transcriptional repressor of hut genes for the utilization of histidine (and urocanate) as sources of carbon and nitrogen. Recent work on the opportunistic human pathogen Pseudomonas aeruginosa and zoonotic pathogen Brucella abortus shows that urocanate, in conjunction with HutC, plays a significant role in the global control of cellular metabolism, cell motility, and expression of virulence factors. We suggest that in addition to being a valuable source of carbon and nitrogen, urocanate may be central to the elicitation of bacterial pathogenesis.

High usage of topical fusidic acid and rapid clonal expansion of fusidic acid-resistant Staphylococcus aureus: a cautionary tale.

Our aim was to assess national prescribing trends and determine longitudinal resistance patterns for topical antimicrobials in New Zealand. We observed a dramatic increase in fusidic acid (FA) resistance, and clonal expansion of FA-resistant Staphylococcus aureus. This increase was concurrent with a significant national increase in topical FA dispensing.

Staphylococcus aureus infections in New Zealand, 2000-2011.

The incidence rate for invasive and noninvasive Staphylococcus aureus infections in New Zealand is among the highest reported in the developed world. Using nationally collated hospital discharge data, we analyzed the epidemiology of serious S. aureus infections in New Zealand during 2000-2011. During this period, incidence of S. aureus skin and soft tissue infections increased significantly while incidence of staphylococcal sepsis and pneumonia remained stable. We observed marked ethnic and sociodemographic inequality across all S. aureus infections; incidence rates for all forms of S. aureus infections were highest among Maori and Pacific Peoples and among patients residing in areas of high socioeconomic deprivation. The increased incidence of S. aureus skin and soft tissue infections, coupled with the demographic disparities, is of considerable concern. Future work should aim to reduce this disturbing national trend.

Late-onset bolus intravenous beta-lactam antibiotic adverse reaction: short-lived symptoms during drug administration and associated laboratory abnormalities.

BACKGROUND: In the 1970s, there were 2 reports of a late-onset adverse reaction during bolus infusions of benzyl penicillin, characterized by short-lived symptoms, most commonly abdominal pain. The mechanism is not known. We set out to further characterize this reaction. METHODS: We conducted a prospective observational study of all adult patients receiving bolus intravenous (IV) beta-lactam antibiotics under the care of our Outpatient IV Antibiotic Service from 1 August 2007 to 31 January 2010, focusing on those who developed infusion-related symptoms. RESULTS: During the 30-month study, 11 of the 163 patients (7%) treated with bolus IV beta-lactam antibiotics developed a late-onset infusion-related adverse reaction. Six of 30 patients (20%) treated with benzyl penicillin developed this adverse reaction compared to 5 of 133 (4%) treated with any other beta-lactam antibiotic (p = 0.006). The median duration of beta-lactam antibiotic before reaction onset was 25 days. Abdominal pain occurred in 9 patients (82%), fever in 3 (27%), and rash in 5 (45%). Seven patients (64%) developed a combination of thrombocytopenia, neutropenia, and/or lymphopenia and 6 (55%), elevated liver enzymes. CONCLUSIONS: This adverse reaction, occurring late during prolonged IV bolus beta-lactam treatment, is most often characterized by short-lived abdominal pain occurring at the time of infusion and is more common in patients receiving benzyl penicillin. It is frequently associated with cytopenias and elevated liver enzymes. It may have both immunological and non-immunological mechanisms.