The effect of renal dysfunction on antimicrobial use measurements.

The defined daily dose, a popular measurement of antimicrobial use, may underestimate the use of antimicrobials that are dose-adjusted in patients with renal insufficiency. To evaluate the effect of renal dysfunction on these measures, we performed a retrospective cohort study that involved patients receiving ceftriaxone, levofloxacin, or vancomycin, with use of defined daily doses and 2 methods based on therapy duration--stop-start days (i.e., entire therapy duration) and transaction days (i.e., unique therapeutic days). The vancomycin use rate for patients with renal insufficiency was 36% lower than that of patients with normal renal function for defined daily doses, and it was 23% lower for transaction days; for levofloxacin, there was a 27% rate reduction for the defined daily dose. No significant reduction was noted when the stop-start day method was used. Compared with the defined daily dose method, measures of therapy duration are less affected by renal function and may improve comparisons between populations.

Improving inpatient antibiotic prescribing: insights from participation in a national collaborative.

BACKGROUND: Increasing rates of antimicrobial resistance and the role antibiotic overuse plays in contributing to this problem have been widely documented and have prompted appeals to change prescribing practices. How to actually achieve such changes represents a major challenge. As part of the Institute for Healthcare Improvement (IHI) Breakthrough Series project Improving Prescribing Practices (IPP), in 1997-1998, Cook County Hospital (Chicago) worked with other institutions that chose antibiotics as their focus in this national collaborative. PRACTICAL SUGGESTIONS: Practical suggestions are offered within six categories--adopting a general approach to improving antibiotic prescribing (marshalling credible evidence, addressing physician concerns and skepticism, and removing barriers to make it easier for prescribers to change); rethinking guidelines (providing syndrome-based guidance, revising national guidelines for local use, defining scenarios in which drug(s) can be safely withheld, offering alternatives, prospectively resolving conflicts over drug of choice and empiric regimens, and defining situations in which immediate treatment is and is not critical); getting the message out and changes implemented (using antibiotic order forms, computer order entry, and infectious disease specialist consultation); building viable linkages to leverage change (bridging disciplines); improving measurement; and promoting nondrug strategies and patients' roles in treating and preventing infection. CONCLUSION: Antimicrobials are unique, being the only class of drug therapy that affects not only the patient to whom it is prescribed but other current and future patients as well. Institutions therefore have a special responsibility to ensure their efficient and judicious use. It is often easier to prescribe antibiotics than to exercise restraint.

Improvements in outcomes of acute respiratory failure for patients with human immunodeficiency virus-related Pneumocystis carinii pneumonia.

In the early 1990s, hospital survival among patients with human immunodeficiency virus (HIV)-related Pneumocystis carinii pneumonia (PCP) and respiratory failure was poor, approximately 20%. We examined ICU use and outcomes for patients with acute respiratory failure from PCP from 1995 to 1997. We conducted a retrospective medical record review using a random sample of 71 hospitals in seven regions of the United States. Among 1,660 patients with confirmed or presumed PCP, 155 (9%) received mechanical ventilation for respiratory failure. Factors that predicted use of mechanical ventilation, independent of severity of illness on hospital admission, included African-American ethnicity and geographic location (p

A new preadmission staging system for predicting inpatient mortality from HIV-associated Pneumocystis carinii pneumonia in the early highly active antiretroviral therapy (HAART) era.

A common severe complication of human immunodeficiency virus (HIV) infection has been Pneumocystis carinii pneumonia (PCP). Recently, with increasing use of PCP prophylaxis and multidrug antiretroviral therapy, the clinical manifestations of HIV infection have changed dramatically and the predictors of inpatient mortality for PCP may have also changed. We developed a new staging system for predicting inpatient mortality for patients with HIV-associated PCP admitted between 1995 and 1997. Trained abstractors performed chart reviews of 1,660 patients hospitalized with HIV-associated PCP between 1995 and 1997 at 78 hospitals in seven metropolitan areas in the United States. The overall inpatient mortality rate was 11.3%. Hierarchically optimal classification tree analysis identified an ordered five-category staging system based on three predictors: wasting, alveolar-arterial oxygen gradient (AaPO(2)), and serum albumin level. The mortality rate increased with stage: 3.7% for Stage 1, 8.5% for Stage 2, 16.1% for Stage 3, 23.3% for Stage 4, and 49.1% for Stage 5. This new staging system may be useful for severity of illness adjustment in the current era while exploring current variation in HIV-associated PCP inpatient mortality rates among hospitals and across cities.

Delays in tuberculosis isolation and suspicion among persons hospitalized with HIV-related pneumonia.

BACKGROUND: Despite awareness of HIV-related tuberculosis (TB), nosocomial outbreaks of multidrug-resistant TB among HIV-infected individuals occur. OBJECTIVE: To investigate delays in TB isolation and suspicion among HIV-infected inpatients discharged with TB or Pneumocystis carinii pneumonia (PCP), common HIV-related pneumonias. DESIGN: Cohort study during 1995 to 1997. SETTING: For PCP, 1,227 persons who received care at 44 New York City, Chicago, and Los Angeles hospitals. For TB, 89 patients who received care at five Chicago hospitals. MEASUREMENTS: Two-day rates of TB isolation/suspicion. RESULTS: For HIV-related PCP, Los Angeles hospitals had the lowest 2-day rates of isolation/suspicion of TB (24.3%/26.6% vs 65.5%/66.4% for New York City and 62.8%/58.3% for Chicago, respectively; p < 0.001 for overall comparison by chi(2) test for each outcome measure). Within cities, hospital isolation/suspicion rates varied from < 35 to > 70% (p < 0.001 for interhospital comparisons in each city). The Chicago hospital with a nosocomial outbreak of multidrug-resistant TB from 1994 to 1995 isolated 60% of HIV-infected individuals who were discharged with a diagnosis of HIV-related TB and 52% discharged with HIV-related PCP, rates that were among the lowest of all Chicago hospitals in both data sets. CONCLUSION: Low 2-day rates of TB isolation/suspicion among HIV-related PCP patients were frequent. One Chicago hospital with low 2-day rates of TB isolation/suspicion among persons with HIV-related PCP also had low 2-day rates of isolation/suspicion among confirmed TB patients. That hospital experienced a nosocomial multidrug-resistant TB outbreak. Educational efforts on the benefits of early TB suspicion/isolation among HIV-infected pneumonia patients are needed.

Description of movement patterns of young adults moving supine from the foot to the head of the bed.

BACKGROUND AND PURPOSE: The purpose of this study was to describe the movement patterns (MPs) in young adults moving supine from the foot to the head of a bed. SUBJECTS: Thirty-six young adults, aged 19 through 44 years, participated in this study. METHODS: Subjects were videotaped performing 10 trial of moving in bed. The MPs of 3 body regions were described and categorized. RESULTS: Six MP categories were developed for the axial region, 8 MP categories were developed for the upper extremities, and 6 MP categories were developed for the lower extremities. Kappa values ranged from .81 to .90 for the 3 body regions, Fifty-nine different combinations of MPs were observed. The most common combination of MPs occurred in 21.2% of the trials, 3 times more frequently than any other combination. CONCLUSION AND DISCUSSION: A variety of MPs are used by young adults for moving from the foot to the head of the bed. A symmetrical pattern of sitting up and pushing with both hands and both feet was found to be the most common pattern. [Cohen BG, Cardillo ER, Lugg D, et al. Description of movement patterns of young adults moving supine from the foot to the head of the bed.

Preventing mismanagement of community-acquired pneumonia at an urban public hospital: implications for institution-specific practice guidelines.

STUDY OBJECTIVES: To assess institutional performance of key diagnostic and therapeutic interventions and to identify areas amenable to improvement in the management of community-acquired pneumonia (CAP). DESIGN: A chart-based retrospective study. SETTING: Cook County Hospital, a large, urban, public teaching hospital. PATIENTS: Adult inpatients with a hospital discharge diagnosis of CAP. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Fifty hospital admissions were reviewed. Only 25 patients (50%) had two specimens obtained for blood culture, and sputum was sent for Gram's stain and culture for only 11 patients (22%). Approximately one third of the patients had portable anterior-posterior instead of standard posterior-anterior and lateral chest radiographs performed. Physicians in the emergency department (ED) tended to be less likely to note the presence of multilobar infiltrates or pleural effusions than the attending radiologists. The antibiotic regimens employed in the ED and on the inpatient wards were widely variable. The mean time from hospital entry until administration of the first dose of antibiotics was 5.5 h for the 18 patients for whom treatment was initiated in the ED vs 16.1 h for the 27 patients admitted through the ED for whom therapy was deferred until ward admission (p < 0.001, Student's t test). CONCLUSIONS: Institutional variations in the performance of basic diagnostic and therapeutic interventions for patients with CAP may be substantial. The local performance of these key processes of care should be assessed to help direct the formulation of institutional practice guidelines for the management of CAP.

Leptotrichia buccalis bacteremia in patients treated in a single bone marrow transplant unit.

We describe four cases of bacteremia due to Leptotrichia buccalis (an organism that is part of the normal human oral flora) that occurred in a bone marrow transplant unit over a 3-month period. All of the patients were neutropenic, all had mucositis or esophagitis, and all were receiving antimicrobial prophylaxis with ciprofloxacin and vancomycin (drugs to which Leptotrichia is resistant). One patient died of adult respiratory distress syndrome; the others had minimal symptoms. Pulsed field gel electrophoresis of bacterial DNA digested with Sma 1 demonstrated a unique banding pattern for each isolate, indicating that the isolates belonged to distinct strains. Quantitative gas-liquid chromatography of whole-cell free fatty acids confirmed the uniqueness of the strains, obviating the need to search for a common source of infection. We postulate that this outbreak resulted from antibiotic selection pressure on the oral flora in patients who had been compromised by severe neutropenia and mucosal disruption.

Infection of an arterial prosthesis as the presenting manifestation of disseminated coccidioidomycosis: control of disease with fluconazole.

We describe an elderly man whose presenting manifestation of disseminated coccidioidomycosis was bilateral infection of femoral arterial prosthetic grafts. After the patient failed to respond to both ketoconazole and amphotericin B, treatment with fluconazole brought about clinical resolution of meningitis and pulmonary disease and, in combination with repeated percutaneous aspiration, control of the arterial infection. The unusual clinical features of this case, along with the incidence and management of prosthetic arterial infections caused by fungi, are discussed.

Improvement of olfaction in laryngectomized patients with the larynx bypass.

Hyposmia following laryngectomy is an often recognized phenomenon. A larynx bypass device was used to determine whether this olfactory deficit could be reversed simply by restoring nasal airflow. Odorant detection thresholds and confusion matrix identification tests were administered to laryngectomy and normal comparison groups. Data on nasal airflow characteristics with and without the bypass were also analyzed. The results suggested that restoration of nasal airflow completely reversed the hyposmia for trigeminal nerve stimuli. However, the reversal of hyposmia was not complete for those odorants which primarily, if not exclusively, stimulate the olfactory nerve. This suggested that other factors may contribute to laryngectomy-induced hyposmia for olfatory nerve stimuli. Additionally, nasal airflow analysis revealed that confusion matrix identification scores were depedent upon inspiratory sniff flow rates with and without the larynx bypass. It is argued that rehabilitation for the laryngectomee should include efforts to restore and maintain preoperative olfactory acuity.

Treatment of a lingual hemangioma by superselective embolization.

A large hemangioma of the tongue was initially treated with superselective embolization using polyvinyl alcohol foam (Ivalon) and absorbable gelatin sponge (Gelfoam) particulates. A marked reduction in vascularity with deflation of the lesion occurred. Subsequent surgery to ablate the residual tumor was canceled due to the patient's request and satisfaction with the initial procedure. Evaluation over the following year revealed no regrowth or symptomatology. This case demonstrates that, in selected cases, large hemangiomas may respond satisfactorily to superselective embolization and may obviate the need for surgical intervention.

Pneumopancreatogram associated with gas in the biliary tract.

A case is presented in which the entire pancreatic duct, including its secondary and tertiary branches, was visualized by the reflux of gas from the biliary ducts. This unusual finding suggests a possible mechanism of the association of pancreatitis with biliary tract disease.