Evaluation of the use of cefuroxime and cefuroxime axetil in an intravenous-oral stepdown program.

OBJECTIVE: To characterize cefuroxime and cefuroxime axetil use under the influence of a parenteral-to-oral (iv-po) stepdown program. DESIGN: Open single-center retrospective review. SETTING: Tertiary care teaching and referral Canadian hospital with 1100 beds. PATIENTS: A random sample of 78 patients receiving cefuroxime was compared with a random sample of 50 patients receiving iv-po cefuroxime stepdown. RESULTS: During the first 6 months following formulary introduction, 1535 patients received cefuroxime. Stepdown to any oral antibiotic occurred in 22% of patients. Cefuroxime axetil was used as the stepdown agent in 64% of these cases. In a comparison of nonstepdown courses with stepdown courses, some differences were apparent. Nonstepdown treatment courses were primarily prophylactic, whereas stepdown courses were typically initiated as primary therapy for the 10-day management of respiratory tract infections (p < 0.001). Conversion to oral therapy typically occurred on day 5 of parenteral therapy and continued for 5 days. Stepdown was considered possible in 46% of treatment courses in which this process did not happen. When stepdown did occur, it was considered timely in 64% of cases, unnecessarily delayed in 32%, and premature in 4% of treatment courses. Stepdown did not appear to be associated with a negative impact on patient outcome. Mean +/- SD cost of drug therapy per day was less for the stepdown group (US $15.78 +/- $5.97) than the nonstepdown group (US $25.47 +/- $7.87; p < 0.001). CONCLUSIONS: As a result of this study we intend to maintain cefuroxime and cefuroxime axetil on the formulary and continue to judiciously promote the timely conversion to oral therapy.

Implementation and evaluation of a standardized herpes simplex virus prophylaxis protocol on a leukemia/bone marrow transplant unit.

OBJECTIVE: To assess the impact of a standardized acyclovir prophylaxis protocol for the prevention of herpes simplex virus (HSV) infection and disease in bone marrow transplant and leukemic patients. DESIGN: Two-phase, open sequential study involving prospective patient monitoring and retrospective health record review. SETTING: Tertiary care teaching hospital. PATIENTS: Fifty-seven patients (35 preprotocol, 22 postprotocol) who received acyclovir for HSV prophylaxis during an 18-month study period. INTERVENTIONS: An acyclovir HSV prophylaxis protocol was developed and implemented. Under this protocol, all HSV immunoglobulin G-seropositive hematology patients received an acyclovir regimen of 125 mg/m2 i.v. q6h or 600 mg p.o. q6h (if tolerated) from day -5 to day 30. Regimens not matching protocol were modified by pharmacists in conjunction with the prescriber. All treatment courses were followed daily by pharmacists to modify dosage according to renal function and assess appropriateness of the i.v. route. Tablets, capsules, or suspensions were promoted if the patient was considered tolerant of the oral route. MAIN OUTCOME PARAMETERS: Outcome parameters included (1) incidence of parenteral, oral, or combined therapy; (2) total prophylactic acyclovir dose per patient; (3) mean prophylactic acyclovir daily dose; (4) mean duration of acyclovir prophylaxis; and (5) HSV reactivation rate. RESULTS: Following implementation of the protocol, the mean total i.v. acyclovir dose per patient decreased from 20.1 g (range 3.6-109.5) to 11.7 g (range 1.0-43.0; p = 0.1162). The mean cumulative oral dose increased from 12.1 g (range 0.4-70.0) to 33.1 g (range 2.4-93.6; p = 0.0007). Mean duration of therapy increased from 27.6 to 33.5 days (p = 0.23). The mean duration of oral therapy increased from 10.5 days (+/- SD 10.9) to 17.2 days (+/- SD 12.1) (p = 0.034). The appropriateness of use of the i.v. dosage form increased from 53 to 88 percent of treatment days (p = 0.013). No difference in HSV reactivation rate was observed when comparing patients prior to and following protocol implementation. A drug acquisition savings of $1112.00 (CDN) per patient was realized. CONCLUSIONS: The implementation of a standardized HSV acyclovir prophylaxis protocol has resulted in significant drug acquisition cost savings without an apparent negative impact on patient outcome.