Comparative evaluation of agar dilution and broth microdilution by commercial and in-house plates for Bacteroides fragilis group: An economical and expeditious approach for resource-limited settings.

OBJECTIVE: To compare the performance of agar dilution and broth microdilution by commercial and in-house prepared plates for the Bacteroides fragilis group. The cost analysis was performed to demonstrate that in-house prepared BMD plates were a suitable alternative to agar dilution given the high cost and low feasibility of incorporating commercial BMD plates in routine, particularly in the tertiary care institutes of many low- and middle-income countries. METHODS: Thirty B. fragilis group isolates were tested against six antibiotics, frequently used as empirical therapy for anaerobic infections including metronidazole, clindamycin, imipenem, piperacillin-tazobactam, cefoxitin, and chloramphenicol. The running consumable expenditure for all methodologies was calculated. RESULTS: The results demonstrated essential and categorical agreement of >90% for all antibiotics except cefoxitin, which showed <90% categorical agreement. No major or very major errors were observed. We observed a high agreement and strong concordance for MIC values between both methods and inter-rate reliability of >0.9 by Cohen's kappa analysis, indicating almost perfect agreement between both methods using either of the plates. In contrast to agar dilution, a 20.5 fold cost reduction was seen in BMD using in-house plates and a 5.8 fold reduction using commercial plates to test a single isolate. However, when testing 30 isolates concurrently the cost significantly increased for commercial BMD plates by 8.4 folds, and only 1.03 fold cost reduction was seen with in-house BMD plates. CONCLUSION: BMD gives comparable results to agar dilution and can be considered a method of choice to test a small number of samples. The technique is an economical option when plates are standardized in-house and could be employed for susceptibility testing of the B. fragilis group.

Cost of Medications Recommended by Canadian Acne Clinical Practice Guidelines.

BACKGROUND: Acne affects a large proportion of the Canadian population and has psychosocial and financial consequences. OBJECTIVE: We provide cost information for treatments recommended by the Canadian acne guidelines. METHODS: Highest level recommendations were selected for 3-month usage cost. RESULTS: Three-month estimated treatment costs were as follows: topical retinoids ($14.40-$73.80), benzoyl peroxide (BPO; $6.75), fixed-dose BPO-clindamycin ($40.95-$44.10) and BPO-adapalene ($73.80), oral antibiotics ($25.20 for tetracycline 250 mg qid; $52.20 and $52.74 for doxycycline 50 mg bid and 100 mg od, respectively), and hormonal therapy ($26.46-$37.80 for ethinyl estradiol [EE] 0.030 mg/drospirenone 3mg and $75.60-108.99 for EE 0.035 mg/cyproterone acetate 2 mg). Oral isotretinoin 3-month costs ranged from $393.96 to $478.80. CONCLUSIONS: Awareness of costs of recommended treatments may facilitate improved outcomes by increasing procurement and adherence.

A practical guide to community-acquired MRSA.

As the number of CA-MRSA skin and soft tissue infections continues to grow, it's important to know which patients are at greatest risk and which evidence-based treatment protocols to turn to when needed.

Comparing a combination of penicillin G and gentamicin to a combination of clindamycin and amikacin as prophylactic antibiotic regimens in prevention of clean contaminated wound infections in cancer surgery.

BACKGROUND AND AIM: Appropriate antibiotic selection and timing of administration for prophylaxis are crucial to reduce the likelihood of surgical site infection (SSI) after a clean contaminated cancer surgery. Our aim is to compare the use of two prophylactic antibiotic (PA) regimens as regards efficacy, timing, and cost. PATIENTS AND METHODS: Two hundred patients with gastric, bladder, or colorectal cancer were randomized to receive preoperative PA, group A received penicillin G sodium and gentamicin and group B received clindamycin and amikacin intravenously. The demographic data of patients were collected, and they were observed for wound infections. RESULTS: Infected wounds occurred in 19 patients with a rate of 9.5%. Highest incidence of SSI was among bladder cancer patients (14.2%); p=0.044. The rate of SSI was 11% in group A, and 8% in group B, p=0.469. The cost of PA administered in group A was significantly less than that of group B (21.96±3.22LE versus 117.05±12.74LE, respectively; p<0.001). SSI tended to be higher among those who had longer time for antibiotic and incision (≥30min) than those who had shorter time interval (<30min), (13% vs. 6.5%, respectively). CONCLUSION: Both penicillin+gentamicin and clindamycin+amikacin are safe and effective for the prevention of SSI in clean contaminated operative procedures. In a resource limited hospital, a regimen including penicillin+gentamicin is a cost-effective alternative for the more expensive and broader coverage of clindamycin+amikacin. Timing of PA is effective in preventing SSIs when administered 30min before the start of surgery.

Ertapenem compared to combination drug therapy for the treatment of postpartum endometritis after cesarean delivery.

OBJECTIVE: Ertapenem is a broad spectrum carbapenem approved for the treatment of postpartum endometritis. Data regarding clinical outcomes after treatment with ertapenem for endometritis after cesarean delivery are limited. Our objectives were to compare clinical outcomes and cost of ertapenem versus a multi-drug regimen for treatment of endometritis after cesarean delivery. METHODS: Retrospectively, patients with endometritis after cesarean delivery who were treated with ertapenem (group A) were compared to those treated with a combination regimen (group B). Mann-Whitney U and Fisher's Exact were used for statistical analysis with p value <0.05 considered statistically significant. RESULTS: Sixty-three patients were included: 31 in group A and 32 in group B. Demographics and intrapartum characteristics did not differ. Number of administered doses (A: 3, B: 11.5 p < 0.0001), cost (A: $156.63, B: $54.48 p < 0.0001) and nursing time in minutes (A: 6.6, B: 25.3 p < 0.0001) were different between both groups. Wound complications were higher in group A, occurring in 7 patients compared to 1 patient in group B (p = 0.024). CONCLUSION: Although time and number of administered doses were less in group A, given the high wound complication rate in patients treated with ertapenem, this drug may not be appropriate for all patients with endometritis after CD.

Clindamycin release determined by high performance liquid chromatography from a novel low-cost local drug delivery system: a new potential treatment option for chronic osteomyelitis.

Osteomyelitis continues to be a severe problem worldwide, causing plenty of hospital admissions and entailing vast expenses. Previously, we developed a low-cost polymethyl-methacrylate (PMMA)-sorbitol based capsule system for local long-term drug delivery. In the present study we aimed to test the in vitro release of clindamycin capsules by high performance liquid chromatography. By the end of the clinically relevant period (42 days), the capsules released 70-100% of their load. Furthermore, the release kinetics suggested that an effective antimicrobial concentration may be maintained within the target area. Our findings indicate that these newly developed capsules may be a versatile device for local clindamycin delivery by providing efficient release and reducing financial burdens.

Treatment of Chlamydia trachomatis infections in pregnant women.

The intent of this article is to provide an overview of the epidemiology and pharmacotherapy, including cost analyses, of Chlamydia trachomatis infections in pregnant women. Chlamydia is a common sexually transmitted infection. For pregnant women, there are concerns both for the mother (post-partum endometritis, horizontal transmission) and the newborn (conjunctivitis, delayed pneumonia). Therapeutic options are restricted because of the fetus and include multi-day treatment with erythromycin, amoxicillin, clindamycin or single dose azithromycin. Clinical cure rates with these options are 86, 92, 93 and 95%, respectively. Pharmacoeconomic analyses have been conducted to determine if the initial increase in acquisition cost of azithromycin (approximately 3-fold higher than erythromycin or amoxicillin) is offset by improvement in compliance and drug efficacy. Clindamycin has received little attention because of its expense (4-fold more than azithromycin). Analyses have been retrospective. As models incorporate more complications of failure to cure, azithromycin increasingly becomes more cost effective and is our recommended treatment.

Clinical and economic impact of a pharmacist-intervention to promote sequential intravenous to oral clindamycin conversion.

A multicentre, prospective, controlled study compared the clinical efficacy, safety and economic impact of a pharmacist intervention to promote sequential intravenous to oral clindamycin conversion. A total of 473 patients receiving intravenous clindamycin for at least 72 hours were included in the study. Two groups were established: an intervention group (204 patients) in which an informative sheet recommending the sequential treatment was provided, and a control group (269 patients). Clindamycin was prescribed for respiratory infections in 38.9% and for prophylaxis in surgery in 25.4% of the patients (71% were contaminated surgery). No difference between groups regarding sex, infection severity, health status or clinical progress was observed. Both the step-down treatments after 72 hours of intravenous clindamycin and the change to the oral route later on, were significantly increased with the intervention (p < 0.001, p < 0.001 respectively). No significant differences between both groups were found in the number of patients with adverse effects associated with the i.v. therapy, although the incidence tended to be lower in the intervention group (49/204 intervention versus 85/269 control, p = 0.07). Compliance with the recommended clindamycin dosing regimen was significantly higher in the intervention group, in which 1.3 days reduction of intravenous therapy provided an average cost savings of PTA5246 (95% CI 2556-7935) per treatment. A higher reduction of 1.7 days was achieved in those patients candidates for switch therapy on the third day of intravenous clindamycin. A sequential program with clindamycin may provide a cost-effective alternative to conventional therapy and the introduction of an information sheet is a cost-effective strategy to promote it.

Oral antibiotics: are the old still gold?

Most common infections in ambulatory care can be treated effectively and safely with conventional antibiotics. A rational approach using such antibiotics as primary choices and reserving newer antibiotics for selected, more difficult-to-treat infections will result in substantial cost savings and may help to prevent the rapid development of drug resistance.

Hospital-wide restriction of clindamycin: effect on the incidence of Clostridium difficile-associated diarrhea and cost.

BACKGROUND: Widespread antibiotic use has been associated with increases in both bacterial resistance and nosocomial infection. OBJECTIVE: To characterize the impact of hospital-wide clindamycin restriction on the incidence of Clostridium difficile-associated diarrhea and on antimicrobial prescribing practices. DESIGN: Prospective, observational cohort study. SETTING: University-affiliated Veterans Affairs Medical Center. PATIENTS: Hospitalized patients with symptomatic diarrhea. MEASUREMENTS: Clinical data on individual patients and data on antibiotic use were obtained from hospital pharmacy records. Hospital-wide use of antimicrobial agents was monitored. Isolates of C. difficile underwent antimicrobial susceptibility testing and molecular typing. RESULTS: An outbreak of C. difficile-associated diarrhea was caused by a clonal isolate of clindamycin-resistant C. difficile and was associated with increased use of clindamycin. Hospital-wide requirement of approval by an infectious disease consultant of clindamycin use led to an overall reduction in clindamycin use, a sustained reduction in the mean number of cases of C. difficile-associated diarrhea (11.5 cases/month compared with 3.33 cases/month; P < 0.001), and an increase in clindamycin susceptibility among C. difficile isolates (9% compared with 61%; P < 0.001). A parallel increase was noted in the use of and costs associated with other antibiotics with antianaerobic activity, including cefotetan, ticarcillin-clavulanate, and imipenem-cilastin. The hospital realized overall cost savings as a result of the decreased incidence of C. difficile-associated diarrhea. CONCLUSIONS: Hospital formulary restriction of clindamycin is an effective way to decrease the number of infections due to C. difficile. It can also lead to a return in clindamycin susceptibility among isolates and can effect cost savings to the hospital.

Reduced incidence of septic arthritis in children by Haemophilus influenzae type-b vaccination. Implications for treatment.

In many countries Haemophilus influenzae type b (Hib) is the second most common cause of septic arthritis in children. In Finland large-scale immunisation against Hib using conjugate vaccines began in 1986, four years after a multicentre prospective study of orthopaedic infections in children had started. Since 1982, including six years before and ten after starting routine Hib vaccination, there has been a major change in the pattern of septic arthritis. From 1982 to 1988, 32 of 61 cases (53%) were caused by staphylococci, 22 (36%) by Hib and 7 (11%) by other bacteria. Since 1988, Hib infection has disappeared, and one-third of cases of childhood septic arthritis has been eliminated. This change has allowed us to reduce initial antimicrobial therapy for such children to cover only Gram-positive cocci. The more limited treatment is safer, reduces cost, and simplifies treatment.

Pharmacoeconomics of aztreonam-clindamycin versus gentamicin-clindamycin in the treatment of penetrating abdominal injury.

STUDY OBJECTIVE: To evaluate the pharmacoeconomic implications of using aztreonam-clindamycin (A-C) versus gentamicin-clindamycin (G-C) from the perspective of the hospital and pharmacy directors. DESIGN: Pharmacoeconomic analysis performed at one of the sites participating in the prospective, randomized, double-blind, comparative, multicenter efficacy study. SETTING: Referral hospital with level 1 trauma center. PATIENTS: Eight-five adults with a suspected penetrating intraabdominal injury requiring laparotomy. INTERVENTIONS: Patients were randomized to receive aztreonam 2 g intravenously every 8 hours or gentamicin 2 mg/kg intravenous load followed by 5 mg/kg/day intravenously initially adjusted to peak concentrations of 6-8 micrograms/ml. All patients received clindamycin 900 mg intravenously every 8 hours. MEASUREMENTS AND MAIN RESULTS: Charge data were gathered from the hospital billing system and converted to cost data using an institutional cost:charge ratio of 0.6. Study drug and aminoglycoside monitoring costs were also calculated. Overall, 43 (97%) of 44 patients receiving A-C had a favorable clinical response compared with 35 (85.4%) of 41 receiving G-C (p = 0.052). The mean hospital cost of $66,336 for 7 infected patients was significantly higher than that of $8014 in 78 noninfected patients (p < 0.0001). Mean hospital costs of $12,058 and $13,742 for A-C and G-C groups, respectively, were not significantly different (p > 0.05) despite having only a single failure (total cost $162,666) in the A-C group. Similarly, mean pharmacy costs of $1411 and $1604, respectively, were not significantly different (p > 0.05). CONCLUSIONS: Hospital costs for infected patients with penetrating abdominal trauma exceed those of noninfected patients by 5-fold. Despite a lower infection rate in the A-C group, neither hospital nor pharmacy costs were significantly different compared with those in the G-C group.

Cost analysis of antibiotic prophylaxis in clean head and neck surgery.

OBJECTIVE: This study was undertaken to assess the excess cost of hospitalization accrued to patients who develop postoperative wound infection following neck dissection in which the wound was not exposed to secretions from the upper aerodigestive tract. DESIGN: A retrospective cohort of patients who underwent "clean" neck dissection from 1976 to 1989 were evaluated. Antibiotic administration (yes or no), post-operative wound infection (yes or no), and duration and cost of hospitalization were assessed. SETTING: All surgeries were performed in a university medical center. PATIENTS: All patients underwent neck dissection in which the procedure was clean, ie, there was no exposure to secretions from the upper aerodigestive tract. MAIN OUTCOME MEASURES: Patients were assessed to determine administration of antibiotics (yes or no), development of postoperative wound infection (yes or no), and duration and cost of hospitalization. RESULTS: Wound infection developed in 10 (10%) of 99 patients who did not receive antibiotics. Of 93 patients who received perioperative antibiotics, three (3.3%) developed wound infection. This difference was not statistically significant. The type II (beta) error was greater than 0.2, suggesting that a significant difference may have been missed (false-negative) as a result of the small number of patients studied. The excess cost accrued to each patient who developed a postoperative wound infection was in excess of $36,000 (1992 dollars). The cost of administration of antibiotic prophylaxis to 100 patients is less than this amount. CONCLUSION: The decision to withhold antibiotic prophylaxis should not be made in an effort to reduce hospital costs.

Impact of a target drug monitoring program on the usage of clindamycin.

The use of parenteral clindamycin at the Health Sciences Centre had not been amendable to traditional cost containment strategies. Clindamycin was targeted through a Target Drug Monitoring (TDM) Program to improve its appropriate use. A retrospective audit was conducted to serve as a baseline. In the concurrent phase, the TDM pharmacist reviewed and assessed clindamycin cases based on approved criteria. Those cases which failed to meet the criteria were targeted in order to convert clindamycin to alternative agents. The concurrent TDM program reviewed 339 cases of clindamycin over a 32-week period, of which 76 cases (22.4%) failed to meet the criteria and were targeted. Of the 76 recommendations, 48 (63.2%) were accepted. Cost-avoidance due to direct intervention was approximately $16,000 annualized compared to $28,000 estimated from the retrospective audit. Fiscal year-end antibiotic usage indicated a dramatic decline (32%) in clindamycin use. Net savings of $37,600 were attributed to modification of physician prescribing. The TDM program was successful in identifying areas of inappropriate clindamycin use and correcting them by direct interaction with the prescriber(s).

Cost analysis of imipenem-cilastatin versus clindamycin with tobramycin in the treatment of acute intra-abdominal infection.

Clinical effectiveness of imipenem/cilastatin (I/C) versus tobramycin with clindamycin (T + C) in treatment of patients presenting with suspected acute intra-abdominal infection was assessed in a multicentre randomised clinical trial conducted during 1985 to 1986. The principal finding was a lower incidence of treatment failure among patients in the I/C arm (p = 0.043). We now report results of retrospective analysis of hospital treatment costs during an episode of infection incurred by patients enrolled in the trial. Treatment costs (in 1989 US dollars) were calculated from a hospital perspective, using an intention-to-treat analysis. Among 161 patients with low illness severity (APACHE II less than or equal to 14) the mean cost for the episode of care was $US7038 in the I/C arm versus $US8404 for the T + C regimen; the difference was not statistically significant (p = 0.40). For 93 more severely ill patients (APACHE II score greater than 14) the mean cost for the I/C arm was $US19 985 versus $US16 582 for the T + C regimen; the difference was not statistically significant (p = 0.36). Multiple regression analysis, controlling for patient demographics and study site, showed that the cost of the episode was positively associated with the severity of illness (p less than 0.01) and presence of malnutrition (p < 0.01), but that the total cost of the episode of infection was not statistically different for the 2 drug regimens (p = 0.45).

Outpatient treatment of febrile episodes in low-risk neutropenic patients with cancer.

BACKGROUND: Hospitalization and intravenous (IV) broad-spectrum antibiotics are the standard of care for all febrile neutropenic patients with cancer. Recent work suggests that a low-risk population exists who might benefit from an alternate approach. METHODS: A prospective randomized clinical trial was performed comparing oral ciprofloxacin 750 mg plus clindamycin 600 mg every 8 hours with IV aztreonam 2 g plus clindamycin 600 mg every 8 hours for the empiric outpatient treatment of febrile episodes in low-risk neutropenic patients with cancer. RESULTS: The oral regimen cured 35 of 40 episodes (88% response rate), whereas the IV regimen cured 41 of 43 episodes (95% response rate, P = 0.19). Although the cost of the oral regimen was significantly less than that of the IV regimen (P < 0.0001), it was associated with significant renal toxicity (P < 0.05), which led to early termination of the study. Overall, combining its safety and efficacy, the IV regimen was superior (P = 0.03). CONCLUSIONS: This prospective study suggested that outpatient antibiotic therapy for febrile episodes in low-risk neutropenic patients with cancer is safe and effective. Better oral regimens are needed.