A tailored implementation strategy to reduce the duration of intravenous antibiotic treatment in community-acquired pneumonia: a controlled before-and-after study.

We previously showed that 40 % of clinically stable patients hospitalised for community-acquired pneumonia (CAP) are not switched to oral therapy in a timely fashion because of physicians' barriers. We aimed to decrease this proportion by implementing a novel protocol. In a multi-centre controlled before-and-after study, we evaluated the effect of an implementation strategy tailored to previously identified barriers to an early switch. In three Dutch hospitals, a protocol dictating a timely switch strategy was implemented using educational sessions, pocket reminders and active involvement of nursing staff. Primary outcomes were the proportion of patients switched timely and the duration of intravenous antibiotic therapy. Length of hospital stay (LOS), patient outcome, education effects 6 months after implementation and implementation costs were secondary outcomes. Statistical analysis was performed using mixed-effects models. Prior to implementation, 146 patients were included and, after implementation, 213 patients were included. The case mix was comparable. The implementation did not change the proportion of patients switched on time (66 %). The median duration of intravenous antibiotic administration decreased from 4 days [interquartile range (IQR) 2-5] to 3 days (IQR 2-4), a decrease of 21 % [95 % confidence interval (CI) 11 %; 30 %) in the multi-variable analysis. LOS and patient outcome were comparable before and after implementation. Forty-three percent (56/129) of physicians attended the educational sessions. After 6 months, 24 % (10/42) of the interviewed attendees remembered the protocol's main message. Cumulative implementation costs were 5,798 (20/reduced intravenous treatment day). An implementation strategy tailored to previously identified barriers reduced the duration of intravenous antibiotic administration in hospitalised CAP patients by 1 day, at minimal cost.

Indications for antibiotic use in ICU patients: a one-year prospective surveillance.

The high prevalence of nosocomial infections in critically ill ICU patients is associated with high antibiotic consumption. Besides its economic impact, there is the constant threat of selection and induction of antibiotic resistance. Surveillance studies recording the incidence of infections, antibiotic use, and antimicrobial susceptibilities of pathogens supply vital information regarding infection control and prevention of antibiotic resistance. In order to analyse antibiotic consumption we recorded antibiotic use in a general ICU during one year by categorizing the indications for antibiotic use into three groups; (i) prophylaxis; (ii) therapy for a bacteriologically proven infection (BPI); (iii) therapy for a non-bacteriologically proven infection (non-BPI). Bronchoscopic techniques were used to diagnose pneumonia. In practice, BPI must be treated, but a proportion of antibiotics prescribed for non-BPI may be unnecessary. The subdivision in BPI and non-BPI may help to identify these cases. In all, 515 patients were admitted to ICU and 36% of these had at least one infection. Of all infections, 53% were ICU-acquired and 99% of these occurred in intubated patients. Antibiotics were prescribed in 61% of admissions. Of all antibiotics prescribed for therapy, 49% were for respiratory tract infections, 19% for abdominal infections and 13% for sepsis eci. Categorized by indication, 59% of all antibiotic prescriptions were for BPI, 28% for non-BPI and 13% for prophylaxis. A theoretical reduction of 25% in the number of non-BPI prescriptions would result only in a 7% decrease of total antibiotic use. We conclude that almost all antibiotics prescribed were for intubated patients and for BPI. Respiratory infections were the single most common infection and accounted for 49% of all antibiotics used. Therefore, in our setting, prevention of respiratory tract infections is probably the most effective mode to reduce antibiotic use.

Assessment of gastric acidity in intensive care patients: intermittent pH registration cannot replace continuous pH monitoring.

OBJECTIVE: To test the accuracy of colour-scaled indicator papers to measure pH values and to study the correlation between this method of measuring gastric juice pH once daily and 24-h continuous intragastric pH monitoring in intensive care patients. DESIGN: The accuracy of indicator papers was tested in the laboratory using colourless solutions and aspirated gastric juice and was then verified with a laboratory pH meter. Continuous intragastric pH monitoring was performed in mechanically ventilated ICU patients. Percentages of time with a pH value <3.0 and median pH values by 24-h continuous intragastric pH monitoring were compared to pH values measured once daily with indicator paper. SETTING: A mixed ICU. PATIENTS: A total of 150 measurements were taken by continuous pH monitoring in 91 mechanically ventilated ICU patients. MEASUREMENTS AND RESULTS: The correlation between the pH measured with the indicator paper and subsequently verified with a laboratory pH meter in colourless solutions was 0.96 [regression coefficient (RC) 0.98, 95% confidence interval (CI) 0.91-1.05]. Measured in gastric juice it was 0.95 (RC 0.95, 95% CI 0.88-1.01). The correlation between median pH values, determined with 24-h continuous intragastric pH monitoring, and values measured with indicator papers was 0.39 (RC 0.43, 95% CI 0.26-0.59). The mean difference in pH, as determined by the analysis of Bland and Altman], was 0.9 with a SD of 4.7. The correlation between the percentage of time with pH < 3.0, as obtained with continuous registration, and median gastric pH values (also obtained with continuous registration) was -0.94 (RC-0.06, 95% CI-0.06- -0.05); the correlation between the time and gastric pH values (measured with indicator paper) was-0.40 (RC-0.02, 95% CI-0.03- -0.02). CONCLUSION: The colour-scaled indicator paper is an accurate method of measuring pH values, but there is a poor correlation between gastric pH values measured once daily and a total measurement derived from 24-h continuous intragastric pH monitoring. Changes in intragastric pH values cannot be accurately studied when measuring acidity once daily. The influence of various treatment regimens on intragastric acidity in relation to the development of gastric colonization and nosocomial pneumonia should be investigated either with continuous intragastric monitoring or with frequent measurements in aspirated gastric juice.