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.

Double-blind comparison of cefazolin and ceftizoxime for prophylaxis against infections following elective biliary tract surgery.

Antibiotics have been shown to reduce the incidence of wound infections after elective biliary tract procedures. Cefazolin and cefoxitin are among the agents most commonly promoted for this purpose. Cefoxitin has been substituted with ceftizoxime in many institutions; however, the role of ceftizoxime as a prophylactic agent in this setting has not been determined. To assess the comparative prophylactic efficacies of cefazolin and ceftizoxime in biliary tract surgery, we conducted a double-blind, randomized prospective clinical trial in a tertiary-care teaching hospital. Adult patients were randomized to one of two treatment groups and received a 30-min preoperative dose of study drug and as many as two postoperative doses at 12 and 24 h, depending on hospitalization status. Cefazolin and ceftizoxime were given as 1,000-mg doses. Patients with infections, those receiving prior antibiotics, or those with beta-lactam allergies were excluded. Over the 19-month study tenure, 167 patients were enrolled. Seventeen patients were excluded from analysis because of protocol violations. Of the 150 evaluable patients (72 and 78 receiving cefazolin and ceftizoxime doses, respectively), there was no significant difference among groups regarding sex, age, weight, preoperative Apache II score, baseline chemistry, and hematological parameters. Groups were also equivalent regarding the surgeon, type of procedure, characteristics (blood loss, drains, organ injury, and complications), and duration of hospital stay (mean, 5.6 versus 4.3 days [P = 0.31]). No clinical evidence of infection (7-day hospital stay and 30-day follow-up) was identified in 93% of cefazolin and 92% of ceftizoxime patients (P = 1.0). Microbiological confirmation was found in only 18% of primary-site infections. In conclusion, cefazolin and ceftizoxime appear to be equivalent for the prevention of infection in biliary tract surgery with the dosage regimens studied.

Antibiotic therapeutic interchange program: six years of experience.

To assess the long-term impact of a therapeutic interchange program on the use of target antimicrobial drugs, we conducted a retrospective study of target drug utilization at our institution--a 1,000-bed Canadian tertiary care teaching hospital. Data were assessed to determine target drug utilization, incidence of therapeutic interchanges, and patient-target drug exposures. Results showed that the incidence of therapeutic interchanges per patient-target drug exposure decreased from a mean of 23% to 2%, resulting in a total net savings for the target drugs of approximately $1.07 million (Canadian) over 6 years. Prescriber acceptance and low manpower requirements combine to make this a useful method of altering prescribing patterns and reducing drug and drug delivery costs.

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.

Intravenous-to-oral stepdown program: four years of experience in a large teaching hospital.

OBJECTIVE: To assess the impact of an intravenous-to-oral (iv-po) stepdown program on the relative use of oral and parenteral dosage forms of select antimicrobials. DESIGN: A retrospective review of drug utilization records before and after a trial comparing metronidazole and clindamycin prescribing trends from a 12-month baseline period to a four-year follow-up period. SETTING: One thousand-bed Canadian tertiary care referral teaching center. INTERVENTION: An authorized iv-po stepdown program was developed to promote the oral route of drug administration. Reminders of iv-po stepdown were produced for metronidazole and clindamycin and these notes were sent to nursing units with the parenteral dosage form. The notes then were attached to the front of the health record to serve as a reminder to prescribers that an equally effective, well-tolerated, and less-expensive oral dosage form was available for use. RESULTS: A 44 percent relative increase in the use of oral metronidazole and a 79 percent relative increase in the use of oral clindamycin occurred. When acquisition and delivery costs were considered, cumulative cost savings from 1988 to 1991 resulted for metronidazole ($31,920) and clindamycin ($53,880). CONCLUSIONS: This intervention represents a simple yet effective method of promoting a process of stepdown from parenteral to oral antibiotic therapy.