A comparison of clinical outcomes associated with dosing metronidazole every 8 hours versus every 12 hours: a systematic review and metaanalysis.

Background: Metronidazole treats obligate anaerobic bacterial and protozoal infections, with an elimination half-life of around 8 hours. The long elimination half-life, the favorable ratio of steady-state serum levels to minimum inhibitory concentration, and the presence of active metabolites have led to the consideration of metronidazole use at 12-hour dosage intervals. This systematic review aimed to compare the clinical outcomes of twice-daily and thrice-daily metronidazole dosing. Methods: Using the PRISMA checklist, we searched five databases to systematically identify all relevant studies published up to June 16, 2023. Results: The final analysis included two published retrospective cohort studies of hospitalized adult patients: a single site study (n = 200) and a multisite study (n = 85) of "good" quality, as measured by the Newcastle-Ottawa scale. The reported baseline characteristics of the 8-hour and 12-hour dosing groups were comparable, and neither study identified significant differences in primary and secondary clinical outcomes. Metaanalysis of the need to escalate antibiotic therapy also showed no statistically significant differences using the Mantel-Haenszel fixed-effect method (95% confidence interval: 47.6% lower to 6.4 times higher risk, P = 0.34) and inverse-variance method (risk ratio: 1.87; 95% confidence interval: 0.52-6.65, P = 0.34). Conclusions: This review suggests that dosing metronidazole every 12 hours is as effective as every-8-hour dosing for hospitalized patients with anaerobic infections. These encouraging findings would benefit from validation by a multicenter randomized controlled trial since there would be many benefits to a 12-hour dosing interval while achieving similar clinical outcomes with traditional dosing. The studies in this systematic review excluded patients with Clostridioides difficile and central nervous system and amebiasis infections, so the findings do not apply to these infection types.

Postpartum Invasive Group A Streptococcus Infection: Case Report and Mini-review.

The overall incidence of postpartum invasive group A streptococcal (GAS) disease is low in the United States. However, postpartum women are much more likely to develop GAS disease than nonpregnant women. Additionally, postpartum GAS has the potential to develop into a severe disease and a delay in diagnosis can have deadly consequences. This case describes a patient with invasive postpartum endometritis in the setting of diastases of the pubic symphysis. Sepsis secondary to the endometritis develops along with bilateral pneumonia. This case characterizes some of the typical and atypical symptoms a patient with invasive postpartum GAS can present with. Further, it outlines the timely identification of the disease and its appropriate treatment to prevent a potentially disastrous outcome.

Streptococcus Gordonii Empyema: A Case Report and Review of Empyema.

Streptococcus gordonii (S. gordonii) is a pioneer oral bacteria that is recognized as an agent of bacterial endocarditis. However, an extensive review of the literature revealed no reported case of S. gordonii causing empyema. We present a case of a 65-year-old male who presented with respiratory distress. Physical examination revealed several dental caries with decreased breath sounds in the bibasilar regions. A computed tomography (CT) scan of the chest and abdomen demonstrated left-sided pleural effusion and a 4.3 cm x 2.8 cm splenic abscess. He received intravenous (IV) antibiotics, and his blood cultures remained negative. Drainage of the splenic abscess grew S. gordonii. A CT-guided thoracentesis yielded 450 ml of exudative fluid. Pleural fluid cultures grew S. gordonii. A CT scan of the head and neck ruled out an intra-oral abscess. He received six weeks of IV penicillin with a follow-up CT scan showing resolution of both the splenic abscess and the left parapneumonic effusion.

Education and Communication in an Interprofessional Antimicrobial Stewardship Program.

CONTEXT: Interprofessional education/interprofessional practice (IPE/IPP) is an essential component in medical education and training. A collaborative interprofessional team environment ensures optimal patient-centered care. OBJECTIVE: To describe the implementation of 2 interprofessional antimicrobial stewardship program (ASP) teams using IPE/IPP and to assess the acceptance rate by the primary medical and surgical teams of ASP recommendations for antimicrobial interventions. METHODS: A business plan for the ASP was approved at 2 academic medical centers used for the present study. During a 3-year study period, 2 interprofessional ASP teams included an attending physician specializing in infectious disease (ID), an ID physician fellow, an ASP pharmacist, physician residents, medical students, pharmacy residents, and pharmacy students. Educational seminars were presented for all adult-admitting physicians to discuss the need for the ASP and the prospective audit and feedback process. Cases were presented for discussion during ASP/ID rounds and recommendations were agreed upon by the ASP team. A motivational interviewing face-to-face technique was frequently used to convey the ASP team recommendation to the primary medical or surgical team in a noncoercive and educational manner. The ASP team recommendations for ASP interventions were documented in the medical records. RESULTS: The overall acceptance rate of recommendations by the primary medical and surgical teams were greater than 90% (2051 of 2266). The most frequent interventions provided were streamline therapy (601), route of administration change (452), bug-drug mismatch (190), and discontinuation of therapy (179). Route of administration change was also the most frequently accepted intervention (96%). CONCLUSIONS: The motivational face-to-face communication technique was particularly useful in conveying ASP team member recommendations to the primary medical or surgical teams. Communicating recommendations as a multidisciplinary team in an educational manner seems to have resulted in to greater acceptance of recommendations.

Review of insulin therapy and pen use in hospitalized patients.

OBJECTIVE: Hyperglycemia is common among hospitalized patients, affecting approximately 40% of patients at the time of hospital admission, despite the fact that 1 in every 8 patients has no previous diagnosis of diabetes. Hyperglycemia has been associated with poor patient outcomes, including higher rates of morbidity and mortality across a range of conditions. This review discusses options for the effective management of hyperglycemia with a focus on the use of disposable insulin pens in the hospital. METHODS: Literature, including guidelines for hospital management of hyperglycemia, and information regarding methods of insulin administration were reviewed. RESULTS: Appropriate glucose control via administration of insulin within hospitals has been acknowledged as an important goal and is consistent with achieving patient safety. Insulin may be administered subcutaneously using a pen or vial and syringe or infused intravenously. Levels of patient and provider satisfaction are higher with pen administration than with vial and syringe. Insulin pens have many safety and convenience features including enhanced dose accuracy and autocover/autoshield pen needles. CONCLUSION: Use of insulin pens instead of vials and syringes can provide several advantages for hospitalized patients, including greater satisfaction among them and health care providers, improved safety, and reduced costs. These advantages can continue following patient discharge.

Faculty and student expectations and perceptions of e-mail communication in a campus and distance doctor of pharmacy program.

OBJECTIVE: To examine faculty members' and students' expectations and perceptions of e-mail communication in a dual pathway pharmacy program. METHODS: Three parallel survey instruments were administered to campus students, distance students, and faculty members, respectively. Focus groups with students and faculty were conducted. RESULTS: Faculty members perceived themselves as more accessible and approachable by e-mail than either group of students did. Campus students expected a shorter faculty response time to e-mail and for faculty members to be more available than did distance students. CONCLUSION: E-mail is an effective means of computer-mediated communication between faculty members and students and can be used to promote a sense of community and inclusiveness (ie, immediacy), especially with distant students.

An evaluation of prefilled insulin pens: a focus on the Next Generation FlexPen(®).

Insulin pen delivery systems are preferred by patients over the traditional vial and syringe method for insulin delivery because they are simple and easy to use, improve confidence in dosing insulin, and have less interference with activities and improved discretion with use. Insulin manufacturers have made numerous improvements to their first marketed pen devices and are now introducing their next generation of devices. Design modifications to the newest generation of prefilled insulin pen devices are intended to improve the ease of use and safety and continue to positively impact adherence to insulin. This review focuses on the Next Generation FlexPen(®) with regard to design considerations to reduce injection force, improve accuracy and ease of use, and evaluate the preference of patient and health-care provider compared with other disposable, prefilled insulin pen devices.

Patient satisfaction and costs associated with insulin administered by pen device or syringe during hospitalization.

PURPOSE: Patient satisfaction, safety and efficacy outcomes, and cost savings with insulin pens versus conventional insulin delivery via vials and syringes in hospitalized patients with diabetes were compared. METHODS: Patients were recruited from two general medical-surgical units from July 2005 to May 2006. Patients completed a survey regarding satisfaction with the method in which insulin was administered before discharge. Patients completed a telephone survey approximately four weeks after discharge to determine home insulin use. Cost savings were determined using the average wholesale price of insulin vials and syringes, pens, and pen needles. RESULTS: A total of 94 patients were randomized to receive insulin administered via pen devices (n = 49) or using conventional vials and syringes (n = 45). Significantly more subjects in the pen group prepared or self-injected at least one dose of insulin during hospitalization, wanted to continue taking insulin at home using the method used during hospitalization, and would recommend their method of insulin administration used during hospitalization to other patients with diabetes compared with the vial and syringe group (p < 0.05). A cost saving of $36 per patient was projected if only insulin pens were dispensed during the entire hospital stay compared to insulin vials and syringes (p < 0.05). CONCLUSION: Increased patient satisfaction and continuation of the method of insulin administration used in the hospital at home were reported by patients who received insulin pens compared with patients who received conventional vials and syringes during hospitalization. A substantial cost saving was projected for patients in the insulin pen group if insulin pens had been dispensed during their entire hospital stay.

An efficiency evaluation of protocols for tight glycemic control in intensive care units.

BACKGROUND: The efficiency of protocols for tight glycemic control is uncertain despite their adoption in hospitals. OBJECTIVES: To evaluate the efficiency of protocols for tight glycemic control used in intensive care units. METHODS: Three separate studies were performed: (1) a third-party observer used a stopwatch to do a time-motion analysis of patients being treated with a protocol for tight glycemic control in 3 intensive care units, (2) charts were retrospectively reviewed to determine the frequency of deviations from the protocol, and (3) a survey assessing satisfaction with and knowledge of the protocol was administered to full-time nurses. RESULTS: Time-motion data were collected for 454 blood glucose determinations from 38 patients cared for by 47 nurses. Mean elapsed times from blood glucose result to therapeutic action were 2.24 (SD, 1.67) minutes for hypoglycemia and 10.65 (SD, 3.24) minutes for hyperglycemia. Mean elapsed time to initiate an insulin infusion was 32.56 (SD, 12.83) minutes. Chart review revealed 734 deviations from the protocol in 75 patients; 57% (n = 418) were deviations from scheduled times for blood glucose measurements. The mean number of deviations was approximately 9 per patient. Of 60 nurses who responded to the workload survey, 42 (70%) indicated that the protocol increased their workload; frequency of blood glucose determinations was the most common reason. CONCLUSIONS: Nurses spend substantial time administering protocols for tight glycemic control, and considerable numbers of deviations occur during that process. Further educational efforts and ongoing assessment of the impact of such protocols are needed.

Oxycodone accumulation in a hemodialysis patient.

Oxycodone and oxycodone-containing analgesics are often used for the relief of pain. In the presence of renal dysfunction, the half-life of oxycodone and metabolites can be prolonged. We describe the case of a 41-year-old chronic hemodialysis patient who received multiple doses of oxycodone/acetaminophen resulting in accumulation of the medication and consequent lethargy, hypotension and respiratory depression. These adverse effects were reversed with multiple bolus doses of naloxone, followed by a continuous infusion administered for 45 hours. Utilizing the Naranjo probability scale, the patient had a "probable" adverse drug reaction to the oxycodone. Oxycodone should be used with caution in patients with chronic renal failure.

Impact of nesiritide on health care resource utilization and complications in patients with decompensated heart failure.

STUDY OBJECTIVE: To determine the impact of nesiritide on health care resource utilization and complications in patients hospitalized with decompensated heart failure. DESIGN: Retrospective case-control study. SETTING: United States hospitals. PATIENTS: Two hundred sixteen patients hospitalized for decompensated heart failure. MEASUREMENTS AND MAIN RESULTS: One hundred eight patients who received a nesiritide infusion for a minimum of 12 hours during the first 48 hours after hospital admission were matched with 108 patients not receiving nesiritide. Health care resource utilization, consisting of hospital length of stay (LOS), rate of rehospitalization within 90 days, concomitant drugs administered, and laboratory and diagnostic tests, was determined for each hospital admission. Rates of adverse events also were recorded. Patients receiving nesiritide had a significantly shorter LOS in a critical care unit (p=0.03). General medical ward or step-down unit LOS was not different between the treatment groups. A favorable trend toward a lower rate of rehospitalization over the 90-day follow-up period was observed with nesiritide (p=0.07). The number of patients who developed life-threatening ventricular arrhythmias and hypotension was similar for both treatment groups. However, in patients receiving nesiritide, significantly less atrial fibrillation (p=0.03) and renal dysfunction (p=0.04) occurred compared with patients not receiving nesiritide. CONCLUSION: Nesiritide therapy is associated with significant reductions in both health care resource utilization and complications in patients with decompensated heart failure.

Nebulized opioids use in COPD.

OBJECTIVE: To evaluate the role of nebulized opioids in COPD. METHODS: A MEDLINE search was completed to obtain pertinent clinical literature. Key search terms included the following: nebulizer, opioids, COPD, dyspnea, morphine, and hydromorphone. RESULTS: Currently, the evidence in the literature is lacking regarding placebo-controlled studies to support nebulized morphine for the relief of dyspnea in patients with COPD. The studies reviewed varied considerably in the dose, opioid used, administration schedule, and methodology. One study found improved exercise capacity in 11 patients not reproducible in a larger sample, and another study found benefit in 54 terminal patients. All other studies found no benefit. CONCLUSIONS: The recently published Global Initiative for Lung Disease guidelines have specifically stated that opioids are contraindicated in COPD management due to the potential respiratory depression and worsening hypercapnia. Nebulized opioids should be discouraged, as current data do not support their use.

Gastrointestinal-related adverse effects of COX-2 inhibitors.

Selective cyclooxygenase-2 (COX-2) inhibitors are used for the treatment of inflammation and pain while having the reported advantage of fewer upper gastrointestinal adverse effects compared to traditional nonsteroidal anti-inflammatory drugs. Although fewer adverse effects occur, there is still a risk for developing upper gastrointestinal adverse effects. Clinical practitioners have increased concern regarding this risk. The belief that COX-2 inhibitors are safe for the gastrointestinal tract has been questioned. This has encouraged the proposal of several explanations on the mechanism of gastromucosal injury and healing relative to COX isoenzymes. These mechanisms are delineated in the following review, along with the gastrointestinal safety, risk factors, clinical and case studies, and cost effectiveness of the COX-2 inhibitors.

Gastrointestinal bleeds associated with rofecoxib.

Data suggest that cyclooxygenase (COX)-2 inhibitors are safer for the gastrointestinal tract than traditional nonsteroidal antiinflammatory drugs (NSAIDs). Rofecoxib, a COX-2-specific NSAID, does not inhibit the COX-1 enzyme, thereby decreasing the potential for gastrointestinal-related adverse effects. Patients who are at an increased risk for NSAID-related gastrointestinal bleeding are therefore appropriate candidates for COX-2 inhibitors. Although the agents provide benefits for many patients, gastrointestinal-related side effects may occur, and caution should be practiced when prescribing COX-2 inhibitors. We report two patients who were admitted to the hospital with diagnoses of gastrointestinal bleeds while they were taking rofecoxib.