Early gram-positive bacteremia in BMT recipients: impact of three different approaches to antimicrobial prophylaxis.

Antimicrobial prophylaxis against gram-positive bacteremia (GPB) following BMT may prevent infections but promote antimicrobial resistance. In a sequential cohort study involving 289 consecutive BMT recipients we compared three protocols for prevention of GPB (vancomycin prophylaxis, penicillin/cefazolin prophylaxis, and no specific GPB prophylaxis) with respect to incidence of GPB, mortality, and vancomycin use. GPB was associated with increased mortality (27% vs 15%; P = 0.02), but contributed to only five of 52 deaths in the study population, and only one of 15 subjects with viridans streptococcal bacteremia developed fatal septic shock. Vancomycin prophylaxis reduced the incidence of GPB (11%) compared to penicillin/cefazolin (27%) or no prophylaxis (40%) (all P < 0.03), but did not significantly reduce mortality. The incidence of fungemia, gram-negative bacteremia, and infection-associated mortality was unaffected by GPB prophylaxis. Vancomycin use was substantially greater in the vancomycin prophylaxis group. We conclude that in comparison with vancomycin prophylaxis, BMT support regimens that do not include vancomycin prophylaxis allow reduced overall vancomycin use without an apparent increase in early post-BMT mortality, despite the greater associated frequency of GPB.

Short- and long-term retention of a nursing home education program on metered-dose inhaler technique.

OBJECTIVE: To evaluate an education program on metered-dose inhaler (MDI) technique designed for nurses and trained medication aides (TMAs). DESIGN: The education program included a handout, a lecture incorporating a videotape on correct inhaler and device technique, and hands-on experience with placebo inhalers. The participants' ability to verbalize and demonstrate correct MDI technique was assessed by the same two-person teams before, immediately after, and two months after the program. SETTING: Five nursing homes. PARTICIPANTS: Fifty-six nurses and TMAs practicing in nursing homes. MAIN OUTCOME MEASURES: Learning and retention. RESULTS: The participants' mean (+/- SD) verbal and demonstration scores increased immediately after the program by 68 +/- 18 points for verbalization and 47 +/- 16 points for demonstration. The participants were always better at demonstrating than verbalizing MDI technique. The participants' baseline verbal and demonstration scores correlated with the amount learned. Learning was influenced by the individual nursing home (verbal and demonstration) and personal use (demonstration only), but not by academic degree, previous training, past instruction of a patient, or current care of a patient who was receiving inhaler therapy. After two months, the scores were lower than immediately after the program test by 0-92 points for verbalization and 10-80 points for demonstration; however, the mean scores were still significantly greater (p less than 0.05) than the baseline scores. Retention of knowledge on the correct technique was greater for the demonstration component. Retention was influenced only by the nursing home in which the participant worked, and not any of the other variables. CONCLUSIONS: Our structured education program significantly improved inhaler technique; however, to maintain retention of the material, the program should be frequently repeated.