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Biomedical subjects

D Nathwani

Publications and source records attributed to D Nathwani.

At least 55 records · Page 3Linked to original sources
PubMed1999

Out-patient and home-parenteral antibiotic therapy (OHPAT): evaluation of the impact of one year's experience in Tayside.

OBJECTIVE: An out-patient and home parenteral antibiotic therapy programme for the treatment of suitable infections was developed over a four year period. This paper describes the impact of one year's experience of its implementation on various measures of outcome. DESIGN: Each patient treatment has a full integrated care pathway (ICP) and patient satisfaction questionnaire completed. The ICP documents the clinical progress of the patient and incorporates various measures of quality of care on the 101 number of patients treated from April 1998 to March 1999 are presented here. SETTING: Dundee Teaching Hospitals NHS Trust (now Tayside University Hospitals NHS Trust). SUBJECTS: Patients with a range of infections requiring intravenous antibiotics. MAIN MEASURES: Number of patients treated with various infections, clinical and microbiological outcome, drug and vascular access complication rates, impact on drug costs and in-patient bed days, and measurement of patient satisfaction/quality of life. RESULTS: Patients were treated over a 12 month period. 51.5 per cent had skin & soft tissue infections and 22.8 per cent bone & joint sepsis. 57 per cent of patients received out-patient and 34 per cent self or carer administered home therapy. Ninety-four per cent of patients were cured or improved following treatment. Only 7.5 per cent of patients required an unscheduled admission to hospital. Twelve per cent of patients had some type of vascular device related adverse event (partly due to a faulty batch of lines) and six per cent of patients had a drug related reaction. The additional daily cost of drugs was minimal (< 12 Pounds/day) and more than 1,461 bed days have been saved across the Directorates. The patient satisfaction level was high.

Ambulatory Care↗
PubMed1999

Clinical record keeping in patients receiving antibiotics in hospital.

BACKGROUND: Antibiotic prescribing is associated with the growth of antibiotic resistance in micro-organisms. Prescribing therefore needs to be restricted by well-designed antibiotic protocols. Audit of such protocols is only possible if clinical information about infection is properly recorded. OBJECTIVE: To assess the quality of clinical data recording in case notes of patients receiving antibiotics in hospital and to assess the effect of feedback of this information on clinical practice. DESIGN: Four point prevalence surveys. SETTING: Directorate of General Medicine, Dundee Teaching Hospitals NHS Trust. SUBJECTS: Inpatients receiving antibiotics. INTERVENTION: Feedback of results from the first two surveys to clinicians. MAIN OUTCOME MEASURES: Proportion of patients in the Medical Directorate with the recording of an antibiotic indication and the temperature in the case notes before, immediately after, and three months after, feedback of survey results. RESULTS: In each survey one third of patients were receiving antibiotics. The antibiotic indication was recorded in 64% of patients prior to feedback and in 86.5% after feedback (p = 0.004). Three months later this had fallen to 74%. Temperature recording improved between 2nd and 3rd surveys (57% to 86.1%, p < 0.001) and declined to 61% in the 4th survey (p < 0.001). Respiratory infection was the commonest recorded indication for an antibiotic; recording of this indication improved between the 2nd and 3rd surveys but declined by the 4th survey. CONCLUSIONS: Audit and feedback of information about clinical record keeping improves standards but improvements are not sustained. Clinical record keeping must be improved so compliance with antibiotic protocols can be properly audited. An "antibiotic sticker" in addition to immediate concurrent feedback may improve such deficiencies.

Anti-Bacterial Agents↗
PubMed1998

Acute Herpes zoster in Tayside: demographic and treatment details in immunocompetent patients 1989-1992.

Medical records of 105 patients admitted to Tayside hospitals with acute Herpes zoster without underlying immunosuppression were examined retrospectively for the period 1984-1992. In this elderly population (median age: 79 years) there was a female preponderance (70.5%), most admissions were for trigeminal zoster (49.5%) and length of stay ranged from 1-70 days (median: 11 days), indicating significant morbidity. There was a wide variation in both pre-admission and inpatient treatment; 53.3% of patients did not receive any anti-viral therapy prior to admission, and prescribing patterns for in-patients revealed marked differences, according to the dermatome affected. Idoxuridine 5% solution was prescribed by 15.24% of General Practitioners. Given the significant morbidity and associated costs of Herpes zoster, and that existing anti-viral agents exert maximal benefit when administered early in the course of the disease, recommendations are made with respect to appropriate therapy, and auditing current management of this serious illness, which is expected to increase in prevalence as the population ages.

Acyclovir↗
PubMed1998

Strategies to rationalize sepsis management--a review of 4 years' experience in Dundee.

Hospitals worldwide are facing an unprecedented crisis of rising cost of antibacterials due to the increasing rapid emergence and dissemination of antibiotic-resistant organisms, improper use of antibiotics and the use of broad spectrum parenteral agents. The last 25 years has seen the introduction of many measures to improve the quality of sepsis management, and specifically antimicrobial use. The present paper reviews the development, implementation and evaluation of some of the key strategies employed within the Dundee Teaching Hospitals NHS Trust (DTHT) to enhance recognition and assessment of sepsis and to rationalize the early and often empiric antibiotic treatment of patients in hospital with infection. Particular emphasis is given to optimizing the use of expensive parenteral agents in conjunction with promotion of oral switch therapy where appropriate.

Administration, Oral↗
PubMed1998

Sequential antibiotic therapy: the right patient, the right time and the right outcome.

The aim of sequential therapy should be to provide better quality of care at lower cost. In comparison with i.v. therapy, oral administration is safer, more acceptable to the patient, facilitates early discharge from hospital and reduces the cost of consumables. However, if given to the wrong patient, oral antimicrobial therapy could both increase the cost and reduce the quality of care, either because of ineffective treatment, or unnecessary prolongation of treatment. Hospitals must develop policies for sequential therapy which define standards against which clinical care can be audited. The standards will need to be revised as new data become available from local audit and from research. Further research on sequential therapy is undoubtedly required, with particular emphasis on the reliability of absorption of oral drugs by hospitalized patients.

Administration, Oral↗
PubMed1998

Evaluation of the impact of non-inpatient i.v. antibiotic treatment for acute infections on the hospital, primary care services and the patient.

The aim of this study was to assess the feasibility of providing i.v. antibiotic therapy outside hospital. The main outcome measures were the direct costs of providing i.v. antibiotic therapy in the community compared with standard hospital treatment and the perceptions of patients and General Practitioners (GPs). A total of 29 patients entered the study, of whom 15 received teicoplanin and 14 ceftriaxone. The costs of drugs exceeded the cost of the estimated alternative treatments (median Pound Sterling 208 and Pound Sterling 126 respectively) and this was only partially compensated for by a small reduction in costs of consumables. The staff time required to train patients was compensated for by savings in drug preparation and administration. Sensitivity analysis showed that these conclusions were sensitive to drug and patient selection, and that treatment of skin and soft tissue infections outside hospital with ceftriaxone was likely to have similar variable costs to treatment in hospital with drugs such as flucloxacillin. Non-inpatient i.v. (NIPIV) therapy was estimated to save a total of 532 bed days in the year of the study. Patients strongly preferred non-inpatient treatment to hospital treatment. GPs identified a number of potential disadvantages, mainly concerning safety and lack of support for patients at home. Following the study a strategy for development of NIPIV services in Tayside has been developed with local GPs and a plan has been agreed for funding a community liaison nurse based on the impact of NIPIV therapy on future bed requirements in Dundee Teaching Hospitals Trust.

Acute Disease↗
PubMed1998

Sequential switch therapy for lower respiratory tract infections: a European perspective.

Traditionally, serious lower respiratory tract infections (LRTIs) are treated in hospital and with parenteral antibiotics. During the past decade, there has been an impetus to reduce the overall cost of antimicrobial therapy. The availability of new oral antibiotics with superior pharmacokinetics profiles and safety has enabled clinicians increasingly to consider their use in managing serious infections effectively. This article reviews the current published literature regarding the practice of switch therapy for LRTIs, examining the evidence for efficacy, safety, appropriate timing of the switch, the economic benefits, and the suitability of various antibiotics. There is an emphasis on comparing current European and US experience and examining key strategies in implementing such programs and means of assessing their impact.

Administration, Oral↗
PubMed1998

Skin and soft tissue infections: development of a collaborative management plan between community and hospital care.

The commonest indication in the US for referral to an outpatient/home i.v. antibiotic therapy programme is the management of skin and soft tissue infections. In the UK, however, these infections account for 10% or more of admissions to infection units. The main indication for hospitalisation is to receive parenteral antibiotics. A retrospective audit of one year of admissions to a regional infection unit revealed that, although most of these patients do not progress to complications ('low risk'), they occupy a mean time of five days in hospital and for nearly half of that time they receive parenteral antibiotics. This period in hospital reflected 11.4% of the unit's bed occupancy. Even if 75% of these patients were treated in the community with parenteral therapy, this would result in bed savings of 8.55%, nearly one-tenth of the unit's occupied capacity. This type of audit should help key decision makers thinking of developing similar services in their region. Outpatient or home parenteral antimicrobial therapy (OHPAT) should be delivered as part of a complete disease management programme in collaboration with primary care.

Algorithms↗
PubMed1998

What is the value of preventing postoperative infections?

The importance of postoperative infections depends on the frequency with which infection occurs as well as on the additional cost per patient with infection. For example, in our hospital the additional cost per patient with infection after hernia repair was $600, compared with $2,106 per patient with infection after colonic surgery. However, the total excess cost per year was similar for hernia surgery ($44,800) and colon surgery ($48,440). The reason is that hernia surgery is much more common than colon surgery. It is a general principle of clinical audit that the importance of problems should be defined by their frequency as well as their individual severity. A third important consideration is the likelihood that the problem can be corrected. Undue attention has been given to the health resource costs of postoperative infection at the expense of information about the intangible costs to the patient (these are nonfinancial costs such as pain and disability). Health resource costs are very dependent on medical practice variation, and comparative studies between countries reveal marked differences in the way that apparently similar infections are managed. Moreover, comprehensive audit of infection-control management often reveals wasteful practice, e.g, antibiotic treatment of patients who do not in fact have infection. Audit of postoperative infection should focus on eliminating wasteful practice (e.g., prophylactic antibiotics continuing > 24 hrs after surgery) as well as on reducing postoperative infection rates.

Cost-Benefit Analysis↗
PubMed1997

Auditory evoked response, median frequency and 95% spectral edge during anaesthesia with desflurane and nitrous oxide.

We have studied in 12 patients the effect of desflurane in nitrous oxide on the electroencephalogram (EEG) and the early cortical auditory evoked response (AER). After induction with desflurane, patients' lungs were ventilated to maintain three different end-expiratory concentrations of desflurane (1.5, 3 and 6%) during four consecutive 10-min periods before surgery. As the end-expiratory concentration of desflurane was increased, Pa and Nb (AER) amplitudes decreased and their latencies increased, and spontaneous EEG showed an increase in amplitude and a slowing of frequency. A linear relationship was demonstrated between log10 concentration of desflurane and all variables (P = 0.001). Pa amplitude showed the greatest linearity followed by the derived variable F95 of the EEG. From regression slopes, mean percentage changes of each variable were calculated for a 1 MAC change in desflurane concentration, Pa amplitude showed the largest change (mean 49% (95% confidence interval 40-56%) decrease for a 1 MAC increase). This was greater than that of F95 for a similar confidence interval, indicating better resolution. This study confirms that the early cortical AER is affected by desflurane in a similar manner to that of other anaesthetic agents and as such remains the most promising EEG derived measure of depth of anaesthesia.

Adult↗
PubMed1997

Information about antimalarial chemoprophylaxis in hospitalised patients--is it adequate?

Malaria remains a huge public health problem worldwide, with over 100 million new cases annually, causing one to two million deaths. This global problem spills over into the UK, with around 2000 cases of reported annually. The proportion of infections due to Plasmodium falciparum (PF) continues to increase and worse still accounts for five to 12 deaths per year. In 1992, Nathwani et al reported the 10 year experience of malaria cases admitted to the Regional Infection Unit, in Aberdeen, Scotland--the "Oil Capital". This study was of interest in that 46% of those British residents who acquired infection had travelled to West or Central Africa on oil related business. The Oil boom of the 1980's appeared to very much centred around Aberdeen and the neighbouring hinterland but did not appear to extend to Dundee which was only 60 miles further down the North-East coast. We, therefore, carried out a retrospective study of patients with malaria admitted to the Regional Infectious Diseases Unit in Dundee over a fifteen year period between 1980 and 1994.

Antimalarials↗
PubMed1996

Intravenous antimicrobial therapy in the community: underused, inadequately resourced, or irrelevant to health care in Britain?

The NHS Executive is keen to promote "hospital at home" services in Britain, as part of its philosophy of keeping more care in the community and also to relieve the increasing demand for hospital beds. One such service is the provision of intravenous antimicrobial therapy in the community. Yet, compared with the United States, where home or outpatient intravenous antimicrobial therapy programmes are well developed, experience in Britain and Europe is limited, reflecting a difference in cultural attitudes and healthcare structures between the two continents. Only a few units in Britain currently run home intravenous antimicrobial therapy programmes, and several issues need to be addressed if more treatment is to be provided outside hospital. These include an assessment of the need for community intravenous antibiotic treatment and which patient groups many benefit. The main motive for community intravenous treatment should be better patient care and not simply a reduction in healthcare costs. At present the pace of change is being set by a few clinical enthusiasts and by commercial organisations, whereas the NHS deserves a more organised strategy for purchasing treatment with intravenous antibiotics in the community.

Anti-Bacterial Agents↗