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PubMed2002

Removing meperidine from the health-system formulary--frequently asked questions.

Meperidine is FDA-approved for relieving moderate to severe pain and has been widely used since its introduction in the 1930s. However, the drug is no longer considered a first-line analgesic. Many clinicians recommend that meperidine be removed from health-systems or that its use be restricted, due to concerns about adverse reactions, drug interactions, and normeperidine neurotoxicity. In addition, clinical evidence shows that meperidine has no advantage over other opioids for biliary colic or pancreatitis. The formulary status of meperidine has been extensively discussed at University of Utah Hospitals and Clinics. The Pharmacy and Therapeutics Committee has been working with hospital staff to assess the impact of either removing meperidine from the formulary, or limiting its use. The Drug Information Service developed this document to help pharmacists respond to prescribers' questions and to alleviate the prescribers' concerns about these changes. Information is provided comparing meperidine with other opioids, including dosage equivalency, pharmacodynamics, pharmacokinetics, cost, adverse effects, and drug interactions. Where available, alternatives to meperidine are suggested for various indications.

Analgesics, Opioid↗
PubMed2003

Routine cycling of antimicrobial agents as an infection-control measure.

Antimicrobial cycling is the deliberate, scheduled removal and substitution of specific antimicrobials or classes of antimicrobials within an institutional environment (either hospital-wide or confined to specific units) to avoid or reverse the development of antimicrobial resistance. True antimicrobial cycling requires a return to the antimicrobial(s) that were first used. Testing of the hypothesis that cycling will result in a lower prevalence of resistance is ongoing, mostly occurs within intensive care units, and largely involves cycling regimens targeted for treatment of suspected gram-negative bacterial infections. Unfortunately, there has been insufficient study to determine whether any meaningful impact on resistance has occurred as a result of a cycling program. Mathematical models question the usefulness of cycling as an infection-control method. Published studies demonstrate that cycling may be one way to change prescribing practices by clinicians without sacrificing patient safety. However, optimizing antimicrobial use through traditional and novel methods (e.g., computer decision support) should not be abandoned.

Anti-Infective Agents↗
PubMed2004

Long-term antibiotic cost savings from a comprehensive intervention program in a medical department of a university-affiliated teaching hospital.

We tested a low-cost, multifaceted intervention program comprising formulary restriction measures, continued comprehensive education, and guidelines to improve in-hospital use of antibiotics and related costs. In a short-term analysis, total antibiotic consumption per patient admitted, which was expressed as defined daily doses (DDD), decreased by 36% (P < .001), and intravenous DDDs decreased by 46% (P < .01). Overall expenditures for antibiotic treatment decreased by 53% (100 US dollars per patient admitted). The 2 main cost-lowering factors were a reduction in prescription of antibiotics (35% fewer treatments; P < .0001) and more diligent use of 5 broad-spectrum antibiotics (23% vs. 10% of treatments; P = .001). Quality of care was not compromised. A pharmacy-based, prospective, long-term surveillance of DDDs and costs over 4 years showed an ongoing effect. This comprehensive intervention program, which aimed to reduce antibiotic consumption and costs, was highly successful and had long-lasting effects.

Aged↗
PubMed2000

Practices to improve antimicrobial use at 47 US hospitals: the status of the 1997 SHEA/IDSA position paper recommendations. Society for Healthcare Epidemiology of America/Infectious Diseases Society of America.

OBJECTIVE: To determine the status of programs to improve antimicrobial prescribing at select US hospitals. DESIGN: Cross-sectional survey. PARTICIPANTS AND SETTING: Pharmacy and infection control staff at all 47 hospitals participating in phase 3 of Project Intensive Care Antimicrobial Resistance Epidemiology. RESULTS: All 47 hospitals had some programs to improve antimicrobial use, but the practices reported varied considerably. All used a formulary, and 43 (91%) used it in conjunction with at least one of the other three antimicrobial-use policies evaluated: stop orders, restriction, and criteria-based clinical practice guidelines (CPGs). CPGs were reported most commonly (70%), followed by stop orders (60%) and restriction policies (40%). Although consultation with an infectious disease physician (70%) or pharmacist (66%) was commonly used to influence initial antimicrobial choice, few (40%) reported a system to measure compliance with these consultations. CONCLUSIONS: In most hospitals surveyed, practices to improve antimicrobial use, although present, were inadequate based on recommendations in a Society for Healthcare Epidemiology of America and Infectious Disease Society of America joint position paper. There is room to improve antimicrobial-use stewardship at US hospitals.

Anti-Bacterial Agents↗
PubMed2002

Extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella species: risk factors for colonization and impact of antimicrobial formulary interventions on colonization prevalence.

OBJECTIVE: The incidence of extended-spectrum beta-lactamase (ESbetaL)-mediated resistance has increased markedly during the past decade. Risk factors for colonization with ESbetaL-producing Escherichia coli and Klebsiella species (ESbetaL-EK) remain unclear, as do methods to control their further emergence. DESIGN: Case-control study. SETTING: Two hospitals within a large academic health system: a 725-bed academic tertiary-care medical center and a 344-bed urban community hospital. PATIENTS: Thirteen patients with ESbetaL-EK fecal colonization were compared with 46 randomly selected noncolonized controls. RESULTS: Duration of hospitalization was the only independent risk factor for ESbetaL-EK colonization (odds ratio, 1.11; 95% confidence interval, 1.02 to 1.21). Of note, 8 (62%) of the patients had been admitted from another healthcare facility. In addition, there was evidence for dissemination of a single K oxytoca clone. Finally, the prevalence of ESbetaL-EK colonization decreased from 7.9% to 5.7% following restriction of third-generation cephalosporins (P = .51). CONCLUSIONS: ESbetaL-EK colonization was associated only with duration of hospitalization and there was no significant reduction following antimicrobial formulary interventions. The evidence for nosocomial spread and the high percentage of patients with ESbetaL-EK admitted from other sites suggest that greater emphasis must be placed on controlling the spread of such organisms within and between institutions.

Academic Medical Centers↗
PubMed2006

Limiting the emergence of extended-spectrum Beta-lactamase-producing enterobacteriaceae: influence of patient population characteristics on the response to antimicrobial formulary interventions.

BACKGROUND: Effective methods to control the emergence of extended-spectrum beta -lactamase-producing Escherichia coli and Klebsiella species (ESBL-EK) remain unclear. Variations in the patient populations at different hospitals may influence the effect of antimicrobial formulary interventions. METHODS: To examine variations across hospitals in the response to antimicrobial interventions (ie, restriction of ceftazidime and ceftriaxone) designed to curb the spread of ESBL-EK, we conducted a 5-year quasi-experimental study. This study was conducted at 2 hospitals within the same health system: Hospital A is a 625-bed academic medical center, and Hospital B is a 344-bed urban community hospital. All adult patients with a healthcare-acquired clinical culture of ESBL-EK from July 1, 1997 through December 31, 2002 were included. RESULTS: After the interventions, the use of ceftriaxone decreased by 86% at Hospital A and by 95% at Hospital B, whereas the use of ceftazidime decreased by 95% at Hospital A and by 97% at Hospital B. The prevalence of ESBL-EK at Hospital A decreased by 45% (P < .001), compared with a 22% decrease at Hospital B (P = .36). The following variables were significantly more common among ESBL-EK-infected patients at Hospital B: residence in a long-term care facility (adjusted odds ratio, 3.77 [95% confidence interval, 1.70-8.37]), advanced age (adjusted odds ratio, 1.04 [95% confidence interval, 1.01-1.06]), and presence of a decubitus ulcer (adjusted odds ratio, 4.13 [95% confidence interval, 1.97-8.65]). CONCLUSIONS: The effect of antimicrobial formulary interventions intended to curb emergence of ESBL-EK may differ substantially across institutions, perhaps as a result of differences in patient populations. Variability in the epidemiological profiles of ESBL-EK isolates at different hospitals must be considered when designing interventions to respond to these pathogens.

Adolescent↗
PubMed1999

Reduction in the incidence of methicillin-resistant Staphylococcus aureus and ceftazidime-resistant Klebsiella pneumoniae following changes in a hospital antibiotic formulary.

In 1995, changes in our hospital formulary were made to limit an outbreak of vancomycin-resistant enterococci and resulted in decreased usage of cephalosporins, imipenem, clindamycin, and vancomycin and increased usage of beta-lactam/beta-lactamase-inhibitor antibiotics. In this report, the effect of this formulary change on other resistant pathogens is described. Following the formulary change, there was a reduction in the monthly number (mean +/- SD) of patients with methicillin-resistant Staphylococcus aureus (from 21.9 +/- 8.1 to 17.2 +/- 7.2 patients/1,000 discharges; P = .03) and ceftazidime-resistant Klebsiella pneumoniae (from 8.6 +/- 4.3 to 5.7 +/- 4.0 patients/1,000 discharges; P = .02). However, there was an increase in the number of patients with cultures positive for cefotaxime-resistant Acinetobacter species (from 2.4 +/- 2.2 to 5.4 +/- 4.0 patients/1,000 discharges; P = .02). Altering an antibiotic formulary may be a possible mechanism to contain the spread of selected resistant pathogens. However, close surveillance is needed to detect the emergence of other resistant pathogens.

Acinetobacter↗
PubMed2001

The puzzle of homeopathy.

Homeopathy is a branch of Western medicine that has mostly been rejected by Western orthodoxy for the last 200 years because of conceptual and scientific clashes. Homeopathy uses microdoses of potential toxins to provoke defense and self-regulatory responses, rather than the more orthodox approach of blocking body reactions. This approach hints at its clinical scope: it can help, at times resolve, conditions that are intrinsically reversible rather than mechanical problems, deficiencies, or irreversible breakdowns in body functions where it is only palliative. In recent years, there has been a renaissance of interest. Public demand has soared, and with it professional interest. Approximately 20% of Scotland's general practitioners have completed basic training. This is partly occasioned by public interest in complementary medicine and a sympathy with the more mind-body approach of homeopathy, and partly by recent scientific evidence. Some homeopathic dilutions are so extreme they are dismissed by critics as only placebo. Yet trials and meta-analyses of controlled trials are pointing toward real effects, mechanism of action unknown. Clinical outcome studies suggest useful clinical impact and excellent safety. There seems to be a potential to enhance patient care by integrating the two systems.

Evidence-Based Medicine↗
PubMed2002

Emergence of resistant microbes in critical care units is transient, despite an unrestricted formulary and multiple antibiotic trials.

BACKGROUND: Antimicrobial resistance is a growing problem in the intensive care setting. This study was designed to evaluate the trends in bacterial prevalence and changes in antibiotic resistance at a large university hospital over the past decade. Antimicrobial resistance data were compared among the surgical intensive care unit (SICU), medical intensive care unit (MICU), and burn unit (BNU). MATERIALS AND METHODS: A large database was created using hospital-wide data from 1989 to 2000. A retrospective analysis of the evolution of organism prevalence, antibiotic resistance, and response to study protocols was evaluated. The formulary was relatively unrestricted. All positive cultures were examined, focusing on wound, blood, and sputum cultures. Six primary antibiotics were targeted specifically to follow resistance patterns. RESULTS: There were 847 identified positive wound cultures, 2,862 positive sputum cultures, and 2,252 positive blood cultures. The incidence of gram-positive and gram-negative organisms changed little in the SICU and BNU; however, there was a large increase in gram-positive organisms and yeast in the MICU over the past 5 years. Anaerobic bacteria and yeast were nearly nonexistent pathogens in the SICU and BNU. The resistance pattern of most organisms changed little following the introduction of a new antibiotic. However, the effectiveness of study antibiotics after formal clinical study periods decreased dramatically, albeit transiently. CONCLUSION: Hospital-wide antibiotic resistance data may be misleading and may not reflect individual critical care units throughout the hospital. Bacterial flora, including resistant organisms, changed little over 10 years, despite an unrestricted formulary. The emergence of resistant and opportunistic organisms is related to antibiotic usage and can vary significantly over time. This suggests that a policy of administering limited duration, narrow spectrum antibiotics may reduce drug resistance.

Anti-Bacterial Agents↗
PubMed1995

Implementation of a criteria-based antimicrobial formulary system.

The development of a criteria-based antimicrobial formulary system for use in a 432-bed university-based tertiary-care hospital is described. A subcommittee of the hospital's pharmacy and therapeutics committee developed prescribing criteria for antimicrobials thought to have a specific place in the treatment of various infections. The criteria were based primarily on patient needs, but when two therapies were thought to have similar effectiveness and similar toxicity profiles, cost became the deciding factor in drug selection. Educational packets were designed to assist physicians in prescribing criteria-based antimicrobials. An antimicrobial order form was also developed. The program was implemented after an extensive orientation and education period; data on antimicrobial use were collected for the first year of the program. Hospitalwide compliance with the criteria was 89%, although compliance in certain departments was poorer. The database was formulated to be both service- and physician-specific for the purposes of reporting and education.

Anti-Infective Agents↗
PubMed1996

Benchmark analysis of strategies hospitals use to control antimicrobial expenditures.

Hospital expenditures on antimicrobial drugs, antimicrobial management practices, and the effects of these practices were studied. A survey on institutional budget, size, and staffing; intensive care unit drug costs and use evaluations; and pharmacy expenditures, including antimicrobial costs, for 1993 and 1994 was sent to 122 hospitals. The written survey was followed by telephoned questions regarding each institution's antimicrobial management and expenditures, and any perceived link between the two. Hospitals were grouped by size and type, data were normalized to costs per occupied bed and costs per occupied bed per case mix index, and averages for each size category were calculated for general institutional information and expenses per antimicrobial. Eighty-eight institutions (72%) responded. Although 61% to 74% of the respondents used an antimicrobial formulary to restrict drug choices and control costs, average total antimicrobial expenses increased by more than $300 per occupied bed between 1993 and 1994. Only 7% of the institutions saw decreased costs of $500 or more per occupied bed. The most common reasons for these decreases were restructuring of pricing contracts and implementation of educational programs. The replacement of one formulary alternative with another led to increases in the use of antimicrobials other than the replacement drug and often did not produce savings. The replacement of one formulary antimicrobial with another led more to costshifting than to overall savings.

Anti-Bacterial Agents↗