[Show abstract][Hide abstract] ABSTRACT: Due to antimicrobial resistance in Streptococcus pneumoniae, national guidelines recommend a respiratory fluoroquinolone or combination antimicrobial therapy for outpatient treatment of community-acquired pneumonia (CAP) associated with risk factors for drug-resistant S. pneumoniae (DRSP). The objectives of this study were to assess the prevalence of these risk factors and antibiotic prescribing practices in cases of outpatient CAP treated in the acute care setting.
This was a retrospective cohort study of adult outpatients treated for CAP in the emergency department (ED) or urgent care center of an urban, academic medical center from May 1, 2009, through October 31, 2009, and comparison of antibiotic therapy in cases with and without DRSP risk factors.
Of 175 patients, 90 (51%) had at least one DRSP risk factor, most commonly asthma (n = 28, 16%), alcohol abuse (n = 24, 14%), diabetes mellitus (n = 18, 10%), chronic obstructive pulmonary disease (n = 16, 9%), age > 65 years (n = 16, 9%), and use of antibiotics within 3 months (15, 9%). Antibiotic prescriptions were similar among cases with and without DRSP risk factors: a macrolide (62% vs. 59%, respectively, p = 0.65), doxycycline (27% vs. 28%, p = 0.82), or a respiratory fluoroquinolone (9% vs. 9%, p = 0.90). Concordance with national guideline treatment recommendations was significantly lower in cases with DRSP risk factors (9% vs. 87%, p < 0.0001).
DRSP risk factors were present in approximately half of outpatient CAP cases treated in the acute care setting; however, guideline-concordant antibiotic therapy was infrequent. Strict adherence to current guidelines would substantially increase use of fluoroquinolones or combination therapy. Whether the potential risks associated with these broad-spectrum regimens are justified by improved clinical outcomes requires further study.
Full-text · Article · May 2012 · Academic Emergency Medicine
[Show abstract][Hide abstract] ABSTRACT: Background: The epidemiology of skin and soft tissue infection (SSTI) has changed with the emergence of community-associated methicillin-resistant Staphylococcus aureus (MRSA). The purpose of this study was to describe the temporal trends and clinical spectrum of SSTI in the ambulatory care setting of an integrated healthcare system.
Methods: Using ICD-9 coding data, we identified adults and children with a primary diagnosis of SSTI from urgent care, emergency department, or outpatient clinic encounters between January 1, 2005 and December 31, 2010. We performed a retrospective cohort study on a random sample of cases between March 1, 2010 and February 28, 2011 and classified infections as uncomplicated cellulitis, wound infection, cutaneous abscess, or SSTI with complicating factors including bites, diabetic or vascular ulcers, periorbital or perineal involvement, peripheral arterial disease, and recurrent infection.
Results: From 2005 to 2010, there was a distinct seasonality of clinical encounters for SSTI, with visits being more common in summer months than non-summer months (p = .035) (Figure).
This seasonality was evident when the data were stratified into adult and pediatric populations. Of 670 cases reviewed for the retrospective cohort study, 428 met criteria for inclusion: 148 (35%) were uncomplicated cellulitis, 41 (10%) wound infections, 167 (39%) abscesses, and 72 (17%) involved complicating factors. Nearly all visits occurred in the urgent care center (189, 44%), primary care clinics (126, 29%), or emergency department (105, 25%). Prior skin infection (105, 25%), alcohol dependence (69, 16%), and diabetes mellitus (56, 13%) were common risk factors. 211 (49%) patients did not have a predisposing comorbid condition or risk factor for SSTI. In total, staphylococci or streptococci were identified in 73 of 76 (96%) cases with a positive culture; MRSA was identified in 27 (36%).
Conclusion: Skin and soft tissue infections exhibit a seasonal pattern and are more frequent in summer months. Urgent care and primary care clinics are common sites of presentation. Uncomplicated abscesses comprise a minority of all skin infections in the ambulatory care setting.
[Show abstract][Hide abstract] ABSTRACT: Lean principles have been used at Denver Health Medical Center since 2005 to streamline nonclinical processes. Despite allocation of significant resources, particularly the expense of low molecular weight heparin (LMWH), to prophylaxis of venous thromboembolism (VTE), the incidence of postoperative VTE was significantly worse than national benchmarks. VTE risk factors were not consistently assessed, and the prescribing of prophylaxis varied widely. Lean was employed to standardize and implement risk assessment and evidence-based VTE prophylaxis for the institution.
In a rapid improvement event, a multidisciplinary group formulated an evidence-based risk assessment tool and clinical practice guideline for VTE prophylaxis, with plans for hospitalwide implementation and monitoring.
The effects were immediate and improved steadily with feedback to clinicians. Within six months, compliance with the standard approached 100%. One year after implementation, the use of LMWH decreased more than 60% below baseline, and the use of sequential compression devices decreased by nearly 30%. With increased use of unfractionated heparin, the cost savings on VTE prophylaxis exceeded $15,000 per month, for a total of $425,000 since implementation. Moreover, the incidence of VTE decreased markedly during the same period. By reducing VTE rates, a total cost savings of $6.2 million was estimated for the past 28 months.
Applying Lean to the clinical management of VTE prophylaxis improved compliance with standards and saved the hospital a significant amount of money. This was achieved without compromising clinical outcomes. This experience could be replicated at other institutions.
No preview · Article · Mar 2011 · Joint Commission journal on quality and patient safety / Joint Commission Resources
[Show abstract][Hide abstract] ABSTRACT: Streptomycin has been available for over 60 years, yet optimal dosing in hemodialysis (HD) patients is not well defined. We report the successful treatment of enterococcal bacteremia in an HD patient with intravenous (IV) penicillin G and IV streptomycin at a dose of 7.5 mg/kg after HD sessions.
No preview · Article · Feb 2011 · Journal of Infection and Chemotherapy