Allan C. Kind

Practice Guidelines for Community-Based Parenteral Anti-Infective Therapy

This is the fourth in a series of practice guidelines commissioned by the Infectious Diseases Society of America through its Practice Guidelines Committee. The purpose of this guideline is to provide assistance to clinicians when making decisions on when and how to best administer parenteral antimicrobial therapy. The targeted providers are internists, pediatricians, family practitioners, and other providers of outpatient antiinfective therapy. Criteria for selecting the appropriate patients and settings to deliver therapy in the community are described. Panel members represented experts in adult and pediatric infectious diseases. The guidelines are evidence-based. A standard ranking system is used for the strength of the recommendations and the quality of the evidence cited in the literature reviewed. The document has been subjected to external review by peer reviewers as well as by the Practice Guidelines Committee and was approved by the IDSA Council. An executive summary and tables highlight the major recommendations.

Bone and serum concentrations of five cephalosporin drugs. Relevance to prophylaxis and treatment in orthopedic surgery.

Bone and serum concentrations of five cephalosporins were assayed in 92 patients undergoing elective hip or knee prosthetic joint arthroplasty. One hundred twenty-five bone samples were assayed. Although there was no direct relation between serum and bone antibiotic concentrations, a trend toward increased bone antibiotic concentration for drugs with higher serum levels and longer half-lifes (cefazolin and ceforanide) was noted. Bone antibiotic concentrations were maximal within 60 minutes of drug administration. Although bone antibiotic concentrations following 2-g doses were greater than those following 1-g doses, the differences were not statistically significant. A trend toward higher bone antibiotic concentrations at hip surgery was noted, and this difference achieved statistical significance (p less than 0.05) for cefazolin. As a result of analysis of bone antibiotic concentrations, antimicrobial sensitivities, and cost, administration of 2 g of cefazolin immediately prior to operation, followed by 1 g every eight hours for 24 hours, is recommended in elective prosthetic joint surgery.

Transplacental passage of methicillin and dicloxacillin into the fetus and amniotic fluid

Abstract The transfer of methicillin and dicloxacillin from maternal blood to fetal blood and amniotic fluid was studied in 105 patients. Significant levels of methicillin were detected in fetal serum within 30 minutes after discontinuing the maternal infusion, with equilibration between maternal and fetal serum levels within one hour. Dicloxacillin is associated with lower levels of antibiotic activity in the fetal serum and insignificant levels in the amniotic fluid. Equilibration between maternal and fetal levels did not occur. Protein binding of antibiotics results in a reduced rate of transfer from the maternal to the fetal compartment.

Outpatient intravenous antibiotic therapy. Ten years' experience.

The experience within the past ten years at Methodist Hospital and Park Nicollet Medical Center, Minneapolis, has clearly demonstrated that outpatient intravenous (IV) antibiotic therapy can be undertaken with relative ease and results in substantial cost savings. During this time, no significant morbidity and no mortality associated with this modality have occurred. Patients of all ages with bone, joint, skin, or soft-tissue infection and other infectious diseases such as meningitis have participated. Patient compliance and enthusiasm have been high. Necessary elements for such a program include an enthusiastic medical staff, a central admixture service, and a team of nurses or other health care professionals available for IV cannula care. Careful patient selection, education, and follow-up are also essential. We believe use of outpatient IV antibiotic therapy will continue to grow in the future, in part because of changes in the financing of medical care.

CLINICAL PHARMACOLOGY OF AMPICILLIN AND HETACILLIN

In addition to providing a broadened antimicrobial spectrum, the reactive basic group (NH,) in the ampicillin molecule confers unique pharmacologic properties upon this drug as compared with other penicillins. Hetacillin, a related compound, contains the 6-amino group as part of an imidazolidinone ring, and this compound can be made by the reaction of acetone with ampicillin.’ The chemical structures of these two penicillin analogues are presented in FIGURE 1.

No Change in Physician Dictation Patterns When Visit Notes Are Made Available Online for Patients

OBJECTIVE To determine whether physicians document office visits differently when they know their patients have easy, online access to visit notes. PATIENTS AND METHODS We conducted a natural experiment with a pre-post design and a nonrandomized control group. The setting was a multispecialty group practice in Minnesota. We reviewed a total of 400 visit notes: 100 each for patients seen in a rheumatology department (intervention group) and a pulmonary medicine department (control group) from July 1 to August 30, 2005, before online access to notes, and 100 each for patients seen in these 2 departments 1 year later, from July 1 to August 30, 2006, when only rheumatology patients had online access to visit notes. We measured changes in visit note content related to 9 hypotheses for increased patient understanding and 5 for decreased frank or judgmental language. RESULTS Changes occurred for 2 of the 9 hypotheses related to patient understanding, both in an unpredicted direction. The proportion of acronyms or abbreviations increased more in the notes of rheumatologists than of pulmonologists (0.6% vs 0.1%; P=.01), whereas the proportion of anatomy understood decreased more in the notes of rheumatologists than of pulmonologists (-5.9% vs -0.8%; P=.02). One change (of 5 possible) occurred related to the use of frank or judgmental terms. Mentions of mental health status decreased in rheumatology notes and increased in pulmonology notes (-8% vs 7%; P=.02). CONCLUSION Dictation patterns appear relatively stable over time with or without online patient access to visit notes.