Reviews of infectious diseases
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A program set up in the Soroka University Medical Center, Beer Sheva, Israel, offers outpatient parenteral antibiotic therapy (OPAT) for children with serious bacterial infections. The following criteria must be met before a child is placed in this program: OPAT must be a suitable form of treatment for the infection, an appropriate drug must be available, the parents must be cooperative and well-informed, and 24-hour-a-day telephone communication and transportation between the home and hospital must be available. With use of ceftriaxone administered im, the OPAT program has shown positive results: a cure rate of 98.5% and an estimated savings of 1,334 hospital days for 140 patients over a 17-month period.
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Occult bacteremia, which precedes many serious infections in children, is most often due Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis, or Salmonella species. Diagnosis on the basis of clinical judgment is unreliable, although the presence of certain risk factors may suggest the diagnosis. ⋯ Although results are delayed, a culture of blood is the only definitive test. Studies suggest that treatment with various antibiotics may be helpful, but that some drugs, particularly orally administered amoxicillin, should not be relied on to eliminate occult bacteremia or prevent its most serious sequela, meningitis.
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Review Case Reports
Necrotizing tracheitis caused by Corynebacterium pseudodiphtheriticum: unique case and review.
The occasional pathogenicity of nondiphtheria corynebacteria in both immunocompetent and immunocompromised individuals is now well established. Previously described sites of infection include heart valves, wounds, urinary tract, and lungs. This report of necrotizing tracheitis caused by Corynebacterium pseudodiphtheriticum illustrates the widening spectrum of infections caused by these organisms. ⋯ Gram staining revealed gram-positive rods typical of corynebacteria, and cultures of tracheal tissue yielded C. pseudodiphtheriticum resistant to erythromycin and clindamycin. There was no clinical or laboratory evidence for exotoxin or cell-associated toxins. Treatment with intravenous penicillin resulted in resolution of the inflammatory process and eradication of the organisms, as assessed by subsequent cultures.
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Outpatient parenteral antibiotic therapy in a health maintenance organization (HMO), as carried out at the Lovelace Medical Center in Albuquerque, New Mexico, has been effective for ambulatory patients (who received their injections at one of the HMO facilities) and for nonambulatory patients (who were visited in their homes by members of the HMO's home health care team). Over a 17-month period, implementation of these procedures resulted in savings of as much as 73% per day over the costs for similar treatment of similar infections in hospitalized patients. The savings derived from treating nonambulatory patients were slightly less than those from treating ambulatory patients because of the costs for home health care personnel.
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Outpatient intravenous antibiotic therapy (OPIVAT) requires selection of patients who are medically and psychologically stable, are capable of being trained to administer iv medications, will not abuse the iv system, and have insurance coverage. Patients with conditions such as osteomyelitis, septic arthritis, pelvic inflammatory disease, endocarditis, and skin and soft tissue infections are appropriate candidates. As clinical experience grows, patients with increasingly complex conditions are being successfully treated at home. ⋯ With appropriate training, such patients learn to properly manage drugs and equipment and to recognize complications. Patients who cannot be treated at home may be candidates for OPIVAT under direct medical supervision. Technical advances in pumps and catheters--as well as future changes in Medicare reimbursement--may greatly increase the number of patients who are capable of receiving OPIVAT.