Although existing noninvasive and invasive techniques have the ability to diagnose venous insufficiency, results from perfusion fluorometry in ischemic legs stimulated us to use it in venous insufficiency. Fourteen individuals received 2 mg/kg diluted sodium fluorescein in the vein of the dorsum of the foot. A ratio of leg/arm fluorescein perfusion was devised. After eighteen minutes of infu sion, patients had a ratio of less than 0.65, whereas all the controls had values of 0.65 or greater. It seems that using perfusion fluorometry is a viable test for diagnosing venous insufficiency syndrome.
A series of 459 hospitalized adults with complicated intra-abdominal infections participated in a randomized, double-blind, multicenter clinical trial. The present study was conducted to add a pharmacoeconomic analysis to the results.A cost-effectiveness analysis from the perspective of the hospital provider was carried out. Decision analysis was used to illustrate outcomes and to provide a basis on which to conduct a sensitivity analysis. Cost-effectiveness ratios, representing the cost per expected successfully treated patient, were calculated to determine the most cost-effective alternative.Among 244 economically evaluable patients, enrolled from 34 centers in the U.S. and Canada, 131 patients received ciprofloxacin-metronidazole (75% clinical success rate), and 113 received piperacillin-tazobactam (65% clinical success rate; p = 0.06). Switch to oral antibiotics was possible for 81 patients who received ciprofloxacin-metronidazole (85% clinical success rate) and 67 piperacillin-tazobactam patients (70% clinical success rate; p = 0.027). The mean hospital cost was US$10,662 +/- 7,793 for patients in the ciprofloxacin-metronidazole group and $10,009 +/- 7,023 for patients in the piperacillin-tazobactam group (p = 0.492). Significantly lower costs were documented for patients who could be switched to oral antibiotics than for those continued on intravenous antibiotic orders ($8,684 +/- 4,120 vs. $12,945 +/- 10,204, respectively; p < 0.001). Patients with appendicitis had lower mean hospital costs than those with other infections ($7,169 +/- 3,705 vs. $12,097 +/- 8,342, respectively; p < 0.001). The cost-effectiveness ratios were $14,216:1 for patients in the ciprofloxacin-metronidazole group and $15,398:1 for patients in the piperacillin-tazobactam group.The mean hospital costs associated with ciprofloxacin-metronidazole were similar to those of piperacillin-tazobactam for the treatment of adults with complicated intra-abdominal infections. Lower costs were documented for patients able to be switched to oral antibiotics and for patients with appendicitis.
FROM THE PERSPECTIVEof uninvolved observers, antibiotic dosing has alternated between unmanaged chaos and de spair over its total irrationality. Two camps have emerged and drawn lines in the sand, as we all undertake that grand experiment called managed care. l .2 On one hand, there are advocates of the one-dose-for-a11 strategy. These scholars are typically reinforced by the marketing efforts of some pharmaceutical companies that encourage simplicity in dosing to gain a marketing advantage. These efforts bring us such rational dosing strategies as once-daily administra tion of antibiotics with a 2-hour half-life. It should be acknowledged that many clinical trials are not designed to challenge the new antibiotic to the point where it may fail. Clearly, even the most poorly designed antibi otic dosing strategies work in the forgiving environment of a patient who is not very ill and/or is culture-negative. 3 Lack of rigor in evaluation of these studies persists to the point where the uninvolved believe dosing matters so little that the accompanying article 4 argues in favor of once-daily dosing of an agent (cefmenoxime) with a half-life of 1 hour. The other side of this dosing fence is populated by a handful of vigorous advocates of individualization, the one dose-for-each antibiotic dosing strategy. SolO While these clinicians and researchers may vigorously argue the rela
Hypoprothrombinemia is a relatively uncommon event in the hospitalized patient. When it does occur, it often is associated with surgery, dietary vitamin K deficiency, renal dysfunction, malignancy, and broad‐spectrum antibiotic therapy. Several mechanisms have been proposed to account for antibiotic‐associated hypoprothrombinemia, including eradication of gastrointestinal bacteria, direct inhibition of vitamin K‐dependent coagulation, and indirect inhibition of coagulation. The anecdotal reports and comparative studies of antibiotic‐associated hypoprothrombinemia were reviewed; these usually implicated broad‐spectrum or the use of several antibiotics. The increased frequency of hypoprothrombinemia associated with moxalactam and cefoperazone also raises questions about the role of their N ‐methylthiotetrazole (NMTT) side chains. The hypoprothrombinemia associated with NMTT antibiotics does not occur in healthy volunteers and is rare in patients without complicating conditions. Although NMTT inhibits vitamin K‐dependent carboxylation in vitro, the parent cephalosporins do not. It is not clear whether NMTT‐containing antibiotics liberate sufficient amounts of NMTT in vivo to antagonize clotting in patients. Thus, although moxalactam, and possibly cefoperazone, may in some cases be responsible for increases in prothrombin time, the most important question for further study is whether the newer NMTT‐containing antiobiotics pose a risk of hypoprothrombinemia that is greater than that of antibiotics lacking this side chain.
