Outpatient antibiotic therapy for elderly patients

Outpatient Antibiotic Elderly Patients

Therapy for

JOSEV. G. ANGEL,M.D., DesMoines,Iowa,AND THEHIATSTUDYGROUP

The purpose of this study wss to determine the safety and efficacy of outpatient intravenous (IV) therapy with a third-generation cephalosporin, cefotaxime, in patients 260 years of age and to determine its effect on length of hospital stay. Subset analysis was performed with 62 patients with various infections who had been enrolled in a prospective, multicenter, open-label trial of IV cefotaxime delivered through a computerized ambulatory delivery system (ADS). Initial treatment was given in hospital if required, followed by home therapy. The overall clinical response rate among evaluable patients was 98%, and the overall bacteriologic response rate was 93%. The mean duration of inpatient therapy was 3.6 days less than the mean of 8.2 days allowed under diagnosisrelated group (DRG) allotments. Outpatient therapy with cefotaxime via infusion pump is safe and effective and may reduce hospitalization requirements.

From Des Moines internists, P.C., Des Moines, Iowa. Requests for reprints should be addressed to Jose V. G. Angel, M.D., Des Moines Internists, P.C., 6800 Lake Drive, West Des Moines, IA 50266.

espite ever-increasing costs of inpatient treatment, it remains customary to hospitalize older patients with serious infections and to treat them, for relatively long periods, with intravenous (IV) antibiotic therapy. Often, they are hospitalized simply because they require IV antibiotic therapy, which until recently was available primarily, if not exclusively, in an inpatient setting. Physicians have few guidelines to assist them when considering hospitalization for the elderly and when trying to determine the necessary length of hospital treatment. These decisions are based on an awareness of increased risk of infection in older patients and the perception that the elderly are fragile; nonetheless, the literature does not support the need for prolonged inpatient antibiotic therapy in otherwise healthy elderly patients [1,2].

D

INFECTIOUSDISEASESIN THE ELDERLY Infectious disease is the most common cause of death among nursing home residents [3] and is a major problem among the elderly in any setting for a variety of reasons, including age-related deficits of the immune system [4]. Among the more common and potentially deadly infections in the elderly are lower respiratory tract infections [5-61. While Streptococcus pneumoniae and Haemophilus influenxae are the most commonly isolated pathogens in pneumonia [7], the elderly are also likely to harbor gram-negative bacilli, resulting in a greater incidence of gram-negative respiratory infections, including both community-acquired and nosocomial types @I. The unexpected pathogens sometimes uncovered in infections in the elderly also affect both the duration and choice of therapy. Hospital-acquired infections, in general, affect hosts differently depending upon their age, underlying disease, and immune status, with consequent increased risk in the elderly [91. Frequent hospital admissions, therefore, must be viewed as posing a potentially serious risk in elderly patients. Gramnegative bacilli are the leading cause of nosocomial infections, but Staphylococcus aureu.s also remains a problem. The pathogenicity of these species is heightened by the development of resistant strains through a variety of mechanisms, including the induction of p-lactamase enzymes.

August 15, 1994

The American

Journal of Medicine

Volume 97 (suppl 2A)

43

SYMPOSIUMON OUTPATIENTANTlBlOTlC ADMINISTRATION/ANGEL and HlAT STUDY GROUP

Postoperative as well as primary bone and joint infections (BJIs) are also common in the elderly, who often have both vascular and immune system deficits. Osteomyelitis is usually caused by S. aureus and Staphylococcus epidermidis, but gramnegative bacteria are frequently implicated [lo]. Surgical wound infections may come from the patient’s resident flora as well as from operating room personnel. Early postoperative infections are commonly caused by group A Streptococcus or Clostridium species; infections appearing rl week postoperatively usually involve staphylococci, gram-negative bacilli, and anaerobic bacteria [9]. The elderly are also at a marked risk for bacteremia -and septicemia (B/S), usually caused by gramnegative bacteria. About two-thirds of cases of gram-negative rod bacteremia occur in hospitalized patients, particularly among those with underlying diseases and in elderly patients with urinary tract problems 1111. Other infections common among the elderly include skin and soft tissue infections (SSTIs; typically staphylococcal, but also infection of decubitus ulcers, usually polymicrobial) [12] and urinary tract infection (UTI). Community-acquired UT1 is typically caused by Escherichia coli [13], whereas Pseudomonas aeruginosa, Proteus mirabilk, and enterococci are often implicated in catheter-associated UT1 [141. Infections tend to last longer in the elderly than in younger patients [15]. Since many of the infectious diseases the elderly acquire, such as osteomyelitis or bacteremia, typically require prolonged therapy 11,161, a need for long-term IV antibiotic therapy arises. Adequate antimicrobial therapy is particularly important in older patients, since they are more susceptible to recurrences than younger people. Recurring infection is a financial burden for all involved in terms of morbidity, mortality, and readmission.

COMPLICATIONS OF HOSPITALIZATION IN THE ELDERLY Hospitalization of the elderly, as has already been suggested, entails a significant risk of increased complications. Foremost is the increased risk of colonization and infection with nosocomial pathogens, including gram-negatives and resistant bacterial strains, leading to catheter-related UT1 and B/S. Other health risks that one must consider include amplification of the potential for falls in unfamiliar surroundings, possible development of decubitus ulcers, and pulmonary emboli related to immobility. Another aspect of hospitalization of the elderly that must be considered is that the economic costs are borne, directly and indirectly, by society as a whole. Invariably, inpatient treatment costs are 44

August 15, 1994

The American

Journal of Medicine

high. They include fixed expenses and the variable costs of purchasing supplies and medications, as well as the labor and monitoring costs involved [17]. Diagnosis-related group (DRG) classification and other governmental and insurance company mandates have not succeeded in lowering hospitalization costs; this is well recognized in the healthcare community, the political arena, and by the public. Discharging patients “quicker and sicker” is part of the equation that bears prominently on the whole question of the societal costs of hospitalization and the obvious need to provide alternatives to prolonged hospital stays. Hospital budgets can be doubly impacted by admission of elderly patients for IV therapy that requires prolonged hospitalization, often exceeding the DRG limit, and the high risk of complications that may lengthen the stay even further. Aside from the medical and economic disadvantages of lengthy hospitalization, emotional burdens can contribute to the difficulties experienced when older patients are hospitalized. Removal from a familiar environment is disruptive and stressful to elderly individuals. This unsettling experience can affect their response to therapy and lead to loneliness, boredom, or frank disorientationparticularly when the acute stage has passed and continued hospitalization is solely for IV therapy. Prolonged separation from normal daily activities as well as from family and friends disrupts the patient’s sense of well-being and places added stress on family members and friends [18]. Elderly patients, when hospitalized for a length of time, may never go home again. They may feel too debilitated to cope with a new disability brought on by infection and its complications. In some cases, family members, healthcare personnel, or medicolegal considerations force patients to transfer from the hospital to a nursing home, rather than allowing them to return to their homes. Appropriate home care for the elderly may solve some of these problems. Perceptions of the elderly as too fragile, too sick, or too inept to contribute to their own care relegate many older patients to institutional care when they might have continued, for months or years, to enjoy the comfort and security of their own homes. Finding and funding trained personnel for home administration of IV antibiotic therapy has frequently been a stumbling block to home care in elderly patients. Improved and simplified home care technology, notably computerized ambulatory drug delivery systems, could enable many older patients to remain in familiar surroundings. The successful, and generally costeffective, use of infusion pumps designed for home care has been described in numerous articles [19-

Volume 97 (suppl 2A)

251. This study was designed to examine the benetits of at-home intravenous therapy specifically in an elderly population.

PATIENTSAND METHODS There were three study objectives: (a) to examine the efficacy of cefotaxime sodium (Claforan; Hoechst-Roussel Pharmaceuticals), a third-generation, broad-spectrum cephalosporin, administered via an ambulatory delivery system (ADS) (CADDPLUS; Pharmacia-Deltec, St. Paul, MN) to elderly patients in home care settings; (b) to compare the length of hospital stay with that allotted by reference DRGs; and (c) to assess how well an elderly patient population tolerates outpatient therapy via infusion pump. Entry Criteria and Methods To be included in the subset analysis of elderly patients of this multicenter study, patients had to be 260 years of age and eligible for home IV antibiotic therapy for one of a specified variety of infections (see the global analysis elsewhere in this supplement). When required, infections were stabilized by prior in-hospital treatment with IV cefotaxime. Empiric treatment was begun on the basis of signs and symptoms consistent with the diagnosis of each type of infection; probable pathogens had to be suspected of being susceptible to cefotaxime. All patients were treated according to standard practice, i.e., complete history-taking and physical examination prior to initiation of therapy; daily observation during hospitalization (vital signs, peak temperature, pulse rate, and lowest blood pressure) and similar observations at scheduled outpatient followup visits; chest x-ray for patients with pneumonia; and laboratory tests within 24 hours before initiation and within 24 hours after completion of therapy. Patients who had been hospitalized were placed on the infusion pump 24 hours before discharge; other patients received their infusion pumps and were given their initial dose of cefotaxime at the home care facility or physician’s office. Cefotaxime IV dosage was 1 g every 8 hours for moderate infections and 2 g every 8 hours for severe infections, as determined by each patient’s initial clinical presentation. The dosage regimen was programmed into the computerized pump, which delivered the prescribed dose over a 60-minute period from a prefilled disposable cassette reservoir. Patients and caregivers were instructed in the use of the infusion pump. Instructions were given for the daily replacement of prefilled cassette reservoirs, a weekly follow-up with the attending physician, and reporting of adverse events. All adverse events were reported and classified

by the investigator as to probable cause: study drug-related (or infusion pump-related), concurrent drug-related, underlying disease, a combination of these factors, or unknown. Therapy was discontinued immediately if a serious or untoward experience occurred. Evaluative Criteria Clinical efficacy was categorized as “cure” (infection completely cleared); “improved” (clinically important diminution of signs and symptoms); or “unsatisfactory” (infection unchanged or worsened). Bacteriologic responses were classified as “eradication” if posttreatment culture was negative for the causative pathogen(s), if the causative pathogen was eradicated but a new organism was present without evidence of new infection, or if the patient improved to the extent that a follow-up culture could not be obtained. “Persistence” was reported if the causative pathogen persisted on posttreatment culture. Weighted averages for mean length of stay according to DRGs and in the study population were determined by multiplying the mean number of days for each infection by the number of patients in each infection group.

RESULTS Study Patient Population Of 62 patients >60 years (33 men, 29 women; mean age 71 years) who were enrolled, all were evaluated for safety; 50 were evaluable for clinical response. A total of 30 patients were diagnosed with SSTIs, 15 with pneumonia, 11 with BJIs, 3 with B/S, and 3 with other infections. To be diagnosed with B/S, patients had to have one or more documented pathogens in at least two blood cultures, fever or hypothermia, hemodynamic instability, elevated white blood cell count or ESR, and leucocytosis. Identified organisms for all enrolled patients are shown in Table I; the bacteriologic profile for evaluable patients was similar. Including the various interspecies classifications, 18 distinct pathogens were identified. Although the majority of infecting organisms were staphylococcal and streptococcal, 18 (35%) of the 52 identified pathogens were gram-negative aerobes including all three pathogens in the B/S group. A total of 12 patients did not complete the study: 4 did not meet protocol criteria; 3 discontinued due to safety reasons; 1 each discontinued due to superinfection or intercurrent problems; 2 had “other” reasons for discontinuing; and 1 requested discontinuation. Efficacy Clinical (n = 50) and bacteriologic (n = 28) response to cefotaxime/ADS therapy in 50 evaluable

August 15, 1994 The AmericanJournal of Medicine Volume 97 (suppl 2A)

45

SYMPOSIUM ONOUTPATIENT ANTIBIOTIC ADMINISTRATION /ANGELand HIATSTUDYGROUP TABLEI Pre-Therapy Pathogens, by Diagnosis, in a Population 260 Years of Age Pneumonia In = 15) Pathogen

N

WI

SSll (n=30)

(n Yl,

N

N

(xl

B/S (II = 3)

(%I

N

1%)

Other (n = 3) N

VW

1 (91

Bacteroides fragilisgroup Enterobactersp Enterococcus Escherichiacoli Fusobactefiumsp Haemophilussp Klebsiellasp Piesiomonassp

1

1 1 1

I71

1

(7)

2

(31 (31

(91 (91

2 (7)

Proteus sp

2 1

2 (131

Pseudomonas aeruginosa Pseudwnonassp Serrat!asp Staphylococcus aureus Staptrjlococcus

N

I%1

1 Il.61

(3)

1 1

Total In = 62)

2

(67)

I671

1

(331

I71 (31

3 (4.8) 1 Il.61 4

16.51

1 1 3 1 2 3

11.61 Il.61 (4.81 11.61 (3.2) (4.8)

1 (31 1 (3) 1 (231

1 (91

(71

5 1171

4 (36)

2 (131 6 (40)

5 1161 18 (601

3 (27) 10 (911

3 mol

3 I1001

10 (16.11 40 164.51

9 (60)

12 (401

1

0

0

22 (35.5)

1

2

(671

1 11.6) 1 (1.6) 10 (16.1) 10 (16.1)

SP Streptococcussp Totalpatients ti pathogens’ Totalpatients withnopathogen Identkd at start oftherapy

191

(0)

(01

I = bone/joint infection; B/s = bacteremiahepticemia; SST1= skin and soft tissue infection. :l pathogen/patient

TABLEII Clinical and Bacteriologic Efficacy: Cefotaxime/ADS in Clinically Evaluable Elderly Patients, by Diagnosis meumunla Clinical Response

In q 14)

,Z5,

N

N

(%I

Cure Improved

11 (78.61 3 (21.41

Unsatisfactory

Bacteriologic Response

PI

N

18 (72.0) 1

(28.01

0 101 Pnemmia (n q 5)

0

(0)

N

N

1%)

(fY2,

(ny1b) (%I

3 150.0) 2 (33.3) 1 116.7)

,“?2,

N

2 (100.0) 0 IO1 0 IO1

[nYbl

IW

N

A

WI

N

1%)

1%)

1 (33.31 2 (66.9) 0 IO1 Other (n = 3)

[n”i”z] N

Total (n=!iO)

IPi,

N

1%)

N

14

35 (70) 14 (281 1 (2) Totd

In= 28) N

1%)

Clinical

2 (40.01 3 (60.0)

8 166.71 4 (33.31

2 (33.31 3 (50.0)

2 (100.01 0 10)

2 166.71 0 101

16 1571 IO 136)

cure/no followup Persistence

0

0

1 (16.7)

0

1 (33.31

2

Eradication

(01

(01

IO1

(71

lbrewahons as in Table I; ADS = ambulatory delrwy system.

patients is shown in Table II. There was only one clinical failure, in a patient with BJI who also had an unsatisfactory bacteriologic response. Bacteriologic response was evaluable in 28 patients. Eradication of the organism was documented in 16 of 46

August 15,

1994 The American Journal of Medicine

these patients (57%); 10 others (36%) were clinically improved so that no culture could be obtained. Of the total, 7% (2 patients, 1 with BJI and 1 with an infection classified as “other”) had unsatisfactory bacteriologic responses (persistent pathogens).

Volume 97 (suppl 2A)

TABLEIII Comparison of Length of Stay: Reference DRGsand Experience in Evaluable Elderly Patients on Cefotaxime/ADS lnfectfon ‘z%y

Actual hlean Length of Stay Wayst

DRG Length of SKY WI

Pneumonia(14) SST1(25) BJI161

9.3 7.1 10.4

1.64

B/S121

7.5

Other13) Totals,allinfections(weightedaverageH50)

8.0

3.60 15.08 5.00 6.17

a.2

4.64

I

Difference in Length of Stay (t or - days)

-7.66 -3.50 t4.68 -2.50 -1.83 -3.56

Abbrevlahons as in Tables I and Il.

Adverse Events There were no deaths during the study period. The incidence of adverse events (classified according to World Health Organization criteria) was low. Of 14 reported events, ‘7 were judged unrelated to therapy. Seven others were thought to be possibly related to therapy: diarrhea, nausea, fever, two cases of rash, and possible drug-related phlebitis in two patients, both of whom had pneumonia. Comparison witi Reference DRGs

The mean length of hospital stay for all evaluable elderly patients was 4.6 days, 3.6 days less than the 8.2 days expected from reference DRGs (Table III>. Mean length of stay was below the DRG in all groups with the exception of BJIs, which included two outliers-patients with nosocomial infections treated as inpatients for 20 and 26 days. A total of 21 patients (42%) received their full course of therapy as outpatients, which is reflected in the mean duration of inpatient days in Table III. COMMENTS The clinical and bacteriologic results reported here are consistent with results with cefotaxime reported in the literature [26]. This study demonstrates the effectiveness of cefotaxime in eradicating pathogens in an elderly population with moderate-to-severe infections. Patients had a wide variety of identified pathogens, including a large number of gram-negative organisms. The high efficacy rates reported here-98% cured or improved in clinical evaluations, 93% documented or presumed eradication-indicate not only that cefotaxime is effective but also that home intravenous antibiotic therapy utilizing portable programmable infusion pumps is a safe and effective delivery system. Further, the low incidence of adverse events and low dropout rate due to safety considerations (three

patients) and superinfection (one patient) are indicative of the level of safety, efficacy, and compliance possible with this regimen. A number of features of the ADS pump used in this study make it particularly suitable for selfadministration by elderly patients, many of whom may have impaired vision and limited manual dexterity, or may not be able to recruit suitable caregivers. First, with this system, the patient (or caregiver) need not mix or measure the antimicrobial agent, since premeasured cassettes are supplied by the pharmacist. The cassettes are easily inserted into the device once a day. The ADS pump is designed with large, square, clearly identified button controls that can be easily set, even by patients with severe arthritis. The pump is lightweight, highly portable, and can be worn in a pouch attached to a belt or shoulder strap. A blinking light indicates that drug delivery is proceeding normally, and an audible and visual alarm system signals when the cassette reservoir is approaching empty, when the batteries are low, or when there are problems with the IV tubing or pump operation. Patients and caregivers, properly instructed, find the system user friendly, and nearly all candidates or their caregivers have been able to utilize it without the need for professional administration. Practical Considerations

In our experience and that of others [27], patient selection, patient/caregiver instruction, and an oncall healthcare resource person are central to the success of home antibiotic therapy. Candidates for home therapy must first be medically stabilizedthat is, they must be free of fever and chills, properly hydrated, and free of any exacerbating coexisting medical problems. The physician must be aware of the patient’s home environment: Is there a fulltime or part-time caregiver? Is there refrigeration available for prefilled cassettes and telephone ser-

August 15,

1994 The American Journal of Medictne

Volume 97 (suppl 2AI

47

vice for checking on patients? Will the home be satisfactorily maintained? Pump operation is begun in the hospital or healthcare facility, and patients/caregivers are given full instruction on its purpose and use. All patients are assigned to an on-call resource person so that any questions or problems can be rapidly resolved. A daily phone call from the physician or nurse further enhances the chances of problem-free success with home antibiotic therapy. Since peripheral IV lines require changing, this visit provides an additional opportunity to review pump operation and answer questions. In our experience, if IV antibiotic therapy is expected to be required for >3 days, a percutaneous intravenous central catheter (PICC) line should be considered. Strong consideration should be given to those patients >60 years of age, those with difficult IV access, and those with malignancy. When standard IV lines are used, they should be changed every 2-3 days. When PICC lines are used, they usually function for the duration of the entire course of therapy. Of course, careful attention to skin care around the access site is paramount. Our PICC lines were sometimes inserted in the physician’s office or emergency department, with placement then checked via chest x-ray. We recommend giving the first dose of all intravenous antibiotics under direct observation in a controlled environment with the physician readily available. Although drug reactions occur infrequently, the severity of the reaction is often magnified by IV administration, and aggressive intervention may be critical to the patient’s well-being. Some special issues may arise when patients in nursing homes or rehabilitation centers require IV antibiotic therapy. In many such facilities, when residents have a serious infection, the policy or the tendency is to have them admitted to the hospital rather than to assume the burden of extra in-house medical Care. In some nursing homes, there may be a policy precluding the use of infusion pumps. However, we have found that when the nursing staff is familiar with the use of the patented CADD-PLUS or similar pumps, and with the potential physical and mental benefits to their patients, approval and acceptance of this form of IV antibiotic therapy can be expected. Providing economic incentives to nursing homes to sanction this type of care would be worthwhile. Some insurance carriers are already paying for outpatient/nursing home IV antibiotic therapy because it is cost-effective. At present, long-term care facilities are financially motivated to keep patients in the hospital until they are well; hospitals are motivated to send patients home as

48

August 15, 1994

The American

Journal of Medicine

quickly as possible; and patient and doctor are caught in the middle of this economic conflict. Infections in elderly patients residing in nursing homes present special concerns. Compared with those living in apartments, elderly patients living in skilled nursing facilities are nearly four times as likely to have oropharyngeal colonization with gram-negative bacilli; both gram-negative bacilli and S. aureus are commonly isolated among nursing home residents with pneumonia [28]. Infections of the urinary tract with resistant pathogens are also frequently encountered in this patient population 1141. Thus, prompt, broad-spectrum empiric treatment is especially important in the nursing home patient [29]. Some elderly patients may be discharged to assisted-living environments, such as retirement complexes. Here residents generally have some independence and yet have access to assistance in receiving meals and medications and in performing their basic activities of daily living. When proper communication is established between the physician, the healthcare professional at the retirement facility, and the patient, home IV antibiotic therapy via a pump can be very successful, allowing the patient to remain at home or to return home from the hospital sooner.

HIATSTUDYGROUP Henry Snead, M.D., Ph.D., Covenant Hospital, Waterloo, IA; Javier D. Morales, M.D., Ashford Presbyterian Community Hospital, San Juan, PR; Arthur A. Mauceri, M.D., University of Florida Medical Center and North Florida Regional Hospital, Garnesville, FL; Robert Brennan, M.D., Centra Heafth, Inc., lynchburg, VA; Donald M. Poretz, M.D., Infectious Diseases Physicians, Inc., Annandale, VA; Larry Von Behren, M.D., Southern Illinois University School of Medicine, Springfield, IL; Jaime Carrizosa, M.D., Florida Hospital, Orlando, FL; Mark Kunkel, M.D., Danbury Hospital, Danbury, CT; Michael S. Gelfand, M.D., Methodist Hospital, Memphis, TN; Bryan Simmons, M.D., Methodist Hospital, Memphis, TN; David N. Williams, M.D., Hennepin County Medical Center, Minneapolis, MN.

REFERENCES 1. Fine MJ. Pneumonia in the elderly: the hospital admission and discharge decisions. Semin Respir Infect 1990; 5: 303-13. 2. Fine MJ, Orloff JJ, Arisumi D, et al. Prognosis of patients hospitalized with community-acquired pneumonia. Am J Med 1990; 88: 5-lN-8N. 3. Mulligan T. Parenteral antibiotic therapy for patients in nursing homes. Rev Infect Dis 1991; 13tSuppl 2): S180-3. 4. Saltzman RL, Peterson PK. lmmunodeficiency of the elderly. Rev Infect Dis 1987; 9: 1127-39. 5. Pegram PS Jr. Respiratory-tract infections in the elderly. Geriatric Med Today 1988; 9: 27-40. 6. Health United States 1991. Hyattsville, MD: U.S. Department of Health and Human Services; 1992. DHHS Pub. No. 92-1232. 7. Venkatesan P, Gladman J, Macfarlane JT, et al. A hospital study of community acquired pneumonia in the elderly. Thorax 1990; 45: 254-8. 8. Valenti WM, Trudell RG, Bentley DW. Factors predisposing to oropharyngeal colonization with gramnegative bacilli in the aged. N Engl J Med 1978; 298: 1108-l 1. 9. Gardner P, Klimek JJ. Hospital-acquired infections. In: Braunwald E, lsselbacher KJ, Petersdorf RG, Wilson JD, Martin JB, Fauci AS, eds. Harrison’s Principles of Internal Medicine, 12th ed. New York: McGrawHill, 1991: 468-71.

Volume 97 (suppl 2A)

SYMPOSIUM ON OUTPATIENTANTIBIOTICADMINISTRATION/ANGEL and HIAT STUDY GROUP 10. Mader JT. Osteomyelitis. In: Braunwald E, lsselbacher KJ, Petersdorf RG, Wilson JD, Martin JB, Fauci AS, eds. Harrison’s Principles of Internal Medicine, 12th ed. New York: McGraw-Hill, 1991: 548-9. 11. Root RK, Jacobs R. Septicemia and septic shock. In: Braunwald E, lsselbacher KJ, Petersdorf RG, Wilson JD, Martin JB, Fauci AS, eds. Harrison’s Principles of Internal Medicine, 12th ed. New York: McGraw-Hill, 1991: 502-7. 12. Ackerman BH, Wolfe JJ. Monitoring chronic outpatient infections: providing comprehensive home healthcare pharmacy services. DICP Ann Pharmacother 1991; 25: 840-8. 13. Neu HC. Therapy and prophylaxis of bacterial infections. In: Braunwald E, Isselbather KJ, Petersdorf RG, Wtlson JD, Martin JB, Fauci AS, eds. Harrison’s Principles of Internal Medicine, 12th ed. New York: McGrawHill, 1991: 478-93. 14. Bjork DT, Pelletier LL, Tight RR. Urinary tract mfections with antibiotic resistant organisms in catheterized nursing home patients. Infect Control 1984; 5: 173-6. 15. Bernstein LH. An update on home intravenous antibiotic therapy. Geriatrics 1991; 46: 47-54. 16. Chamberlain TM, Lehman ME, Groh MJ, Munroe WP, Reinders TP. Cost analysis of a home intravenous antibiotic program. Am J Hosp Pharm 1988; 45: 2341-5. 17. lannini PB. DRGs and outpatient antibiotics. Infect Control 1986; 7: 289-90. 16. Rehm SJ, Weinstein AJ. Home intravenous antibiotic therapy: a team approach. Ann Intern Med 1983; 99: 388-92.

19. Baptista RJ, Miiano FP. Experience with 211 courses of home intravenous antimicrobial therapy. Am J Hosp Pharm 1989; 46: 315-6. 20. Bruera E. Ambulatory infusion devices in the continuing care of patients with advanced diseases. J Pain Symptom Manage 1990; 5: 287-96. 21. Brown RB, Sands M. Outpatient intravenous antibiotic therapy. Am Fam Physician 1989; 40: 157-62. 22. Dover SB. Syringe driver in terminal care. Br Med J 1987; 294: 553-5. 23. Kane RE, Jennison K, Wood C, Black PG, Herbst JJ. Cost savings and economic considerations using home intravenous antibiotic therapy for cystic fibrosis patients. Pediatr Pulmonol 1988; 4: 84-9. 24. Lawson M. Overview of small-volume portable infusion pumps. J Pediatr Oncol Nurs 1991; 8: 64. 25. Rrch DS. Evaluation of a disposable, elastomeric infusion device in the home environment. Am J Hosp Pharm 1992; 49: 1712-6. 26. Todd PA, Brogden RN. Cefotaxime: an update of its pharmacology and therapeutic use. Drugs 1990; 40: 608-51. 27. Harris LF, Buckle TF, Coffey FL Jr. Intravenous antibiotics at home. South Med J 1986; 79: 193-6. 26. Stein D. Managing pneumonia acquired in nursing homes: special concerns. Geriatrics 1990; 45: 39-47. 29. Waltman RE. Treating infection in the nursing home. Geriatr Consultant 1989; May/June: 24-7.

August 15, 1994

The American

Journal of Medicine

Volume 97 (suppl 2A)

49