Do physicians apply an early-switch strategy (from intravenous to oral antibiotics) in clinically stable patients hospitalised with community-acquired pneumonia (CAP)? If not, why not?In a multicentre prospective cohort study, adult patients admitted for i.v. CAP treatment were included. On day 3 of antibiotic treatment, clinical stability was assessed and treating resident physicians were interviewed on their switch strategies. Additionally, treating physicians were interviewed to evaluate their knowledge of and adherence to guideline advice.149 (92%) out of 162 patients were included and 97 (91%) out of 107 physicians were interviewed. A switch to oral antibiotics was possible in 68 (46%) out of 149 patients on day 3 of treatment but not performed in 27 (40%) out of 68. Patient factors delaying the switch were high CURB-65 (confusion of new onset, urea .7 mmol?L -1 , respiratory rate of o30 breaths?min -1 , blood pressure ,90 mmHg or diastolic blood pressure f60 mmHg, and age o65 yrs) score (on admission) (p50.04) and oxygen treatment (p50.04), high temperature (p50.00) and high respiration rate (p50.04) (day 3). Physicians' barriers to an early switch in clinically stable patients included misconceptions (26 (55%) out of 47), practical considerations (13 (28%) out of 47) and organisational factors (eight (17%) out of 47). Strikingly, 91 (94%) out of 97 interviewed physicians were not aware of guideline advice. The switch from i.v. to oral antibiotics is often unnecessarily delayed in patients hospitalised with CAP due to different types of barriers.

The evidence for the benefits of POC CRP measurement in LRTI patients in primary care is limited, contradictory and does not support its use to guide treatment decisions yet.

Vibrio cholerae non-O1 serogroup (VCNO) bacteraemia is a severe condition with a high case-fatality rate. We report three cases diagnosed in the Netherlands, identified during a national microbiological congress, and provide a literature review on VCNO bacteraemia. A search strategy including synonyms for 'VCNO' and 'bacteraemia' was applied to PubMed, Medline, Web of Science and Embase databases. The three cases were reported in elderly male patients after fish consumption and/or surface water contact. The literature search yielded 82 case reports on 90 cases and six case series. Thirty case reports were from Asia (30/90; 33%), concerned males (67/90; 74%), and around one third (38/90; 42%) involved a history of alcohol abuse and/or liver cirrhosis The presenting symptom often was gastroenteritis (47/90; 52%) which occurred after seafood consumption in 32% of the cases (15/47).Aside from the most frequent symptom being fever, results of case series concurred with these findings. Published cases also included rare presentations e.g. endophthalmitis and neonatal meningitis. Based on the limited data available, cephalosporins seemed the most effective treatment. Although mainly reported in Asia, VCNO bacteraemia occurs worldwide. While some risk factors for VCNO were identified in this study, the source of infection remains often unclear. Clinical presentation may vary greatly and therefore a quick microbiological diagnosis is indispensable.

Timely LUAT use in accordance with current guidelines allows early detection and treatment of CAP caused by Legionella spp. at considerable expense.

No abstract

A positive pneumococcal urinary antigen test (PUAT) for Streptococcus pneumoniae allows an early switch from empiric to targeted treatment in hospitalised community-acquired pneumonia (CAP) patients. The economic and treatment consequences of this widespread implemented test are, however, unknown. We retrospectively evaluated all tests performed since its introduction in two teaching hospitals. Data on patient characteristics, treatment, admission and outcome were retrieved from the electronic patient files. Test benefits were expressed as the number of days that targeted therapy (i.e. penicillin) was administered to hospitalised CAP patients due to a positive PUAT. This calculation was based on the timing of the PUAT and the initiation of targeted therapy. Subsequently, we performed two direct cost analyses from a hospital perspective, first including tests performed for CAP only, and second including costs of all (excessive) tests. Between 2005 and 2012, 3,479 PUATs were performed, of which 1,907 (55 %) were for CAP. A total of 1,638 PUATs (86 %) were negative and 269 (14 %) were positive. Fifty-two (19 %) positive tests were excluded. In 75 (35 %) of the 217 remaining positive tests, a positive PUAT led to targeted treatment during 293 cumulative admission days. Testing costs for CAP only were €131 per targeted treatment day. These costs were €257 if local protocol dictated PUAT use for all CAP cases, as opposed to €72 if the test was reserved for severe cases only. When including all tests, PUAT costs were €254 per targeted treatment day. Therefore, improving the selective use of the PUAT in hospitalised CAP patients may lead to increased (cost-)efficiency.

We previously showed that 40 % of clinically stable patients hospitalised for community-acquired pneumonia (CAP) are not switched to oral therapy in a timely fashion because of physicians' barriers. We aimed to decrease this proportion by implementing a novel protocol. In a multi-centre controlled before-and-after study, we evaluated the effect of an implementation strategy tailored to previously identified barriers to an early switch. In three Dutch hospitals, a protocol dictating a timely switch strategy was implemented using educational sessions, pocket reminders and active involvement of nursing staff. Primary outcomes were the proportion of patients switched timely and the duration of intravenous antibiotic therapy. Length of hospital stay (LOS), patient outcome, education effects 6 months after implementation and implementation costs were secondary outcomes. Statistical analysis was performed using mixed-effects models. Prior to implementation, 146 patients were included and, after implementation, 213 patients were included. The case mix was comparable. The implementation did not change the proportion of patients switched on time (66 %). The median duration of intravenous antibiotic administration decreased from 4 days [interquartile range (IQR) 2-5] to 3 days (IQR 2-4), a decrease of 21 % [95 % confidence interval (CI) 11 %; 30 %) in the multi-variable analysis. LOS and patient outcome were comparable before and after implementation. Forty-three percent (56/129) of physicians attended the educational sessions. After 6 months, 24 % (10/42) of the interviewed attendees remembered the protocol's main message. Cumulative implementation costs were 5,798 (20/reduced intravenous treatment day). An implementation strategy tailored to previously identified barriers reduced the duration of intravenous antibiotic administration in hospitalised CAP patients by 1 day, at minimal cost.