Sequential parenteral and oral ciprofloxacin regimen versus parenteral therapy for bacteremia: a pharmacoeconomic analysis

OBJECTIVE

To compare, in patients with gram-negative bacteremia, a course of parenteral antibiotic therapy alone with initial parenteral therapy followed by oral ciprofloxacin in terms of the length of hospitalization, clinical effectiveness, toxicity, and cost.

DESIGN

A prospective, controlled, randomized, open trial in select hospitalized patients.

SETTING

Large metropolitan teaching hospital.

PATIENTS

Fifty hospitalized patients with proven gram-negative bacteremia were randomized to receive either oral ciprofloxacin (group 1) following a 72-hour initial intravenous antibiotic regimen or to continue parenteral therapy alone (group 2). To compare the length of hospitalization, an additional group of 50 hospitalized patients with bacteremia (not enrolled in the study, group 3) were analyzed.

INTERVENTION

Parenteral antibiotics for 72 hours followed by continuation of a parenteral regimen or oral ciprofloxacin 750 mg bid.

MAIN OUTCOME MEASURES

Clinical response, toxicity, and length of hospitalization.

RESULTS

Clinical resolution was comparable in the 24 group 1 patients receiving intravenous antibiotics followed by oral ciprofloxacin (83%), the 26 group 2 patients receiving parenteral therapy alone (77%), and the 50 comparison patients (76%). There was little toxicity noted in any group, and the initial parenteral antibiotic regimens were similar. The mean numbers of hospital days on antibiotics were 9.1, 11.2, and 10.6 days in groups 1,2, and 3, respectively (p < 0.05 for group 1 vs. group 2 or 3), and the lengths of hospitalization were 9.8, 15.7, and 12.1 days, respectively (p < 0.05 for group 1 vs. group 2 or 3). Shortening the length of hospitalization and days of antibiotic therapy was associated with a cost savings of up to $78 000 for group 1 patients.

CONCLUSIONS

Parenteral therapy for 72 hours followed by oral ciprofloxacin significantly shortened both the number of hospital days taking antibiotics and the length of stay compared with parenteral therapy alone. Both regimens were equally effective and safe in the therapy of gram-negative bacteremia, and initial parenteral therapy followed by oral ciprofloxacin was cost-effective.

Transplantation for end stage liver disease related to alpha 1 antitrypsin

Alpha 1 antitrypsin deficiency (AT) is an autosomal recessive disease associated with chronic liver disease in adults and children and emphysema in adults. The disease is one of the most common inherited disorders of the Caucasian population of North Europe and North America and is the most common genetic reason for pediatric orthotopic liver transplantation (OLTx), although it is a rare indication in adults. The natural history of the disease is unpredictable and the pathogenesis of the liver injury unclear. Thirty-five patients with histologically apparent alpha 1 AT accumulation in the liver (22 adults, 13 children) have been transplanted in this center. Clinical features were correlated with the pretransplant phenotype, serum alpha 1 antitrypsin levels and potential precipitating factors. All children were PiZZ homozygotes, most of whom had presented with neonatal hepatitis. The majority of adult patients were heterozygotes presenting with portal hypertension and liver cirrhosis. Current one-year posttransplant survival figures are 73% for adults and 87.5% for children. Replacement of the cirrhotic liver results in acquisition of the donor phenotype, a rise in serum levels of alpha 1 antitrypsin, and apparent prevention of associated disease.

Clinical significance of serum hepatocyte growth factor in orthotopic liver transplantation

BACKGROUND

Hepatocyte growth factor (HGF) plays a key role in the regulation of liver regeneration after hepatocyte damage. Changes in HGF production reflect the status of the regeneration process.

METHODS

Serum concentrations of HGF and energy substrates were measured during and after liver transplantation in 30 recipients.

RESULTS

In the patients with compromised grafts (group A) HGF concentrations were persistently high after reperfusion, whereas in the patients with well-functioning grafts (group B), HGF concentrations decreased rapidly and remained low 4 hours after reperfusion. The patients in group A who died had persistently high concentrations of HGF. The surviving patients with reversible primary graft dysfunction in group A exhibited low concentrations 48 hours after reperfusion. The decrease in HGF concentration preceded the decrease in aspartate aminotransferase concentration. The metabolic parameters that reflect carbohydrate metabolism by the graft paralleled the changes in HGF.

CONCLUSIONS

HGF may be more sensitive and specific in predicting early graft function than prothrombin time, ratio, aspartate aminotransferase, or arterial ketone body ratio. The determination of HGF levels after liver transplantation may yield valuable information for evaluating early graft function and making an early decision to repeat a graft procedure in an acutely ill patient.

Combined liver-spleen-small intestine grafting in a rat model: role of transplanting additional lymphoid tissue on survival

The aim of this study was to develop suitable models of combined intestinal grafting to examine the enhancing effect of intestinal grafting with additional lymphoid tissue using 30% of the liver mass and the whole spleen on recipient survival in the absence of immunosuppression. Grafts from DA (RT1a) rats were transplanted orthotopically to PVG (RT1(1)) recipients according to the following design: group 1 (n = 6), en bloc 30% liver/entire SB/spleen; group 2 (n = 7), en bloc 30% liver/SB; group 3 (n = 7), SB/spleen and group 4 (n = 7), SB control for the preceding groups. The orthotopic nature and proximal interposition of the SB graft allowed the assessment of protection afforded by components of the cluster on the SB graft using survival endpoints. Although group 4 hosts survived half as long compared to other groups, statistical significance was reached only in the case of group 1; group 1 MST equalled 15.3 days, significantly higher than group 4 (p = 0.01). Acute rejection was present in every grafted tissue and was equivalent whether liver was included or excluded in the cluster. GVHD was absent postoperatively using clinical or histological criteria; recipient spleens showed hyperplasia, donor spleens depicted lymphocytic depletion on histology. This study determined that statistically proven enhanced survival was obtained only after grafting 30% liver plus spleen with the entire SB. GVHD was rare in the fully allogeneic system despite transplanting a massive load of lymphoid tissue. The surgical models used in this study employing liver in the cluster, address the important question of how best to evaluate the role of heterotopic accessory liver grafting in providing tolerance to co-transplanted small intestine.

Two-year data from the European multicentre tacrolimus (FK506) liver study

To provide a more definitive assessment of the efficacy and safety of tacrolimus therapy in comparison with cyclosporin, the extended follow-up of the European multicentre study is reported. Two-year Kaplan-Meier estimates indicated significant reductions in acute (tacrolimus 45.4%, cyclosporin 55.8%; P = 0.006), refractory (1.2% versus 6.4%; P = 0.003) and chronic rejection (2.0% versus 6.9%; P = 0.015) despite significantly lower steroid usage in patients receiving tacrolimus therapy. Patient and graft survival rates (80.6% versus 74.8% and 74.5% versus 70.0%, respectively) were also superior, although these failed to reach statistical significance. Safety profiles were comparable for most major categories (including renal, neurological and glucose metabolic disorders) and in certain aspects were more favourable for tacrolimus. Hypertension (28.0% versus 39.6%, P < 0.01) and cytomegalovirus infection (14.8% versus 22.3%, P < 0.01), two events with important long-term clinical consequences, were reported significantly less frequently. Hirsutism (0.0% versus 8.7%, P < 0.01) and gum hyperplasia (0.0% versus 2.3%, P < 0.05) were absent in patients receiving tacrolimus. Tacrolimus appears to provide effective and safe long-term immunosuppression.

Bile duct splintage in liver transplantation: is it necessary?

The choledochochole-dochal (duct-duct, D-D) anastomosis in orthotopic liver transplantation (OLT) is usually splinted by a T-tube to facilitate easy cholangiography, monitor bile quality and allow biliary decompression. T-tubes, however, are a focus for sepsis and sludge deposition, and their removal may result in bile leakage. From January 1993 to December 1994, 199 consecutive adult OLTs in 183 patients (median age 50 years, range 16-69 years, 118 females) with a D-D anastomosis were studied prospectively with a median follow-up of 16 (3-27) months. Of the 199 OLTs, 110 had an 8 Fr T-tube (group 1) and 89 had no T-tube (group 2). The two groups were similar for indication, preservation solution, median cold and warm ischaemia times and early graft function parameters. Biliary complications developed in 26/110 patients, including 10 with bile leaks on T-tube removal in group 1 compared to 10/89 biliary complications in group 2 (P = 0.024). The use of T-tubes is associated with increased morbidity and their routine use should be discontinued.

Effect of RS61443 in combination with leflunomide or FK506 on rat heart allograft survival

Mycophenolate Mofetil (RS61443) is a potent inhibitor of de novo purine synthesis and lymphocyte proliferation. It is known to prevent ongoing rejection and even reverse established rejection, alone and in combination with, cyclosporin. We investigated whether RS61443 in combination with leflunomide (Lef) or FK506 (FK) could prolong allograft survival in a rat heart model, since combination therapy might help to overcome drug toxicity. Abdominal heart grafting was performed from DA to LEW rats (250 g) and RS61443, 10 mg/kg or 30 mg/kg monotherapy or combination treatment (RS 10 mg/kg with Lef 5 mg/kg or FK 0.5 mg/kg) was begun orally at transplantation and continued daily until the ninth posttransplant (post-Tx) day. Ventricular motion was graded daily and rejection was defined as lack of contractions, confirmed by histology. Results were analysed using non-parametric tests. A two-tail P value < 0.05 was considered significant. RS at 10 mg/kg was ineffective and all grafts were rejected under immunosuppression between 5 and 6 post-Tx day, whereas RS at 30 mg/kg was immunosuppressive for as long as it was given. The combinations of RS at 10 mg/kg with either Lef at 5 mg/kg or FK at 0.5 mg/kg were immunosuppressive in the majority of cases, for as long as they were given. However, the combination of RS at 10 mg/kg with FK at 0.5 mg/kg was attendant with graft vein anastomosis rupture (3/5). The combination of RS with Lef was clinically therapeutic for as long as it was given; grafts were rejected 3-4 days after withdrawing immunosuppression. The combination of RS with FK resulted in over-immunosuppression, leading to graft vein anastomosis non-healing and rupture within 5 days of grafting; histology demonstrated evidence of bacterial infection with complete destruction of the vein wall. These data suggest that the combination of RS with Lef or FK in subtherapeutic doses might be a potentially promising strategy for combination therapy in solid organ transplantation.

Effect of pre-reperfusion portal venous blood flush on early liver transplant function

Portal venous blood for rinsing out the University of Wisconsin solution (UWs) has the advantages of being a physiological fluid, removing acidotic mesenteric venous blood and perhaps resulting in more stable haemodynamic parameters during reperfusion. A group of 209 consecutive adult OLTs carried out between July 1993 and February 1995 were studied prospectively. The UWs was flushed out with 500 ml portal blood in 95 OLTs (group 1) and with 1.0 L 0.5% dextrose at 37 degrees C in 114 OLTs (group 2). The median day 1 and peak day 1-5 AST levels were significantly elevated in the 5% dextrose group: median 755 (118-11090) vs. 546 (121-6150) IU/I (P = 0.007, Wilcoxon); and median 1095 (159-11090) vs. 744 (157-7870) IU/l (p = 0.008, Wilcoxon), respectively. A median of 5 (0-27) units of blood were transfused in group 1 compared to 4 (0-54) units in group 2 (n.s.). There was no difference in peak bilirubin, lowest day 1-5 PT levels, primary nonfunction, median ITU stay, total inpatient stay and 1-month graft survival between the two groups (89% vs. 88%). Pre-reperfusion blood flush may be associated with less hepatocellular damage, without significant additional blood usage.

Liver transplantation in Birmingham: indications, results, and changes

The improvements in survival following liver grafting during the last five years reflect refinements in technique and in immunosuppressive regimens. Cirrhosis due to Hepatitis C and alcohol have become more common indications in this center. Efforts are being made to overcome the problems of donor organ shortage by using 'marginal' donors and by splitting liver grafts.

Therapeutic drug monitoring of tacrolimus in clinical transplantation

Initial clinical trials of FK did not incorporate available FK levels, and difficulties were quickly experienced particularly with neurotoxicity and nephrotoxicity. The introduction of routine assay allowed broad parameters to be identified, which assisted in evaluating effective therapeutic parameters. Levels approximately 20 ng/ml were frequently associated with toxicity and the initial therapeutic range between 10-25 ng/ml was probably excessive. Reliable effective assay > 5 ng/ml using the Abbott IMx is not available, and many patients will have excellent hepatic or renal function with what are currently undetectable levels of FK. However, IncStar have an ELISA assay with a sensitivity of 0.5 mg/ml. Clinical practice does not, at this time, dictate elevation of FK, although careful monitoring continues. Education of oral administration from 0.15 mg/kg to 0.1 mg/kg in combination therapy with steroids and 0.05 mg/kg with azathioprine and steroids has led to revision of therapeutic parameters, e.g., 5-15 ng/ml is now widely used. Therapeutic drug monitoring is important to avoid unnecessary toxicity, but the lower limit has not been fully defined. Clearly, many patients with < 5 ng/ml have excellent hepatic function.

Restorative proctocolectomy and pouch anal anastomosis for ulcerative colitis following orthotopic liver transplantation

This study reports on the outcome of four patients having ileal pouch anal anastomosis after orthotopic liver transplantation for sclerosing cholangitis complicating ulcerative colitis. There were no deaths on follow up. Early postoperative bleeding was a complication of colectomy or rectal excision in three, one of whom developed hepatic artery thrombosis and the overall complication rate was high. All patients are continent but one has chronic pouchitis (while receiving longterm metronidazole) and one patient has recurrent sclerosing cholangitis in the transplant.

Timing, significance, and prognosis of late acute liver allograft rejection

Liver allograft rejection is usually divided into acute (cellular) rejection and chronic (ductopenic) rejection. Most cases of acute rejection occur within four weeks of transplantation. There is a paucity of published literature on late acute rejection (LAR) in liver allografts and little is known about factors affecting its occurrence and outcome. To study the predisposing factors, clinical presentation, and prognosis of LAR, data prospectively collected on consecutive adult patients who underwent liver transplantation between 1982 and 1994, were analyzed. LAR was defined as histologically confirmed acute cellular rejection occurring 30 or more days after liver transplantation. Of the 717 patients, 59 (7.5%) had 71 episodes of LAR. Fifty-seven episodes were seen during the first year after transplantation, the remaining occurring between 1 and 6 years. Age, sex, pretransplant diagnosis, donor match of HLA, and blood groups was not associated with risk of LAR. Twenty-seven (38%) episodes were preceded by subtherapeutic blood levels of cyclosporine/FK506 (< 100 ng/ml and < 5 ng/ml, respectively) while an additional 6 (8%) had marginally low blood levels (< 150 ng/ml and < 10 ng/ml, respectively). Treatment with high-dose prednisolone resulted in complete resolution of rejection in 36 (51%) episodes, partial response in 21, and no response in 14 patients. Sixteen patients (27%) developed chronic rejection and graft loss. Development of chronic rejection was not affected by age or sex of the patient, timing of LAR, or histological severity of AR. Delayed response to therapy during an earlier episode of AR, and histological findings of centrilobular necrosis or bile duct loss at the time of diagnosis of LAR were associated with high risk of progression to chronic rejection and graft loss.