Adjustments being made to insulin regimens are based on fasting, pre-meal and bedtime glucose as well as the novel approach of bolus insulin after meals with short-acting insulin (i.e., lispro).
Unfortunately although the protocol does perhaps yield itself to being looked at more stringently—in terms of cost effectiveness, improved length of hospital stay, and improved clinical outcomes—the outcome studied here was primarily one of hospitalwide education in advancing the understanding and culture of aggressive individualized insulin protocols. These can often be even more statistically difficult to quantify. As self-reported, improvements were made.
One of the most important aspects of this paper is that it draws attention to the paucity of evidence for improved clinical and monetary outcomes supporting the aggressive hospital management of hyperglycemia in the non-acutely ill patient. Often, the guiding principle is to avoid hypoglycemia. Detailing the specific protocols of one such approach serves as an example for the motivated reader.
Early Switch from IV to Oral Antibiotic in Severe CAP
Oosterheert JJ, Bonten JM, Schneider MME, et al. Effectiveness of early switch from intravenous to oral antibiotics in severe community acquired pneumonia; multicentre randomised trial. BMJ. 2006 Dec 9; 333:1193.
Community acquired pneumonia (CAP) is a common and potentially fatal infection with high healthcare costs. When patients are first admitted to hospitals, antibiotics are usually given intravenously to provide optimal concentrations in the tissues.
The duration of intravenous treatment is an important determinant of length of hospital stay (LOS). The concept of early transition from intravenous to oral antibiotic in the treatment of CAP has been evaluated before, but only in mild to moderately severe disease—and rarely in randomized trials.
This multicenter random controlled trial from five teaching hospitals and two medical centers in the Netherlands enrolled 302 patients in non-intensive care units with severe CAP. The primary outcome was clinical cure and secondary outcome was LOS. The inclusion criteria were adults 18 or older with severe CAP; mean pneumonia severity index of IV-V, new progressive infiltrate on chest X-ray, plus at least two other criteria (cough, sputum production, rectal temperature >38o C or <36.1o C, auscultative findings consistent with pneumonia, leukocytes >109 WBC/L or >15% bands, positive cultures of blob or pleural fluids, CRP three times greater times upper limit of normal).
Exclusion criteria included the need for mechanical ventilation, cystic fibrosis, a history of colonization with gram-negative bacteria due to structural damage to the respiratory tract, malfunction of the digestive tract, life expectancy of less than one month because of underlying disease, infections other than pneumonia that needed antibiotic treatment, and severe immunosuppression (neutropenia [<0.5 109 neutrophils/liter] or a CD4 count< 200/mm3).
Treatment failure was defined as death, still in hospital at day 28 of the study, or clinical deterioration (increase in temperature after initial improvement or the need for mechanical ventilation, switch back to intravenous antibiotics, or readmission for pulmonary reinfection after discharge).
Clinical cure was defined as discharged in good health without signs and symptoms of pneumonia and no treatment failure during follow-up.
The control group comprised 150 subjects who were to receive a standard course of seven days’ intravenous treatment. Meanwhile, 152 subjects were randomized to the early switch group. Baseline characteristics were similar in both groups. More than 80% of patients were in pneumonia severity class IV or V. Most patients received empirical monotherapy with amoxicillin or amoxicillin plus clavulanic acid (n=174; 58%) or a cephalosporin (n=59; 20%), which is in line with Dutch prescribing policies.
The most frequently identified microorganism was S pneumoniae (n=76; 25%). Atypical pathogens were detected in 33 patients (11%). Before day three, 37 patients (12%) were excluded from analysis, leaving 132 patients for analysis in the intervention group and 133 in the control group.