Reviews of infectious diseases
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This office-based program for parenteral therapy began with the im administration of therapy to outpatients in 1981. Since then it has expanded in scope and staff and has provided more than 1,200 courses of i.v. antibiotics. ⋯ This office model has resulted in excellent quality of care for patients who have experienced few adverse effects or complications. The cost savings of an office program are significant compared to hospitalization for i.v. administration of antibiotics, but issues related to reimbursement are a constant issue.
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Reimbursement policies of third-party payers, including Medicare, reflect a variety of coverage patterns. For a limited group of Medicare patients who are, in Medicare terms, confined to home and require skilled and intermittent care, Medicare Part A covers home care services deemed medically necessary by a physician. Medical equipment and supplies may be included under this coverage. ⋯ The latter must be administered directly by a physician or by an employee of a physician with direct supervision by a physician. These restrictions have, in general, prevented reimbursement by Medicare for iv antibiotic therapy in the home. Medicaid, Blue Cross/Blue Shield, various commercial insurers, and health maintenance organizations usually cover iv antibiotics, but in many cases prior approval is necessary for coverage.
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A program set up in the Soroka University Medical Center, Beer Sheva, Israel, offers outpatient parenteral antibiotic therapy (OPAT) for children with serious bacterial infections. The following criteria must be met before a child is placed in this program: OPAT must be a suitable form of treatment for the infection, an appropriate drug must be available, the parents must be cooperative and well-informed, and 24-hour-a-day telephone communication and transportation between the home and hospital must be available. With use of ceftriaxone administered im, the OPAT program has shown positive results: a cure rate of 98.5% and an estimated savings of 1,334 hospital days for 140 patients over a 17-month period.
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Prompt administration of antibiotics is of the utmost importance in the treatment of wounds inflicted during a war or disaster. A single injection of a broad-spectrum drug with a long half-life should be given prophylactically to personnel on the battlefield to provide bactericidal coverage from the earliest possible moment after injury occurs. ⋯ Use of antimicrobial agents will never replace careful surgical debridement, and these drugs should be used again later only if a bacterial infection develops. Other considerations include the choice of a drug that penetrates tissue thoroughly, is simple to store and administer, is easily available, and is cost effective.
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Occult bacteremia, which precedes many serious infections in children, is most often due Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis, or Salmonella species. Diagnosis on the basis of clinical judgment is unreliable, although the presence of certain risk factors may suggest the diagnosis. ⋯ Although results are delayed, a culture of blood is the only definitive test. Studies suggest that treatment with various antibiotics may be helpful, but that some drugs, particularly orally administered amoxicillin, should not be relied on to eliminate occult bacteremia or prevent its most serious sequela, meningitis.