Reviews of infectious diseases
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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.
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Outpatient parenteral treatment of infectious diseases has developed from primitive beginnings to its present state as the standard of care in many areas. The large infusion center described here is headed by physicians who specialize in infectious diseases and occupies a free-standing building where the pharmacy, laboratory, physicians' offices, examination rooms, and finance departments are centralized for efficiency, flexibility, and convenience. ⋯ Costs in the center run between 50% and 60% lower than those in the hospital. Reimbursement, although difficult in the past, has improved considerably, but some third-party payers, including Medicare, have not reimbursed for outpatient intravenous antibiotic therapy.
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Outpatient intravenous antibiotic therapy (OPIVAT) requires selection of patients who are medically and psychologically stable, are capable of being trained to administer iv medications, will not abuse the iv system, and have insurance coverage. Patients with conditions such as osteomyelitis, septic arthritis, pelvic inflammatory disease, endocarditis, and skin and soft tissue infections are appropriate candidates. As clinical experience grows, patients with increasingly complex conditions are being successfully treated at home. ⋯ With appropriate training, such patients learn to properly manage drugs and equipment and to recognize complications. Patients who cannot be treated at home may be candidates for OPIVAT under direct medical supervision. Technical advances in pumps and catheters--as well as future changes in Medicare reimbursement--may greatly increase the number of patients who are capable of receiving OPIVAT.
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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.