Study design: Retrospective cohort using historic and concurrent control.
Setting: Tertiary-care teaching hospital in Chicago.
Synopsis: Structured interdisciplinary rounds, led by a nurse manager and medical director, and including nurses, residents, pharmacists, social workers, and case managers, were implemented on a medical teaching unit. New patients were discussed using a structured communication tool; existing patients were discussed in an unstructured format. Medical records were abstracted for 370 patients hospitalized after implementation of the intervention, equally divided between intervention and control units. One hundred eighty-five patients hospitalized on the intervention unit prior to the implementation of rounds served as a historic control.
Patients in the intervention unit had significantly lower rates of total adverse events (3.9 per 100 patient days in the intervention, compared with 7.2 and 7.7 per 100 patient days for the concurrent and historic control units, respectively), and preventable adverse events (0.9 per 100 patient days, compared with 2.8 and 2.1 per 100 patient days for the concurrent and historic controls, respectively).
Limitations of the study include lack of blinding of the medical record, slightly different patient populations in intervention and control groups, and the one-hospital setting, which could limit generalizability.
Bottom line: Structured interdisciplinary rounds might serve to improve communication between nurses, pharmacists, and physicians, resulting in decreases in adverse events.
Citation: O’Leary KJ, Buck R, Fligiel HM, et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011;171(7):678-684.
Pediatric HM Literature
Short-Course Antibiotic Therapy Effective for Bacterial Meningitis
Clinical question: Is five days of parenteral ceftriaxone as effective as 10 days for the treatment of bacterial meningitis in children?
Background: Morbidity and mortality in bacterial meningitis remain high, particularly in developing countries. Antibiotics are effective treatment, yet the optimal duration of treatment remains uncertain. Some data support a shorter duration of treatment (three to five days).
Study design: Multicountry, double-blind, placebo-controlled, randomized equivalence study.
Setting: Ten pediatric referral hospitals in Bangladesh, Egypt, Malawi, Pakistan, and Vietnam.
Synopsis: Children aged two months to 12 years with bacterial meningitis (due to Haemophilus influenza, Streptococcus pneumonia, Neisseria meningitidis, or culture-negative with indicative cerebrospinal fluid findings) and without complicating medical conditions were enrolled at participating centers. All children received 80 mg/kg to 100 mg/kg of parenteral ceftriaxone daily and a repeat lumbar puncture 48 to 72 hours after initiation of therapy.
Ultimately, 1,004 children without resistant organisms, persistently positive cultures, or suppurative complications were randomized on day five of therapy to placebo or continuance of ceftriaxone for five more days.
No bacteriologic failures (primary endpoint) were evident with either five or 10 days of treatment.
In addition, no statistically significant differences were found between the groups with respect to clinical treatment failure, hearing loss, neurological sequelae, or death. Secondary analysis by organism revealed similar results.
The primary limitation of this study is that it occurred in developing countries with a fair incidence of H. influenzae meningitis and a low rate of third-generation cephalosporin resistance.
However, pneumococcal and meningococcal disease remained prominent, and this study suggests that clinically stable patients might be treated with a shorter course of parenteral ceftriaxone therapy than currently is recommended.
Bottom line: Five days of ceftriaxone is as effective as 10 days for uncomplicated bacterial meningitis in children.
Citation: Molyneux E, Nizami SQ, Saha S, et al. 5 versus 10 days of treatment with ceftriaxone for bacterial meningitis in children: a double-blind randomised equivalence study. Lancet. 2011;377:1837-1845.
Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.