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The cost-effectiveness of different approaches to antimicrobial prophylaxis for cardiovascular surgery patients labeled penicillin allergic was studied. A decision-analytic model was used to examine the cost-effectiveness of six strategies for antimicrobial prophylaxis in cardiovascular surgery patients at a tertiary care hospital. The strategies consisted of (1) giving vancomycin to all patients labeled penicillin allergic, (2) giving cefazolin to all patients labeled penicillin allergic, (3) giving vancomycin to all patients with a history suggesting an immunoglobulin E (IgE)-mediated reaction to penicillin and cefazolin to patients without such a history, (4) administering a penicillin skin test to patients with a history suggesting an IgE-mediated reaction to penicillin and giving vancomycin to patients with positive results and cefazolin to all others, (5) skin testing all patients labeled penicillin allergic and giving vancomycin to those with positive results and cefazolin to those with negative results, regardless of history, and (6) skin testing all patients and giving vancomycin to those with positive results or a history suggesting an IgE-mediated reaction to penicillin and cefazolin to all others. Giving cefazolin to all patients labeled penicillin allergic was the least expensive strategy but was associated with the highest rate of both anaphylactic and non-life-threatening serious reactions. Selective use of vancomycin in patients with a history suggesting an IgE-mediated reaction to penicillin was associated with an added cost and a slightly lower rate of anaphylaxis. Although skin-testing strategies may decrease both non-life-threatening and anaphylactic reactions, the incremental cost was high. When vancomycin was given to all patients labeled penicillin allergic, the incremental cost was very high. A decision-analytic model indicated that selective use of vancomycin is more cost-effective than indiscriminate use of vancomycin for surgical prophylaxis in cardiovascular surgery patients labeled penicillin allergic.

The role played by a hospital pharmacy department in managing an influenza outbreak at an affiliated long-term-care facility is described. In February 1998 an outbreak of influenza A was confirmed in a 570-bed long-term-care facility. During the outbreak, a total of 48 cases of influenza-like illness (ILI) were reported to infection control, and 62 staff members missed work because of ILI. Infection control measures included a recommendation for prophylaxis with amantadine. Pharmacists assumed responsibility for educating patients and families about amantadine prophylaxis, providing individualized dosing, evaluating reported adverse effects, and drug distribution. Pharmacists developed an information sheet on amantadine for patients and met with patients and their families. The overall acceptance rate for chemoprophylaxis was 91%. Of the 349 patients receiving amantadine during the outbreak, 203 (58%) were given 100 mg daily, 136 (39%) were given 100 mg every other day, and 10 (3%) were prescribed 100 mg weekly. Pharmacists confirmed a total of 22 adverse effects; generally the problem was solved by reducing the dosage rather than discontinuing the drug. In all cases, the first dose of amantadine was provided to the nursing units within three hours of an order being written. Pharmacists played an active role in managing an influenza A outbreak at a long-term-care facility.