The role of diagnostic CT imaging in the acute assessment of battlefield external genital injuries.

INTRODUCTION: The external genitalia are routinely included in the 'CT-Traumagram' at the Role 3 hospital in Afghanistan. Although the radiologist may have the opportunity to diagnose clinically undetected genital injury, little emphasis has been placed on the CT appearances of the external genitalia after Improvised Explosive Device related injury. METHODS: A prospective observational study was carried out on casualties admitted during 1 month in 2011. Genital findings on CT were correlated with clinical operative findings. RESULTS: One hundred and twenty-eight casualties were admitted of which 12 (9%) had genital injury. 17 testes were exposed to blast injury-5/17 (29%) were unharmed, one was dislocated, two were lost, one had a testicular haematoma and 8/17 (47%) were disrupted and underwent salvage. The CT findings-loss of the definition of the tunica albuginea and intra-testicular contrast blushing correlated with testicular disruption in all cases. The single dislocated testis and the two cases where there were no testes remaining after injury were all evident on CT. DISCUSSION: The CT appearance of the external genitalia following trauma are unfamiliar. However, despite the small numbers and clear limitations, the results suggest that CT has an important role to play in the diagnosis of significant genital trauma. Ultrasound assessment should be considered if there is persisting uncertainty. CONCLUSIONS: 'CT-Traumagram' provides rapid, whole body information in casualties exposed to blast injury and this should be exploited in its entirety by the trauma team. Abnormal genital findings on contrast CT should alert radiologists and surgeons to the possibility of significant genital trauma.

Factors associated with effective reassessment of antibiotic therapy on day 3.

UNLABELLED: Reassessment of antibiotic therapy (RA) after 3 days is constitutive of French antibiotic stewardship. This delay is required because of the need for clinical reappraisal and for obtaining microbiological data. Our aim was to determine the factors associated with an effective RA. PATIENTS AND METHOD: A prospective study was made in a 350-bed general hospital in which all prescriptions are computerized and validated daily by prescribers. All curative antibiotic therapies were reassessed during 4 weeks. RA was defined as effective if the initial antibiotic treatment was modified. All clinical, biological, and radiological data having contributed to the initial prescription and to RA were recorded during bedside visit with the prescribers, two hospital physicians and one infectious diseases specialist. RESULTS: In one month, 148 antibiotic treatments were reassessed. Pulmonary, digestive, and urinary infections accounted for two thirds of the cases. An effective RA was recorded in 28 cases (19%) and associated with hospitalization in the ICU (P=0.001), imaging supporting the diagnosis (P=0.016), and persistence or aggravation of clinical signs (P=0.007). Microbiological findings were not contributive to an effective RA. CONCLUSION: RA was associated to hospitalization in the ICU, to an inflammatory syndrome, and to the clinical outcome after 3 days. These results should help to improve the implementation of infectious diseases advice.

An antibiotic stewardship program in a French teaching hospital.

OBJECTIVES: An antibiotic stewardship program was implemented in our teaching hospital in 1999, and strengthened in 2005. We report its organization and impact on antibiotic use. METHODS: This observational study was conducted during a 10-year period (2002-2011). RESULTS: Many interventions were implemented: Infectious Diseases Specialists (IDS) led systematic ward rounds in several departments (1999); nominative antibiotic order form (2005); documentation of IDS advice in the patient's electronic medical record (2007); IDS advice triggered by the pharmacist (formulary restriction, 2007) or because of positive blood cultures (2009); automated weekly extraction of advice given into a database (2011). Seven thousand two hundred and five pieces of advice were recorded between 2007 and 2011: 63% following physician request, 26% triggered by the pharmacist and 9% because of positive blood cultures. Advice was provided by IDS in 95% of cases (63% by phone). The number of antibiotic prescriptions remained stable since 2005 at around 400 defined daily doses (DDD)/1000 patient-days. Documenting, sharing, and choice of action were improved due to the database. CONCLUSIONS: Our antibiotic stewardship program is well accepted by physicians and allows controlling antibiotic use in our hospital.

Impact of an assisted reassessment of antibiotic therapies on the quality of prescriptions in an intensive care unit.

OBJECTIVES: The study's objective was to assess the impact of a professional multifaceted intervention designed to improve the quality of inpatient empirical therapeutic antibiotic courses at the time of their reassessment, i.e. 24 to 96 hours after treatment initiation. DESIGN: We conducted a 5-month prospective pre- and post-intervention study in a medical Intensive Care Unit (ICU) in a teaching hospital, using time-series analysis. The intervention was a multifaceted professional intervention combining systematic 3-weekly visits of an infectious diseases specialist to discuss all antibiotic therapies, interactive teaching courses, and daily contact with a microbiologist. RESULTS: Eighty-one antibiotic prescriptions were assessed, 37 before and 44 after the intervention. The prevalence of adequate antibiotic prescriptions was high and not statistically different before and after the intervention (73% vs. 80%, P=0.31), both for sudden change (P=0.67) and linear trend (P=0.055), using interrupted time-series analysis. The intervention triggered a more frequent reassessment of the diagnosis between day 2 and day 4 (11% vs. 32%, P=0.02) and slightly improved the adaptation of antibiotic therapies to positive microbiology (25% before vs. 50% after, P=0.18). CONCLUSIONS: Our multifaceted intervention may have improved the quality of antibiotic therapies around day 3 of prescription, but the difference did not reach statistical significance, possibly because of a ceiling effect.

[Computerized management of a medical department, disease-related group management, clinical research and evaluations]. / Gestion de services, tarification à l'activité, recherche clinique et évaluation des pratiques professionnelles: un même outil informatique.

The current French hospital reform is based on the disease-related group (DRG) approach and the constitution of bigger units pooling several departments of different specialties. This reform needed an efficient assessment of various medical activities. We report our experience of a medical table of our hospital activities used for 27 months. This medical table was made with a basic software integrating 24 parameters. The original concept was the translation of the specific final diagnosis for DRG defined by the site of infection. To create this medical table, we first simplified the conclusions of the patient's chart using a consensual and systematic plan. The number of patients per DRG and their evolution were therefore specifically determined. The medical table helped us in the daily management of our department, to identify the area of recruitment, the potential for heterogeneous care, allowing the implementation of protocols and their applications. Moreover, the table quantified morbidity and mortality, indicating our need for cooperation with other departments. All this data used medical-lexical terms, allowing other than economic analyses, even if this table identifies hospitalization-related costs, namely duration of hospital-stay, nosocomial infections and iatrogenic events. Finally, our table supports medical research and evaluation of practice. Our future goals are to introduce this table in several infectious-diseases units, and create specific tables for the main RDG, including economic parameters.

[Motives for the prescription of antibiotics in the emergency department of the University Hospital Center in Nice. A prospective study]. / Motifs de prescriptions des antibiotiques dans le service des urgences du centre hospitalier universitaire de Nice. Enquête prospective.

OBJECTIVES: Since April 1999, we have set-up an infectious disease consultation in the emergency unit of the University Hospital in Nice. Unjustified antiobiotherapy is often initiated. We therefore conducted a survey to study the motives and validity of antibiotic prescriptions. METHOD: This prospective study was conducted in two phases. The first consisted in asking the emergency physicians prescribing antibiotics to fill-in a questionnaire giving information on the diagnosis established and the antiobiotherapy proposed. In the second phase, the diagnoses and corresponding treatments were submitted to 4 experts who assessed the acceptability of the diagnoses and the antibiotics prescribed. The experts only had access to the clinical and para-clinical data available. Moreover, their therapeutic judgement was based on previously published consensuses. RESULTS: The 6-month survey collected 117 questionnaires that could be analysed. The rate of error in diagnosis was of 33% (39/117). Thoracic x-rays could not be interpreted in 11% of cases. In single variant analysis, factors of erroneous diagnosis were due to its interpretation by an internist, the diagnostic category of "broncho-pulmonary infections" and the lack of documentation. In multi variant analysis, only the lack of documentation was related to erroneous diagnosis (OR = 5.5; IC 95% (2.03; 15.30), p < 0.0002). The rate of antibiotherapy not adapted to the diagnosis made by the physician was of 32% (37/117). In 24 cases the modalities of the prescription were incorrect and in 13 cases the prescription was unjustified. Only the status of the prescriber (internist) was statistically associated with an antibiotherapy not adapted to the diagnosis (OR = 2.2; IC 95% (0.93; 5.26), p < 0.05). CONCLUSION: Unjustified antibiotherapy in an emergency unit is generally due to erroneous diagnosis of infection. The lack of documentation and inexperience of the prescribers appear to be the two elements contributing to unjustified antibiotherapy.

[Systematic infection consultation in the intensive care unit. Impact of short-term antibiotic use]. / Consultation systématique d'infectiologie en réanimation médicale. Impact à court terme sur la consommation antibiotique.

OBJECTIVES: Multiresistant bacteria are regularly isolated in nosocomial infections occurring in intensive care units due to wide use of antibiotics. We evaluated the impact of systematic infectiology consultations on the quality of antibiotic prescriptions in an intensive care unit. PATIENTS AND METHODS: Infectiology consultations (3 per week) were initiated mid February 1999. The infectiologist gave oral advice to be implemented (or not) by the intensive care unit according to ongoing therapeutic options. The hospital pharmacy recorded antibiotic use for March and April 1999 for comparison with use recorded in 1998 for a similar period. We retrospectively reviewed the files of patients hospitalized during these periods and who had received antibiotics to determine the modalities of antibiotic use. The 4 antibiotics used for the longest period for each patient were recorded. RESULTS: Thirty-one patients in 1999 and 30 in 1998 were given antibiotics. The SAPS score was similar for the two groups. Mean duration of antibiotic treatment was lower during the March-April 1999 period than during the corresponding period in 1998: 13 +/- 9 days/patient versus 23 +/- 21 days/patient respectively, p = 0.037. In 1998, there were 596 antibiotic-days and in 1999 there were 455 (-24%). The cost of antibiotic therapy in 1998 was 70,342 FrF compared with 56,804 FrF in 1999 (-19%). CONCLUSION: Infectiology consultation, in association with the opinion of the intensive care physician, is a simple way to limit antibiotic use.

[Malaria attacks after returning from endemic areas. Failure or inadequate chemoprophylaxis?]. / Accès palustre au retour de zone d'endémie. Echec ou inadéquation de la chimioprophylaxie?

OBJECTIVE: Determine the causes of malaria attacks in subjects who have returned from endemic areas by assessing prescriptions for chemical prophylaxis and compliance. PATIENTS AND METHODS: All patients who developed a paroxysmal episode of malaria diagnosed at the University of Nice hospital in 1995 answered specific questions concerning their anti-malaria prophylaxis. RESULTS: Thirty-three patients were hospitalized for paroxysmal episodes of malaria in 1995. In 32 cases (97%) the attack resulted from either the lack of any prophylaxis (17 cases, 52%), inadequate prescription (11 cases, 12%) or poor compliance (4 cases, 12%). The prescribed chemical prophylaxis was not adapted to the chloroquinone-resistant area in 8 cases (24%) and medical recommendations concerning administration rules were inadequate in 3 cases (9%). Only one patient developed a paroxysmal episode despite correct compliance to a chloroquine-resistant zone-adapted well-conducted prescription. The cost of poor prophylaxis in terms of human suffering and financial cost was high for this preventable disease. Four patients had to be hospitalized in the intensive care unit and one died during hospitalization. The cumulative cost of hospitalization for these 33 cases was evaluated at 660,000 FF. CONCLUSION: Preventive measures for malaria must include better information for physicians on changing recommendations for chemical prophylaxis as well as better information for travelers provided by all those involved in organizing travel to endemic areas.