Factors associated with meropenem pharmacokinetic/pharmacodynamic target attainment in septic critically ill patients treated with extended intermittent infusion or continuous infusion.

OBJECTIVES: The use of extended intermittent infusion (EII) or continuous infusion (CI) of meropenem is recommended in intensive care unit (ICU) patients, but few data comparing these two options are available. This retrospective cohort study was conducted between 1 January 2019 and 31 March 2020 in a teaching hospital ICU. It aimed to determine the meropenem plasma concentrations achieved with CI and EII. METHODS: The study included septic patients treated with meropenem who had one or more meropenem plasma trough (Cmin) or steady-state concentration (Css) measurement(s), as appropriate. It then assessed the factors independently associated with attainment of the target concentration (Cmin or Css ≥ 10 mg/L) and the toxicity threshold (Cmin or Css ≥ 50 mg/L) using logistic regression models. RESULTS: Among the 70 patients analysed, the characteristics of those treated with EII (n = 33) and CI (n = 37) were balanced with the exception of estimates glomerular filtration rate (eGFR): median 30 mL/min/m2 (IQR 30, 84) vs. 79 mL/min/m2 (IQR 30, 124). Of the patients treated with EII, 21 (64%) achieved the target concentration, whereas 31 (97%) of those treated with CI achieved it (P < 0.001). Factors associated with target attainment were: CI (OR 16.28, 95% CI 2.05-407.5), daily dose ≥ 40 mg/kg (OR 12.23, 95% CI 1.76-197.0; P = 0.03) and eGFR (OR 0.98, 95% CI 0.97-0.99; P = 0.02). Attainment of toxicity threshold was associated with daily dose > 70 mg/kg (OR 35.5, 95% CI 5.61-410.3; P < 0.001). CONCLUSION: The results suggest the use of meropenem CI at 40-70 mg/kg/day, particularly in septic ICU patients with normal or augmented renal clearance.

Involvement of Pharmacists in the Emergency Department to Correct Errors in the Medication History and the Impact on Adverse Drug Event Detection.

(1) Incomplete or wrong medication histories can lead to missed diagnoses of Adverse Drug Effects (ADEs). We aimed to evaluate pharmacist-identified ED errors in the medication histories obtained by physicians, and their consequences for ADE detection. (2) This prospective monocentric study was carried out in an ED of a university hospital. We included adult patients presenting with an ADE detected in the ED. The best possible medication histories collected by pharmacists were used to identify errors in the medication histories obtained by physicians. We described these errors, and identified those related to medications involved in ADEs. We also identified the ADEs that could not have been detected without the pharmacists' interventions. (3) Of 735 patients presenting with an ADE, 93.1% had at least one error on the medication list obtained by physicians. Of the 1047 medications involved in ADEs, 51.3% were associated with an error in the medication history. In total, 23.1% of the medications involved in ADEs were missing in the physicians' medication histories and were corrected by the pharmacists. (4) Medication histories obtained by ED physicians were often incomplete, and half the medications involved in ADEs were not identified, or were incorrectly characterized in the physicians' medication histories.

Acquisition of extended-spectrum cephalosporin-resistant Gram-negative bacteria: epidemiology and risk factors in a 6-year cohort of 507 severe trauma patients.

OBJECTIVES: Severe trauma patients are at higher risk of infection and often exposed to antibiotics, which could favor acquisition of antimicrobial resistance. In this study, we aimed to assess prevalence, acquisition, and factors associated with acquisition of extended-spectrum cephalosporin-resistant Gram-negative bacteria (ESCR-GNB) in severe trauma patients. METHODS: We conducted a retrospective monocentric cohort study in a French level one Regional Trauma Centre between 01 January 2010and 31 December 2015. Patients admitted for ≥ 7 days, with an Injury Severity Score ≥ 15, and ≥ 1 microbiological sample were included in the analysis. Prevalence and acquisition rate of ESCR-GNB were determined then, factors associated with ESCR-GNB acquisition were assessed using a Cox model. RESULTS: Of 1873 patients admitted during the study period, 507 were included (median Injury Severity Score = 29 [22-34] and median intensive care unit length of stay = 16 days [10-28]). Most of them (450; 89%) had an antimicrobial therapy. Prevalence of ESCR-GNB increased from 13% to 33% during intensive care unit stay, bringing the ESCR-GNB acquisition rate to 29%. Acquisition of ESCR-GNB was mainly related to AmpC beta-lactamase Enterobacterales and was independently associated with mechanical ventilation needs (hazard ratio [HR] = 6.39; 95% confidence interval [CI] [1.51-27.17]; P = 0.01), renal replacement therapy needs (HR = 2.44; 95% CI [1.24-4.79]; P = 0.01), exposure to cephalosporins (HR = 1.06; 95% CI [1.01-1.12]; P = 0.02), and/or combination therapy with non-beta-lactam antibiotics such as vancomycin, linezolid, clindamycin, or metronidazole (HR = 1.03; 95% CI [1.01-1.06]; P = 0.02). CONCLUSIONS: Acquisition of ESCR-GNB was prevalent in severe trauma patients. Our results suggest selecting antibiotics with caution, particularly in the most severely ill.

Remdesivir for Patients Hospitalized with COVID-19 Severe Pneumonia: A National Cohort Study (Remdeco-19).

BACKGROUND: Given the rapidly evolving pandemic of COVID-19 in 2020, authorities focused on the repurposing of available drugs to develop timely and cost-effective therapeutic strategies. Evidence suggested the potential utility of remdesivir in the framework of an early access program. REMDECO-19 is a multicenter national cohort study assessing the ability of remdesivir to improve the outcome of patients hospitalized with COVID-19. METHODS: We conducted a retrospective real-life study that included all patients from the early access program of remdesivir in France. The primary endpoint was the clinical course evolution of critically ill and hospitalized COVID-19 patients treated with remdesivir. Secondary endpoints were the SOFA score evolution within 29 days following the admission and mortality at 29 and 90 days. RESULTS: Eighty-five patients were enrolled in 22 sites from January to April 2020. The median WHO and SOFA scores were respectively reduced by two and six points between days 1 and 29. Improvement in the WHO-CPS and the SOFA score were observed in 83.5% and 79.3% of patients, respectively, from day 10. However, there was no effect of remdesivir on the 90-day survival based on the control cohort for hospitalized COVID-19 patients with invasive ventilation. CONCLUSIONS: SOFA score appeared to be an attractive approach to assess remdesivir efficacy and stratify its utilization or not in critically ill patients with COVID-19. This study brings a new clinical benchmark for therapeutic decision making and supports the use of remdesivir for some hospitalized COVID-19 patients.

Frequency, Characteristics, and Predictive Factors of Adverse Drug Events in an Adult Emergency Department according to Age: A Cross-Sectional Study.

Adverse drug events (ADEs) are a major public health concern, given their consequences in terms of morbi-mortality and associated healthcare costs. Many studies have focused on the elderly, who are considered particularly vulnerable in this respect. We aimed to determine and compare the frequency, characteristics, and predictive factors of ADEs according to age in an adult population. A prospective seven-year cross-sectional study was conducted in a university hospital emergency department. Structured medication reviews and ADE detection were performed. Patient data and ADE characteristics were collected. Descriptive statistics and logistic regression were performed in two age groups: Group 1 (age < 65 years) and 2 (age ≥ 65 years). Among the 13,653 patients included, 18.4% in Group 1 and 22.6% in Group 2 experienced an ADE. Differences were identified in terms of the ADE type (more ADEs due to noncompliance in Group 1) and ADE symptoms (greater bleeding in Group 2). In the multivariable analysis, several specific predictive factors were identified, including kidney failure and antidiabetic drug use in Group 1 and inappropriate prescription and antithrombotic treatment in Group 2. Analysis by age provided a more refined vision of ADEs as we identified distinct profiles of iatrogenesis. These results will lead to a better detection of ADEs.

Impact of Hospitalization in an Endocrinology Department on Vaccination Coverage in People Living with Diabetes: A Real-Life Study.

Background and Objectives: Vaccination coverage is suboptimal in people living with diabetes. The objectives of this study were to determine the impact of hospitalization on vaccination coverage and the variables associated with vaccination during hospital stay. Materials and Methods: This observational study was conducted from May 2019 to December 2019 in the Endocrinology-Nutrition-Diabetes Department of the University Hospital of Montpellier, France. This department encompasses three medical units, two of which have a full-time clinical pharmacist involved in the multidisciplinary management of patients. All adult diabetic patients who completed a questionnaire about vaccines were prospectively included by a clinical pharmacist and followed until department discharge. Coverage at the time of admission for the tetanus, diphtheria, pertussis (Tdap), pneumococcal, influenza, and herpes zoster vaccines was assessed from patient interviews and/or contact with the general practitioner and/or with the community pharmacist. Multivariable logistic regression analysis was performed to identify the factors associated with a vaccination update during the hospital stay. Results: A total of 222 patients were included (mean age: 59.4 years, 68.5% type 2 diabetes). Vaccination coverage increased by 26.7% (47.3% to 59.9%), 188.0% (10.8% to 31.1%) and 8.9% (45.9% to 50.0%), respectively, for the Tdap, pneumococcal and influenza vaccines during hospital stay. Female sex, admission to a diabetes care unit with a full-time pharmacist, favorable feelings about vaccination, unknown immunization coverage for pneumococcal vaccines, and evaluation and recording of vaccine coverage at admission in the patient medical records were associated with at least one vaccination during hospital stay. Conclusions: Our real-life study highlights that hospitalization and multidisciplinary management (i.e., physician-pharmacist) may be key points in the diabetes care pathway to improve vaccination coverage, especially for patients with advanced diabetes and comorbidities.

Compliance with Prescription Guidelines for Glucose-Lowering Therapies According to Renal Function: Real-Life Study in Inpatients of Internal Medicine, Endocrinology and Cardiology Units.

Background and objectives: Renal failure is a contraindication for some glucose-lowering drugs and requires dosage adjustment for others, particularly biguanides, sulfonylureas, and inhibitors of dipeptidyl peptidase 4. In this study, we assessed adherence to prescription recommendations for glucose-lowering drugs according to renal function in hospitalized diabetic subjects. Materials and Methods: This prospective cohort study was carried out over a 2-year period in a university hospital. Glomerular filtration rate (GFR) was determined by averaging all measurements performed during hospitalization. Glucose-lowering drug dosages were analyzed according to the recommendations of the relevant medical societies. Results: In total, 2071 diabetic patients (53% hospitalized in cardiology units) were examined. GFR was <30 mL/min/1.73 m2 in 13.4% of these patients, 30-44 in 15.1%, 45-60 in 18.3%, and >60 in 53.3%. Inappropriate oral glucose-lowering treatments were administered to 273 (13.2%) patients, including 53 (2.6%) with a contraindication. In cardiology units, 53.1% and 14.3% of patients had GFRs of <60 and <30 mL/min/1.73 m2, respectively, and 179 (15.4%) patients had a contraindication or were prescribed an excessive dose of glucose-lowering drugs. Conclusions: We showed that the burden of inappropriate prescriptions is high in diabetic patients. Given the high number of patients receiving these medications, particularly in cardiology units, a search for potential adverse effects related to these drugs should be performed.

The COVID-19 Pandemic Led to a Small Increase in Changed Mentality Regarding Infection Risk without Any Change in Willingness to Be Vaccinated in Chronic Diseases Patients.

The objective of this study was to assess the impact of the COVID-19 pandemic on patients' perceptions regarding infection risk and vaccination in subjects suffering from chronic diseases. A prospective observational multicentric study conducted from December 2020 to April 2021 in three French University Hospitals. Patients with chronic diseases were proposed to complete a questionnaire regarding the impact of the COVID-19 pandemic on infectious risk knowledge and vaccination. A total of 1151 patients were included and analyzed (62% of which were people with diabetes). The COVID-19 pandemic increased awareness of infectious risks by 19.3%, significantly more in people with diabetes (23.2%, from 54.4% to 67.0%, p < 0.01) when compared to the other high-risk patients (12.5%, from 50.5% to 56.8%, p = 0.06). Respectively, 30.6% and 16.5% of patients not up-to-date for pneumococcal and flu vaccines reported wanting to update their vaccination due to the COVID-19 pandemic. By contrast, the proportion of patients against vaccines increased during the COVID-19 pandemic (6.0% vs. 9.5%, p < 0.01). The COVID-19 pandemic has led to a small increase in awareness regarding the risks of infection in patients with chronic diseases, including people with diabetes, but without any change in willingness to be vaccinated. This underlines the urgent need to sensibilize people with diabetes to infection risk and the importance of vaccination.

Impact of medication characteristics and adverse drug events on hospital admission after an emergency department visit: Prospective cohort study.

OBJECTIVES: Emergency department (ED) overcrowding is a problem for the delivery of adequate and timely emergency care. To improve patient flow and the admission process, the quick prediction of a patient's need for admission is crucial. We aimed to investigate the variables associated with hospitalisation after an ED visit, with a particular focus on the variables related to medication. METHODS: This prospective study was conducted from 2011 to 2018 in subacute medical ED of a French University Hospital. Specialised EDs (paediatric, gynaecologic, head and neck and psychiatric) and the outpatient unit of the ED were not included. Participation in this study was proposed to all adult patients who underwent a medication history interview with a pharmacist. Pharmacists conducted structured interviews for the completion of the medication history and the detection of adverse drug events (ADE). Relations between patient characteristics and hospitalisation were analysed using logistic regression. RESULTS: Among the 14 511 included patients, 5972 (41.2%) were hospitalised including 69 deaths. In total, 7458 patients (51.4%) took more than 5 medications and 2846 patients (19.6%) had an ADE detected during the ED visit. In hospitalised patients, bleeding (32.2%) and metabolic disorders (16.8%) were the most observed ADE symptoms. Variables associated with increased hospital admission included 2 demographic variables (age, male gender), 4 clinical variables (renal and hepatic failures, alcohol addiction, ED visit for respiratory reason) and 6 medication-related variables (medications >5, use of blood, systemic anti-infective, metabolism and antineoplastic/immunomodulating medications and ADE). CONCLUSION: We identified variables associated with hospitalisation including drug-related variables. These results point out the importance and the relevance of collecting medication data in a subacute medical ED (study registered on ClinicalTrials.gov, NCT03442010).

Clinical, Economic, and Organizational Impact of the Clinical Pharmacist in an Orthopedic and Trauma Surgery Department.

AIM: The aim of this study was to evaluate the clinical, economic, and organizational impact of clinical pharmacist services added to an adult orthopedic and trauma surgery unit in a university hospital. METHODS: This was a prospective, observational study performed from January to February 2017. All pharmacists' interventions were documented, and their clinical, economic, and organizational impact and the probability of adverse drug events (ADEs) were assessed using the clinical, economic and organizational scale three-dimensional scale. An expert panel composed of three clinical pharmacists, one surgeon and one anesthetist classified the pharmacist intervention. The potential clinical impact was determined through a consensus by the expert panel. Cost avoidance was calculated for serious ADEs with a major impact by avoiding an additional cost of €4912 per event and taking into account the probability of ADE occurrence. RESULTS: The pharmacists performed 1014 interventions for 28 days with a 95.3% acceptance rate by prescribers. Thirty-nine interventions were rated to have a major clinical impact (3.8%). The organizational impact was estimated favorable for 856 (84.4%) pharmacist interventions. Cost avoidance was estimated at €24,364, and the indirect costs benefit was estimated at €11,864 during the study. The cost-benefit ratio of the clinical pharmacist intervention was €1.94 in savings for every €1 invested. CONCLUSIONS: Clinical pharmacist services in an orthopedic and trauma surgery department have the potential to improve patient outcomes and avoid healthcare costs. Furthermore, the presence of a pharmacist in surgical units allows for communication between the unit and the pharmacy, which produces better fluidity and improves the quality of care.

Medication Errors at Hospital Admission and Discharge: Risk Factors and Impact of Medication Reconciliation Process to Improve Healthcare.

OBJECTIVE: First, the aim of the study was to assess the prevalence, characteristics, and severity of unintended medication discrepancies (UMDs) and medication errors (MEs) at admission and discharge of hospitalization. Second, the aim of the study was to identify clinical and hospitalization factors associated with risk of UMDs as well as characteristics of the medication reconciliation process associated with UMDs detection. METHODS: This prospective observational study included all adult patients admitted from 2013 to 2015 in the Endocrinology-Diabetology-Nutrition Department of Montpellier Hospital, France. Clinical pharmacists conducted medication reconciliation by collecting the best possible medication history from different sources and comparing it with admission and discharge prescriptions to identify discrepancies. Unintended medication discrepancies corrected by the physician were considered as MEs. Risk factors of UMDs were identified with logistic regression. RESULTS: Of 904 patients included, 266 (29.4%) had at least one UMD, at admission or at discharge. In total, 378 (98.2%) of 385 UMDs were considered to be MEs. Most MEs were omissions (59.3%). Medication errors were serious or very serious in 36% of patients and had potentially moderate severity in almost 40% of patients. The risk of UMDs increased constantly with the number of treatments (P < 0.001). Thyroid (adjusted odds ratio [OR] = 1.79, 95% CI = 1.12-2.86) and infectious diseases (adjusted OR = 1.80, 95% CI = 1.17-2.78) were associated with UMDs risk at admission. The best type of source for the detection of UMDs was the general practitioner or nurse (OR = 2.64, 95% CI = 1.51-4.63). CONCLUSIONS: Unintended medication discrepancies are frequent at hospital and depend on intrinsic clinical parameters but also on practice of medication reconciliation process, such as number and type of sources used.

Adverse Drug Events Detected by Clinical Pharmacists in an Emergency Department: A Prospective Monocentric Observational Study.

OBJECTIVES: Adverse drug events (ADEs) are a major public health issue in hospitals. They are difficult to detect because of incomplete or unavailable medication history. In this study, we aimed to assess the rate and characteristics of ADEs identified by pharmacists in an emergency department (ED) to identify factors associated with ADEs. METHODS: In this prospective observational study, we included consecutive adult patients presenting to the ED of a French 2600-bed tertiary care university hospital from November 2011 to April 2015. Clinical pharmacists conducted structured interviews and collected the medication history to detect ADEs (i.e., injuries resulting directly or indirectly from adverse drug reactions and noncompliance to medication prescriptions). Unsure ADE cases were reviewed by an expert committee. Relations between patient characteristics, type of ED visit, and ADE risk were analyzed using logistic regression. RESULTS: Among the 8275 included patients, 1299 (15.7%) presented to the ED with an ADE. The major ADE symptoms were bleeding, endocrine problems, and neurologic disorders. Moreover, ADEs led to the ED visit, hospitalization, and death in 87%, 49.3%, and 2.2% of cases, respectively. Adverse drug event risk was independently associated with male sex, ED visit for neurological symptoms, visit to the ED critical care unit, or ED short stay hospitalization unit, use of blood, anti-infective, antineoplastic, and immunomodulating drugs. CONCLUSIONS: This study improves the knowledge about ADE characteristics and on the patients at risk of ADE. This could help ED teams to better identify and manage ADEs and to improve treatment quality and safety.

Using the clinical information system and self-supervision to rationalize the need for antibiotic stewardship: An interventional study in a 2000-bed university hospital.

OBJECTIVES: To describe the usefulness of electronic medical records (EMRs) and a computerized physician order entry (CPOE) system to support and assess an antimicrobial stewardship programme (ASP). METHODS: At the study hospital, infectious diseases specialists supervise antimicrobial prescription when solicited by physicians in charge of patients. From January to October 2015, treatment days of antibiotic prescription, supervised or unsupervised by infectious disease specialists (SAP or UAP, respectively) in all wards, except intensive care units emergency department, bone marrow transplantation units, and paediatric units, were calculated. Embedding recommendations on carbapenem indications as a checklist into the CPOE system, a self-administered ASP was implemented in 2017. EMRs were reviewed to determine global compliance with carbapenem prescription guidelines (combining introduction of therapy and 72-h assessment) before and after implementation of a self-administered ASP in departments with a low SAP rate for these antibiotics. RESULTS: Among 16 090 prescriptions extracted, 19.9% were SAPs. Three patterns of prescription were identified. The first pattern (amoxicillin-clavulanate, ceftriaxone) was characterized by a high UAP rate in every department, the second pattern (cloxacillin, rifampin) was characterized by a high SAP rate in every department, and the third pattern (broad-spectrum beta-lactams) was characterized by heterogeneous distribution of SAP/UAP among departments. Carbapenem prescription was reviewed in five departments with a low SAP rate for carbapenems over 6 months: 94 before and 107 after implementation of the self-administered ASP. Global compliance with guidelines increased significantly from 22% to 37% (risk difference 15%, 95% confidence interval 2.3-28.5%; P=0.02). CONCLUSION: A clinical information system may help to rationalize antibiotic stewardship in a context of scarce medical resources. Mapping of antibiotic prescriptions and self-supervision are efficient, complementary and easy-to-implement tools.

Development and validation of a score to assess risk of medication errors detected during medication reconciliation process at admission in internal medicine unit: SCOREM study.

BACKGROUND: Medication errors (ME) can be reduced through preventive strategies such as medication reconciliation. Such strategies are often limited by human resources and need targeting high risk patients. AIMS: To develop a score to identify patients at risk of ME detected during medication reconciliation in a specific population from internal medicine unit. METHODS: Prospective observational study conducted in an internal medicine unit of a French University Hospital from 2012 to 2016. Adult hospitalised patients were eligible for inclusion. Medication reconciliation was conducted by a pharmacist and consisted in comparing medication history with admission prescription to identify MEs. Risk factors of MEs were analysed using multivariate stepwise logistic regression model. A risk score was constructed using the split-sample approach. The split was done at random (using a fixed seed) to define a development data set (N = 1256) and a validation sample (N = 628). A regression coefficient-base scoring system was used adopting the beta-Sullivan approach (Sullivan's scoring). RESULTS: Pharmacists detected 740 MEs in 368/1884 (19.5%) patients related to medication reconciliation. Female gender, number of treatments >7, admission from emergency department and during night or weekend were significantly associated with a higher risk of MEs. Risk score was constructed by attributing 1 or 2 points to these variables. Patients with a score ≥3 (OR [95% CI] 3.10 [1.15-8.37]) out of 5 (OR [95% CI] 8.11 [2.89-22.78]) were considered at high risk of MEs. CONCLUSIONS: Risk factors identified in our study may help prioritising patients admitted in internal medicine units who may benefit the most from medication reconciliation (ClinicalTrials.gov number NCT03422484).

Hypoglycemia While Driving in Insulin-Treated Patients: Incidence and Risk Factors.

OBJECTIVES: This study aimed to investigate a potential daily-life concern for patients with diabetes hypoglycemia while driving by (1) estimating their incidence in insulin-treated drivers, (2) determining factors associated with their occurrence, and (3) analyzing patients' behavior regarding prevention of hypoglycemia. METHODS: We conducted an observational study from November 2013 to May 2018 in the endocrinology-diabetology-nutrition department of our university hospital. All patients treated for diabetes older than 18 years admitted in the department were eligible. A specific questionnaire assessing attitudes, knowledge, and consequences of hypoglycemia was provided. In this study, only insulin-treated patients who regularly drive were analyzed. RESULTS: On the 233 insulin-treated drivers included, 45 (19%) self-reported at least 1 hypoglycemia while driving in the preceding year. Two factors were significantly associated with their occurrence: type 1 diabetes (odds ratio [OR] = 3.19; 95% confidence interval [CI] = 1.55-6.57) and experiences of asymptomatic hypoglycemia (OR = 2.20; 95% CI = 1.05-4.63). Awareness of the treatment hypoglycemia risk because of information provided by a medical specialist was also but nonsignificantly associated with hypoglycemia while driving (OR = 2.61; 95% CI = 0.86-7.92). Forty-one patients (18%) combined those 3 variables, 20 (49%) of them self-reported hypoglycemia while driving. Thirty-four percent of the patients never carried carbohydrates for hypoglycemia correction. Seventy-six percent do not monitor blood glucose level before driving. CONCLUSIONS: Our questionnaire allowed us to highlight that 19% our cohort of insulin-treated drivers declared experiencing hypoglycemia while driving. Risk factors identified and prevention data collected should help us better target patient education.

Acute kidney injury during daptomycin versus vancomycin treatment in cardiovascular critically ill patients: a propensity score matched analysis.

BACKGROUND: Gram-positive organisms are a leading cause of infection in cardiovascular surgery. Furthermore, these patients have a high risk of developing postoperative renal failure in intensive care unit (ICU). Some antibiotic drugs are known to impair renal function. The aim of the study was to evaluate whether patients treated for Gram-positive cardiovascular infection with daptomycin (DAP) experienced a lower incidence of acute kidney injury (AKI) when compared to patients treated with vancomycin (VAN), with comparable efficacy. METHODS: ICU patients who received either DAP or VAN, prior to or after cardiovascular surgery or mechanical circulatory support, from January 2010 to December 2012, were included in this observational retrospective cohort study. We excluded patients with end stage renal disease and antibiotic prophylaxis. The primary endpoint was the incidence of AKI within the first week of treatment. Secondary endpoints were the incidence of AKI within the first 14 days of treatment, the severity of AKI including renal replacement therapy (RRT), the rates of clinical failure (unsuccessful infection treatment) and of premature discontinuation and mortality. To minimize selection bias, we used a propensity score to compare the 2 groups. Univariate and multivariate analysis were performed to determine factors associated with AKI. RESULTS: Seventy two patients, treated for infective endocarditis, cardiovascular foreign body infection, or surgical site infection were included (DAP, n = 28 and VAN, n = 44). AKI at day 7 was observed in 28 (64%) versus 6 (21%) of the VAN and DAP patients, respectively (p = 0.001). In the multivariate analysis adjusted to the propensity score, vancomycin treatment was the only factor associated with AKI (Odds Ratio 4.42; 95% CI: 1.39-15.34; p = 0.014). RRT was required for 2 (7%) DAP patients and 13 (30%) VAN patients, p = 0.035. Premature discontinuation and clinical failure occurred more frequently in VAN group than in DAP group (25% versus 4%, p = 0.022 and 42% versus 12%, respectively, p = 0.027). CONCLUSIONS: Daptomycin appears to be safer than vancomycin in terms of AKI risk in ICU patients treated for cardiovascular procedure-related infection. Daptomycin could be considered as a first line treatment to prevent AKI in high-risk patients.

Non-achievement of LDL-cholesterol targets in patients with diabetes at very-high cardiovascular risk receiving statin treatment: Incidence and risk factors.

BACKGROUND: Cardiovascular diseases are the first cause of mortality in patients with diabetes, and LDL-cholesterol is a well-established cardiovascular risk factor. This study aimed to assess rate of LDL-cholesterol target attainment among patients with diabetes at very-high cardiovascular risk treated with statins, and to identify predictive factors of non-attainment of target in this population. METHODS: Patients were recruited in the Nutrition-Diabetes unit of Montpellier University Hospital, France, from 2014 to 2017. We included all consecutive patients with type 1 or type 2 diabetes receiving statin treatment and at very-high cardiovascular risk according to 2016 ESC guidelines, therefore having a LDL-cholesterol target of <1.8 mmol/L. LDL-cholesterol levels were measured upon admission. Variables independently associated with non-attainment of LDL-Cholesterol target were assessed using multivariable logistic regression. RESULTS: 654 patients were included. Mean age was 63.8 years (SD 11.0), 41.9% were women and 42.3% had a history of cardiovascular disease. 59% of patients did not achieve LDL-cholesterol target, with a median value (interquartile range) of 2.4 mmol/L (2.1-2.9) versus 1.4 mmol/L (1.1-1.6) in patients at target. Risk of non-attainment of LDL-cholesterol target value was increased in women (odds ratio [95% confidence interval]: 2.27 [1.62-3.17]) and decreased in patients with history of coronary artery disease (0.64 [0.45-0.89]) or history of stroke or transient ischemic attack (0.59 [0.33-1.07]). CONCLUSIONS: Management of dyslipidemia is suboptimal, even in very-high risk patients with diabetes under statins. Lipid-lowering treatment should be intensified, in particular in very high risk patients with diabetes who are women or in primary cardiovascular prevention. Clinical Trial number: NCT03449784.

Leech management before application on patient: a nationwide survey of practices in French university hospitals.

Background: Leech therapy in plastic/reconstructive microsurgery significantly improves a successful outcome of flap salvage but the drawback is a risk of severe infection that results in a drop of the salvage rates from 70-80% to below 30%. We report the results of a national survey conducted in all the French university hospitals to assess the current extent of use of leech for medical practices in the hospital and to investigate maintenance, delivery practices and prevention of the risk of infection. Methods: Data concerning conditions of storage, leech external decontamination, microbiological controls, mode of delivery and antibiotic prophylaxis were collected from all the French university hospitals in practicing leech therapy, on the basis of a standardized questionnaire. Results: Twenty-eight of the 32 centers contacted filled the questionnaire, among which 23 practiced leech therapy, mostly with a centralized storage in the pharmacy; 39.1% of the centers declared to perform leech external decontamination and only 2 centers recurrent microbiological controls of the water storage. Leech delivery was mostly nominally performed (56.5%), but traceability of the leech batch number was achieved in only 39.1% of the cases. Only 5 centers declared that a protocol of antibiotic prophylaxis was systematically administered during leech therapy: either quinolone (2), sulfamethoxazole/trimethoprim (2) or amoxicillin/clavulanic acid (1). Conclusions: Measures to prevent infectious complications before application to patient have to be better applied and guidelines of good practices are necessary.

Patients with diabetes are at high risk of serious medication errors at hospital: Interest of clinical pharmacist intervention to improve healthcare.

BACKGROUND: Medication errors (ME) are major public health issues in hospitals because of their consequences on patients' morbi-mortality. This study aims to evaluate the prevalence of ME at admission and discharge of hospitalization in diabetic and non-diabetic patients, and determine their potential clinical impact. METHOD: This prospective observational study was conducted at the Endocrinology-Diabetology-Nutrition Department. All adult patients admitted were eligible. A total of 904 patients were included, of which 671 (74.2%) with diabetes mellitus. Clinical pharmacists conducted medication reconciliation: they collected the Best Possible Medication History and then compared it with admission and discharge prescriptions to identify medication discrepancies. ME were defined as unintended medication discrepancies if corrected by the physician. RESULTS: Clinical pharmacists allowed correcting ME in 176/904 (19.5%) patients at admission and in 86/865 (9.9%) patients at discharge. More than half of ME were omissions. Diabetic patients were more affected by ME than non-diabetic patients, both at admission (22.1% vs 12.0%, p<0.001) and at discharge (11.4% vs 5.7%, p=0.01). The diabetic group also had more potentially severe and very severe ME. Diabetic patients had on average twice more medications than non-diabetic patients (8.7±4.5 vs 4.4±3.4, p<0.001). The polypharmacy associated with diabetes, but not diabetes mellitus itself, was identified as a risk factor of ME. CONCLUSIONS: The intervention of clinical pharmacists allowed correcting 378 ME in 25.8% of the cohort before they caused harm. Clinicians, pharmacists and other health care providers should therefore work together to improve patients' safety, in particular in high-risk patients such as diabetic patients.