Late delivery of antibiotics: a new proxy for antimicrobial stewardship?

OBJECTIVES: To analyse the time elapsed between the prescription of antibiotics and their pick-up at the pharmacy and identify their determinants. METHODS: We used the National Health Insurance reimbursement databases on antibiotics delivery in 2021 in La Manche, Western France. Delayed delivery was defined as the time between prescription and antibiotic pick-up of >24 hours. RESULTS: We enrolled 207 250 prescriptions, of whom 18 728 (9.0%) collected their antibiotics at the community pharmacy >24 hours after prescription. Independent factors associated with delayed delivery were age >15 years (15-64 years: OR, 2.08 [1.98-2.19]; p < 0.001 and >65 years OR, 3.27 [3.09-3.46]; p < 0.001), male sex (OR, 00.77 [0.75-0.80]; p < 0.001), low income (OR, 1.08 [1.02-1.15]; p = 0.013), chronic diseases (OR, 1.29 [1.25-1.34]; p < 0.001), prescription during the weekend (OR, 1.49 [1.43-1.56]; p < 0.001), summer season (OR, 1.11 [1.07-1.16]; p < 0.001), lock-down period (OR, 4.15 [3.80-4.53]; p < 0.001), and distance from the patient home to his general practitioner office and the pharmacy >10 km (OR, 1.17 [1.13-1.21]; p < 0.001). DISCUSSION: The delayed delivery of antibiotics after prescription is not uncommon, especially in elderly patients, those with low income or chronic diseases, in case of weekend prescriptions, summer season and when the pharmacy is > 10 km away from the patient's home and his general practitioner office. If confirmed, this potential indicator of unnecessary prescriptions, readily available in some databases, may be used to target antimicrobial stewardship programmes and monitor the effect of interventions.

Benefits and harms of perioperative high fraction inspired oxygen for surgical site infection prevention: a protocol for a systematic review and meta-analysis of individual patient data of randomised controlled trials.

INTRODUCTION: The use of high fraction of inspired oxygen (FiO2) intraoperatively for the prevention of surgical site infection (SSI) remains controversial. Promising results of early randomised controlled trials (RCT) have been replicated with varying success and subsequent meta-analysis are equivocal. Recent advancements in perioperative care, including the increased use of laparoscopic surgery and pneumoperitoneum and shifts in fluid and temperature management, can affect peripheral oxygen delivery and may explain the inconsistency in reproducibility. However, the published data provides insufficient detail on the participant level to test these hypotheses. The purpose of this individual participant data meta-analysis is to assess the described benefits and harms of intraoperative high FiO2compared with regular (0.21-0.40) FiO2 and its potential effect modifiers. METHODS AND ANALYSIS: Two reviewers will search medical databases and online trial registries, including MEDLINE, Embase, CENTRAL, CINAHL, ClinicalTrials.gov and WHO regional databases, for randomised and quasi-RCT comparing the effect of intraoperative high FiO2 (0.60-1.00) to regular FiO2 (0.21-0.40) on SSI within 90 days after surgery in adult patients. Secondary outcome will be all-cause mortality within the longest available follow-up. Investigators of the identified trials will be invited to collaborate. Data will be analysed with the one-step approach using the generalised linear mixed model framework and the statistical model appropriate for the type of outcome being analysed (logistic and cox regression, respectively), with a random treatment effect term to account for the clustering of patients within studies. The bias will be assessed using the Cochrane risk-of-bias tool for randomised trials V.2 and the certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluation methodology. Prespecified subgroup analyses include use of mechanical ventilation, nitrous oxide, preoperative antibiotic prophylaxis, temperature (<35°C), fluid supplementation (<15 mL/kg/hour) and procedure duration (>2.5 hour). ETHICS AND DISSEMINATION: Ethics approval is not required. Investigators will deidentify individual participant data before it is shared. The results will be submitted to a peer-review journal. PROSPERO REGISTRATION NUMBER: CRD42018090261.

Evolution of the incidence of COVID-19 during the first five waves in residents and professionals of nursing homes in Normandy, France.

BACKGROUND: Older adults living in nursing homes (NH) paid a heavy price to the COVID-19 pandemic, despite early and often drastic prevention measures. AIMS: To study the characteristics and the impact of the pandemic on NH residents and professionals over 2 years. METHODS: Cross-sectional study of COVID-19 clusters among residents and/or professionals in NH, from March 2020 to February 2022, in Normandy, France. We used data from the French mandatory reporting system, and cross-correlation analysis. RESULTS: The weekly proportion of NH with clusters was strongly correlated with population incidence (r > 0.70). Attack rates among residents and professionals were significantly lower in period 2 (vaccination rate in residents ≥ 50%) compared with periods 1 (waves 1 and 2) and 3 (Omicron variant ≥ 50%). Among residents, mortality and case fatality rates decreased drastically during periods 2 and 3. CONCLUSION: Our study provides figures on the evolution of the pandemic in NH.

Proton Pump Inhibitor Use and Associated Infectious Complications in the PICU: Propensity Score Matching Analysis.

OBJECTIVES: We aimed to evaluate the association between proton pump inhibitor (PPI) exposure and nosocomial infection (NI) during PICU stay. DESIGN: Propensity score matched analysis of a single-center retrospective cohort from January 1, 2017, to December 31, 2018. SETTING: Tertiary medical and surgical PICU in France. PATIENTS: Patients younger than 18 years old, admitted to the PICU with a stay greater than 48 hours. INTERVENTION: Patients were retrospectively allocated into two groups and compared depending on whether they received a PPI or not. MEASUREMENTS AND MAIN RESULTS: Seven-hundred fifty-four patients were included of which 231 received a PPI (31%). PPIs were mostly used for stress ulcer prophylaxis (174/231; 75%), but upper gastrointestinal bleed risk factors were rarely present (18%). In the unadjusted analyses, the rate of NI was 8% in the PPI exposed group versus 2% in the nonexposed group. After propensity score matching ( n = 184 per group), we failed to identify an association between PPI exposure and greater odds of NI (adjusted odds ratio 2.9 [95% CI, 0.9-9.3]; p = 0.082). However, these data have not excluded the possibility that there is up to nine-fold greater odds of NI. CONCLUSIONS: This study highlights the prevalent use of PPIs in the PICU, and the potential association between PPIs and nine-fold greater odds of NI is not excluded.

Professional practice for COVID-19 risk reduction among health care workers: A cross-sectional study with matched case-control comparison.

BACKGROUND: Health care workers (HCWs) are particularly exposed to COVID-19 and therefore it is important to study preventive measures in this population. AIM: To investigate socio-demographic factors and professional practice associated with the risk of COVID-19 among HCWs in health establishments in Normandy, France. METHODS: A cross-sectional and 3 case-control studies using bootstrap methods were conducted in order to explore the possible risk factors that lead to SARS-CoV2 transmission within HCWs. Case-control studies focused on risk factors associated with (a) care of COVID-19 patients, (b) care of non COVID-19 patients and (c) contacts between colleagues. PARTICIPANTS: 2,058 respondents, respectively 1,363 (66.2%) and 695 (33.8%) in medical and medico-social establishments, including HCW with and without contact with patients. RESULTS: 301 participants (14.6%) reported having been infected by SARS-CoV2. When caring for COVID-19 patients, HCWs who declared wearing respirators, either for all patient care (ORa 0.39; 95% CI: 0.29-0.51) or only when exposed to aerosol-generating procedures (ORa 0.56; 95% CI: 0.43-0.70), had a lower risk of infection compared with HCWs who declared wearing mainly surgical masks. During care of non COVID-19 patients, wearing mainly a respirator was associated with a higher risk of infection (ORa 1.84; 95% CI: 1.06-3.37). An increased risk was also found for HCWs who changed uniform in workplace changing rooms (ORa 1.93; 95% CI: 1.63-2.29). CONCLUSION: Correct use of PPE adapted to the situation and risk level is essential in protecting HCWs against infection.

Healthcare associated coronavirus disease 2019 among health care workers in Normandy, France: a multi-center study.

INTRODUCTION: In the early phase of the coronavirus disease (COVID-19) epidemic in France, knowledge of SARS-COV-2 characteristics was limited, and personal protective equipment (PPE) was lacking. Thus, health care workers (HCWs) were exposed to nosocomial transmission. METHODS: A multicenter regional descriptive study of fifty-two heath care facilities covering 30,533 HCWs in western Normandy, France, from March 3 to March 27, 2020, before the incidence threshold of 10/100,000 inhabitants was crossed in the study area. The incidence rate of COVID-19 in HCWs, the attack rates and the serial interval distribution of nosocomial transmission were computed. Demographic characteristics of HCWs, contacts with index cases, and the use of personal protective equipment were collected by a structured questionnaire. RESULTS: The incidence rate of COVID-19 in HCWs was 2.7‰. Among 19 situations (13 clusters >2 cases), 10 were HCW-HCW and 9 patient-HCW transmission, the global attack rate was 13.7% (95% confidence interval, 10.6%-17.3%), and 68 HCWs were involved (10 index cases, with 58 secondary cases). Exposure of secondary cases was only in the presymptomatic phase of the index case in 29% of cases, 48% for HCW-HCW and 10% for patient-HCW transmission (P<0.001). The mean serial interval was 5.1 days (95% CI, 4.2-5.9 days). Preventative measures were not optimal. CONCLUSIONS: Our investigation demonstrated that HCWs who were not assigned to the care of COVID-19 patients were not prepared for the arrival of this particularly insidious new virus, which spread rapidly from an often asymptomatic colleague or patient.

Impact of maternal underweight on obstetric and neonatal prognosis: A retrospective study.

INTRODUCTION: Maternal underweight (BMI < 18.5) is an uncommon situation with potentially serious obstetric consequences, though data in the literature are scarce. OBJECTIVE: To compare the obstetrical prognosis of patients with normal BMI and BMI < 18.5. STUDY DESIGN: We performed a retrospective study in France (Normandy). RESULTS: We included 14,246 patients between January 2011 and November 2017, among whom 12,648 (88.8 %) had normal BMI, 1269 were considered mild underweight (17 ≤ BMI < 18.5 kg/m²) and 329 (2.3 %) were considered severe to moderate underweight (BMI < 17 kg/m²). The risk of preterm birth was all the greater as the thinness was severe (ORa: 1.34 [1.12-1.60] and ORa 1.77 [1.31-2.34]) and the risk of intrauterine growth retardation also increased with severe thinness (ORa: 1.63 [1.35-1.96] and ORa 2.28 [1.69-3.07]). The risk of a caesarean section or scheduled labour was no different. Neonatal parameters were comparable between the groups. CONCLUSION: Our study confirms an increased risk of preterm delivery and intrauterine growth retardation with increased thinness after adjusting for confounding factors. This link had only been shown previously in 2 studies Neither the type of prematurity (induced or spontaneous) nor the severity of prematurity is influenced by the severity of thinness; however, the low prevalence of thinness limits the power of these data. It would be interesting to study the medico-economic relevance of a policy of close maternal-foetal surveillance in this target population.

Maternal obesity in prolonged pregnancy: Labor, mode of delivery, maternal and fetal outcomes.

INTRODUCTION: Obesity is currently not a medical indication for elective induction of labor although obese patients may not be eligible for expectant management after 41 W G. Few data on labor and complications in this population undergoing prolonged pregnancy are known. The objective of our study was to evaluate labor, mode of delivery, maternal and fetal outcomes in prolonged pregnancy in obese patients compared to normal body mass index (BMI). MATERIALS AND METHODS: It was a retrospective cohort study in patients who, after prolonged pregnancy gave birth to a single fetus, in cephalic presentation, between the first of January 2002 and December 31, 2018 in the Caen University Hospital Center. Patient's characteristics were compared within each BMI class using uni- and multivariate analysis with regression logistics models. RESULTS: Overall, 9159 patients were included. Term of birth and spontaneous labor calculated rates were significantly increased in case of obesity (p < 0.001). The adjusted Odds Ratio (ORa) for induced labor in class III obesity was 1.73 [1.13-2.66]. After induction of labor, 83.0 % patients with normal BMI delivered vaginally versus 61.8 % in case of class III obesity (p < 0.001). The ORa for an emergency cesarean was 3.39 [2.04-5.63] and 1.78 [1.06-2.99] for neonatal morbidity in class III obesity. CONCLUSION: Morbid obese patients do not belong to a low risk patient's group when pregnancy is prolonged. Elective induction in case of morbid obesity may entail less risk than allowing the pregnancy to progress after 41 W G or even 39 W G. Further randomized prospective studies are nevertheless required.

General practitioners' clinical practice on the management of cystitis in Normandy, France: A clinical vignettes-based study.

RATIONALE, AIMS, AND OBJECTIVES: The objective was to measure the quality of clinical practice for the management of cystitis in adult women in general practice by collaborating with quality circles and the regional centre for antibiotic counsel. METHOD: This descriptive cross-sectional study was performed in 2018 in Normandy, France. A questionnaire composed of clinical vignettes was used to evaluate practices of general practitioners (GPs) with regard to cystitis classified into four categories: simple, at risk of complication, recurrent, and caused by multidrug-resistant bacteria. The 2017 French Infectious Diseases Society's guidelines were used as a reference. RESULTS: A total of 142 GPs participated in the study (45.5% of the solicited). Fosfomycin-trometamol and pivmecillinam were cited as first-line treatments for simple cystitis by 134 (94%) and 38 (27%) participants, respectively. For at risk of complication cystitis, the treatments cited were cefixime by 64 participants (45%), ofloxacin by 50 (35%), pivmecillinam by 49 (35%), fosfomycin-trometamol by 38 (27%), nitrofurantoin by 36 (25%), and amoxicillin-clavulanic acid by 28 (20%). Mean compliance rates were 85% for simple cystitis, 39% for at risk of complication cystitis, 60% for recurrent cystitis and 14% for cystitis caused by multidrug-resistant bacteria. Two criteria had less than 10% of the compliant answers: comprehensive knowledge of cystitis complication risk factors (9%) and positivity thresholds of urine cultures (10%). CONCLUSIONS: In this study, diagnostic means, follow-up testing, and simple cystitis treatment (with fosfomycin predominantly mentioned) were broadly compliant. The use of critical antibiotics was too frequent for at risk of complication cystitis. There may be a need to improve the knowledge of professionals on antibiotic resistance and appropriate antibiotic use.

Effectiveness of an intervention campaign on influenza vaccination of professionals in nursing homes: A cluster-randomized controlled trial.

BACKGROUND: Seasonal influenza has a major individual and collective impact, especially among the elderly living in nursing homes. To prevent infection by influenza viruses, vaccination of residents and professionals is an essential measure. However, while the vaccination rates of residents are generally high (>85%), rates among professionals are generally approximately 20%. To evaluate the effectiveness of an intervention campaign on the improvement of the influenza vaccination rate of professionals, a regional intervention study was proposed for nursing homes during the 2014-15 season. METHODS: Cluster-randomized controlled trial (with a nursing home representing a cluster). In the intervention group, a campaign on influenza vaccination was offered to staff, combining different teaching aids in a multimodal approach. In the control group, no intervention was proposed. The primary endpoint was the rate of influenza vaccination among staff. Before and after the study, professionals were asked to complete short questionnaires on their perceptions of influenza vaccination. A multilevel analysis was carried out to compare the vaccination rates between the 2 groups and their evolution before/after the winter period. RESULTS: A total of 32 nursing homes were randomized, and 6 were excluded. Initial vaccination rates were 27.6% in the intervention group and 24.2% in the control group (p = 0.16). After the study, these rates increased to 33.7% and 22.9%, respectively, which was a relative difference of +22.1% in the intervention group compared to -5.4% in the control group, p = 0.0025. CONCLUSIONS: Despite professionals' reluctance to be vaccinate, participation in a promotional campaign with a pragmatic approach has increased the rate of influenza vaccination. The approach will be offered to all nursing homes in the region after revision of the tools to enhance their ease of use and pedagogical messages focused on the direct benefits to professionals.

Hemodialysis in satellite dialysis units: incidence of patient fallback to the in-center dialysis unit.

BACKGROUND: Patient fallbacks occur when a patient treated in a satellite dialysis unit (SDU) must be transferred to an in-center dialysis unit. Fallbacks have an impact on the in-center dialysis unit organization. This study was carried out to estimate the incidence and risk factors of patient fallback. METHODS: Between 01/01/2006 and 31/12/2010 there were 193 patients starting dialysis in SDUs in one French region. The primary outcome was the incidence of temporary and permanent fallbacks with or without hospitalization. A survival analysis and binomial negative regression were used for the statistical analysis. RESULTS: Among the 193 patients, 117 (60.6%; 95% confidence interval [CI]: 53.3-67.6) had at least one fallback, which occurred within a median of 249 days (interquartile range [IQR]: 71-469) after the first session in the SDU. The median number of fallbacks by subject was 1 (IQR: 0-4). The median duration of the fallback period was 4 days (IQR: 1-8) and median number of dialysis sessions during the fallback time was 1 (IQR: 1-3). Of the 494 temporary fallbacks, 210 were due to patient hospitalization, the main cause of which was cardiovascular disease. At univariate analysis, patients permanently transferred to in-center hemodialysis units were older, had more peripheral arteriopathy, cancer and arrhythmia. At multivariate analysis, peripheral arteriopathy (relative risk [RR] 2.06, 95% CI 1.05-4.09) and the center (center 2: RR 0.42, 95% CI 0.21-0.84; center 3: RR 2.88, 95% CI 1.20-6.91) were significantly associated with the number of fallbacks. CONCLUSION: Fallback is a common event in hemodialysis patients treated in SDUs. Yet, the SDU system operates well since a third of patients treated in these units are still in SDUs at 2 years of follow-up. Factors associated with patient fallback are the center and cardiovascular disease.

Frequency, causes and avoidability of outborn births in a French regional perinatal network.

OBJECTIVES: To evaluate the rate and circumstances of outborn deliveries within a French perinatal network, and to determine their avoidability. STUDY DESIGN: Cohort study including preterm infants <33 weeks gestation and/or weighing <1500g born outside a level III maternity unit in Lower Normandy region, France, in 2008-2010. In 2008 and 2009, only neonates transferred to the Caen University Teaching Hospital (CHU) were included. In 2010, all outborn neonates in the region were included by means of a medical information system program. A panel of 7 experts was set up to determine the avoidability of each outborn case using a two-stage modified Delphi procedure. Inter-expert agreement was evaluated using the kappa index. RESULTS: Sixty-four cases (71 neonates) were included. The outborn rate in 2010 was 16.1% (40/248, 95% CI (116-207%)). The most common reason for delivery was spontaneous onset of labour (57.8%). In 12 cases, the place of birth (level 2b maternity unit) was considered to be appropriate by the experts (term ≥32WG), but 8 cases involved infants of low birth weight (<1500g). For the 52 cases born in inappropriate sites, 9.6% were considered to be avoidable (kappa index=0.42 (p<10-3)). CONCLUSION: Our outborn rate meets regionalisation targets. Our method of expert evaluation identified a small percentage of avoidable births in inappropriate sites. Regular reassessment of obstetric practices and good coordination between network actors are crucial to improve the management of pregnancies at risk of outborn delivery.

Enterobacteriaceae surgical site infection after cardiac surgery: the hypothetical role of vancomycin.

BACKGROUND: In the middle of October 2011, the Hygiene Department of Caen University Hospital suspected an outbreak of surgical site infections (SSI) after open-heart operations with an unusually high proportion of microorganisms belonging to the Enterobacteriaceae family. The attack rate was 3.8%, significantly different (p = 0.035) from the attack rate of 1.2% in 2010 over the equivalent period. A case-control study was conducted to search specifically for risk factors for Enterobacteriaceae infections after median sternotomy in cardiac patients. METHODS: Case patients were defined retrospectively as patients with superficial or deep surgical site infection with Enterobacteriaceae within 30 days of median sternotomy. Four control patients were selected per case patient from patients matched for date of operation (± 15 days) and European System for Cardiac Operative Risk Evaluation (<5, [5-10], >10). RESULTS: Univariate analysis identified the following risk factors: inappropriate skin preparation on the morning of the intervention (p = 0.046), use of vancomycin (p = 0.030), and number of sternotomy dressings (p = 0.033). A multivariate logistic regression analysis found that vancomycin use was independently associated with an increased risk of postoperative SSI with Enterobacteriaceae (p = 0.019; odds ratio = 7.4). CONCLUSIONS: Although vancomycin is known to be effective for preventing infection with methicillin-sensitive organisms, our results suggest that it was associated with a risk for the development of SSI with gram-negative organisms after median sternotomy. This study led to a multidisciplinary meeting that defined new guidelines for prophylactic antibiotic therapy before open-heart operations.

Effect of perioperative oxygen supplementation on 30-day surgical site infection rate in abdominal, gynecologic, and breast surgery: the ISO2 randomized controlled trial.

BACKGROUND: Benefits and limitations of supplementation with 80% fraction of inspired oxygen for preventing surgical site infections have not yet been clearly defined. Some studies have reported benefits in colorectal surgery, whereas trials in abdominal and gynecologic surgery have reported either no effect or a deleterious effect. METHODS: Controlled, randomized, assessor-blind multicenter trial, the ISO2 study, comparing the effects of hyperoxygenation (fraction of inspired oxygen, 80%) with those of 30% oxygen on the frequency of surgical site infections in routine abdominal, gynecologic, and breast surgery on 434 patients. Patients not seen in consultation after discharge were contacted. RESULTS: In total, 208 patients received 30% perioperative oxygen and 226 received 80%. There was no difference between the two groups for baseline, intraoperative, and postoperative characteristics, except for oxygen saturation at closure, higher in the 80% group (P=0.01). The frequency of 30-day surgical site infections was 7.2% (15/208) in the 30% group and 6.6% (15/226) in the 80% group (relative risk, 0.92; 95% CI [0.46-1.84], P=0.81). Frequency of adverse events (nausea and vomiting, sternal pain, cough, hypotension) was similar in the two groups. Desaturation and bradycardia were more frequent in the 30% group. In an updated meta-analysis including the result of this trial and those of eight published randomized trials, the overall relative risk was 0.97; 95% CI (0.68-1.40), I2 (inconsistency degree)=73%, (P=0.88). CONCLUSIONS: The routine use of hyperoxygenation throughout abdominal, gynecologic, and breast surgery had no effect on the frequency of 30-day surgical site infections and was not accompanied by more frequent adverse effects.

Long-term clinical and economic benefits associated with the management of a nosocomial outbreak resulting from extended-spectrum beta-lactamase-producing Klebsiella pneumoniae.

OBJECTIVE: In 2005, there was an epidemic of infections resulting from extended-spectrum ß-lactamase-producing Klebsiella pneumoniae in the intensive care department. The aim of this study was to evaluate the potential long-term clinical and economic benefits resulting from the management of this epidemic and the resulting changes in practices. DESIGN: Two periods were defined: the period leading up to and including the epidemic (2003-2005; period I) and the postepidemic period (2006-2008; period II). We estimated the number of nosocomial infections prevented between these two periods in three ways: comparison of attack rates, incidence rates, and calculation of standardized infection ratios. A cost-benefit analysis was then carried out by multiplying the number of nosocomial infections prevented by their cost as estimated from a literature review. MEASUREMENTS AND MAIN RESULTS: The characteristics of the populations hospitalized during these two periods were comparable in terms of age, sex, Simplified Acute Physiologic Scale II score, origin, and type of diagnosis. The death rate was similar in the two periods (21.8% vs. 23.3%; p = .63). The number of nosocomial infections prevented was 54.1 (95% confidence interval 25.8-83.1; 30.4, 95% confidence interval 5.3-54.9; 32.8, 95% confidence interval 6.0-63.7; and 30.1, 95% confidence interval 17.7-42.5) according to the methodology. The savings cost potentially associated with the infection control intervention ranged from €149,928 (USD $183,781) to €269,472 (USD $330,318). CONCLUSION: The management of this epidemic and the change in medical practices that it triggered were associated with a significant decrease in the number of infections acquired in the intensive care unit. There were substantial cost savings, highlighting the value of investment in the prevention of nosocomial infections.

Surgical site infection associated with the use of bovine serum albumine-glutaraldehyde surgical adhesive (BioGlue) in cranial surgery: a case-control study.

PURPOSE: To enhance the water tightness of dura mater closure in cranial surgery, an organic glue called BioGlue was used in our neurosurgical department between January 2006 and June 2007. During this period of time, we noticed an important increase in the surgical site infection (SSI) incidence. We conducted a case-control study to identify risk factors for these infections. Our objective was to test the hypothesis that BioGlue was one of the risk factors. METHODS: Cases with infection were defined retrospectively. We included two controls per case. Study data were age, sex, time of year, in stay hospital preoperative time, length of surgery, type of surgery, surgeon, use of BioGlue, and use of duraplasty. We first performed a univariate analysis and then the significant variables were introduced in a logistic regression model. RESULTS: Thirty patients were defined as cases (60 controls). In multivariate analysis, risk factors were young age (p = 0.04), extended operative length (p = 0.02) and the use of BioGlue (p = 0.007). The combined use of BioGlue and Neuropatch appeared to be a significant risk factor for SSI (p = 0.002). CONCLUSIONS: BioGlue seems to increase the risk of SSI for patients who underwent craniotomy, especially when associated with synthetic dural graft. BioGlue triggers an intense inflammatory response, which causes wound breaches allowing bacteria to spread down in the wound, and then creates an ideal environment for bacterial growth.

Elevated D-dimer level in the differential diagnosis of venous malformations.

OBJECTIVE: To evaluate if elevated D-dimer level is specific for venous malformations (VMs) and thus useful for differential diagnosis, which can be problematic even in specialized interdisciplinary centers. Localized intravascular coagulopathy, characterized by elevated D-dimer levels, has been observed in approximately 40% of patients with VMs. DESIGN: Prospective convenience sample accrued from 2 interdisciplinary sites. SETTING: Two interdisciplinary centers for vascular anomalies in Brussels, Belgium, and Caen, France PARTICIPANTS: The study population comprised 280 patients with clinical data, Doppler ultrasonograms (for 251 patients), and coagulation parameter measurements. Main Outcome Measure Measurement of D-dimer levels. RESULTS: A VM was diagnosed in 195 of 280 patients (69.6%), and 83 of them had elevated D-dimer levels; the sensitivity of D-dimer dosage was 42.6% (95% confidence interval, 35.6%-49.5%). Among the 85 patients without VM, D-dimer levels were elevated only in 3 patients; the specificity of the dosage was 96.5% (95% confidence interval, 92.5%-100%). CONCLUSIONS: Elevated D-dimer level is highly specific for VMs (pure, combined, or syndromic), and therefore this easy and inexpensive biomarker test should become part of the clinical evaluation of vascular anomalies. It can detect hidden VMs and help differentiate glomuvenous malformation (normal D-dimer levels) from other multifocal venous lesions. Elevated D-dimer level also differentiates a VM from a lymphatic malformation. Moreover, slow-flow Klippel-Trenaunay syndrome (capillaro-lymphatico-venous malformation with limb hypertrophy) can be distinguished from fast-flow Parkes Weber syndrome (capillary malformation with underlying multiple microfistulas and limb hypertrophy). For these reasons, D-dimer level measurement is a useful complementary tool for diagnosing vascular anomalies in everyday practice.

Association of localized intravascular coagulopathy with venous malformations.

OBJECTIVE: To determine which venous malformations (VMs) are at risk for coagulopathy. Venous malformations are slow-flow vascular malformations present at birth, and localized intravascular coagulopathy (LIC) causes pain and thrombosis within a lesion and severe bleeding during surgical procedures. DESIGN: Prospective convenience sample accrued from 2 multidisciplinary sites in Brussels, Belgium, and Caen, France. PARTICIPANTS: The study population comprised 140 patients with clinical data and coagulation parameters. Magnetic resonance imaging was performed for 110 patients. MAIN OUTCOME MEASURE: Measurement of D-dimer levels. RESULTS: Of the 140 participants, 59 (42%) showed high D-dimer levels, 36 (61%) of whom had levels higher than 1.0 microg/mL. Six of the participants had low fibrinogen levels. In univariate analysis, large surface, presence of palpable phleboliths, and truncal localization were associated with high D-dimer levels. In the multivariate analysis, only large surface area and presence of phleboliths remained independently associated with high D-dimer levels. Severe LIC, characterized by concomitant low fibrinogen level, was associated with extensive venous malformations of the extremities. CONCLUSIONS: Localized intravascular coagulopathy is statistically significantly associated with large and/or deep venous malformations that affect any location, which can have a palpable phlebolith. These patients are at risk of local pain due to thrombosis. Lesions with elevated D-dimer levels associated with low fibrinogen levels (severe LIC) commonly affect an extremity and have a high risk of hemorrhage. Low-molecular-weight heparin can be used both to treat the pain caused by LIC and to prevent decompensation of severe LIC to disseminated intravascular coagulopathy.

Fluoroquinolone use and methicillin-resistant Staphylococcus aureus isolation rates in hospitalized patients: a quasi experimental study.

BACKGROUND: We investigated the possible association between fluoroquinolone use and the rate of methicillin-resistant Staphylococcus aureus (MRSA) recovery from consecutive hospitalized patients. METHODS: We conducted a nonrandomized, prospective, controlled interventional "fluoroquinolone-free" study at 4 large teaching hospitals in northwest France, catering to a total of 5,882,600 persons. During the intervention period (January through December 2001), fluoroquinolone use was prohibited at 1 of the 4 hospitals (Caen Hospital), unless no effective alternative was available. Three university hospitals were used as controls because they had similar preintervention rates of MRSA. RESULTS: During the intervention period (2001), the annual rate of fluoroquinolone use decreased from 54 to 5 defined daily doses per 1000 patients per day at Caen Hospital and remained stable in the control hospitals. At the end of the intervention, the rate of MRSA isolation was significantly lower at Caen Hospital than at the control hospitals (353 [32.3%] of 1093 S. aureus isolates were MRSA, compared with 2495 [36.8%] of 6787 isolates; odds ratio, 0.82; 95% confidence interval, 0.69-0.99; P=.036), as determined on the basis of a marginal model that took into account within-hospital clustering. In a before-after time series analysis, compared with forecasted rates, there was a significant downward trend in observed monthly rates of MRSA isolation at Caen Hospital at the end of the intervention. CONCLUSION: This quasi experimental study confirms the association between fluoroquinolone use and MRSA isolation among hospitalized patients.