[Antimicrobial in nursing homes in a French region: point prevalence survey and consumption in 2012]. / Antibiotiques en établissements d'hébergement pour personnes âgées dépendantes dans une région française : prévalence et consommations en 2012.

Infectious diseases and bacterial resistance are gaining importance in nursing homes. A few studies about antibiotic (AB) consumption in nursing homes (NHs) already exist. A national survey was performed by the European surveillance of antimicrobial consumption with the aim of gaining insight in NHs care to all European countries. This study shows that the surveillance of AB use is not organised in continuous for many countries and have shown that the prevalence of infections in French nursing homes was 4.8%. In France, there is no national data collection system of AB consumption for NHs. Data were obtained from a point prevalence survey conducted in 2012 in 80 NHs. In total, 1.366 residents were included and 48 residents were treated with antimicrobials (3.5%). Antimicrobials were most frequently prescribed for the treatment of respiratory (45.8%) and urinary tract infections (27.1%). For 4 prescriptions, the indication was not found. Consumption datas for 52 NHs were collected. The AB consumption mediane was 39 defined daily dose/1.000 PD (DDD/1.000 PD). The mediane of AB consumption for the region was 39.4 DDD/1.000 PD. Coamoxi-clav is the main AB consumed (39%) followed by amoxicillin with 30%.

[Developing a terminology in the French language for clinical practice and research in drug safety]. / Iatrogénie médicamenteuse : contribution à l'uniformisation de la terminologie en langue française pour la pratique de soins et la recherche clinique.

While several attempts have been made to clarify the English terminology of drug-related iatrogeny, a consensus has still not been reached in the French language. We set up a multidisciplinary task force to propose a terminology that differs from the one used in pharmacovigilance and risk management. We prefer the term "adverse drug event" (ADE) over "adverse drug reaction", and recommend avoiding the term "adverse event", which is too general. We propose to classify ADEs as "direct drug effect" or "drug involvement in a multifactorial pathological condition", taking into account the close relationship commonly found between drug and non-drug etiologies of a pathology. The consistent association between the notions "error" and "preventability" is also questionable, and we suggest assessing the "ameliorability" of ADEs rather than their "preventability". "Misuse" (i.e., the non-respect by the patient of the drug label) must be distinguished from "off-label use or substance abuse".

Establishing a pharmacy presence in the emergency department: opportunities and challenges in the French setting.

Overview of clinical pharmacy practice around the world shows that pharmaceutical services in emergency departments (EDs) are far less common in Europe than in North America. Reported experiences have shown the impact of a clinical pharmacy service on drug utilisation and safety issues. This commentary presents the implementation of a pharmacy presence in the ED of a French tertiary care hospital. Our experience helps to define the role of the clinical pharmacist in the ED, including patient interviewing, providing medication reconciliation, promoting drug safety, and supporting specific interventions to improve quality of care and patient safety. The role of ED pharmacists in the improvement of quality of care is not necessarily limited to drug therapy, e.g. by helping outpatients to access care and treatment facilities as best suits their needs. Challenges of implementing ED pharmacy services have been identified well, but still require developing strategies to be overcome.

Adverse drug event nonrecognition in emergency departments: an exploratory study on factors related to patients and drugs.

BACKGROUND: Many adverse drug events (ADEs) are not identified by emergency physicians. Research has been done to study risk factors for ADEs and help emergency physicians diagnose ADEs. However, no research has specifically examined the causes underlying a lack of attribution of ADEs to medications in emergency department (ED) patients. OBJECTIVE: We conducted an exploratory study in a medical ED to search for the factors associated with ADE nonrecognition that are related to ED patients and ADEs. METHODS: We conducted an observational study in the medical ED of a French tertiary care hospital between January and December 2009. The study focused on all ADEs, whether or not they were related to the patient's chief complaint. ADEs were identified by an expert physician and pharmacist based on National Electronic Injury Surveillance System criteria. An ADE was considered "attributed" if any evidence of ADE suspicion, ADE diagnosis, or ADE management was documented on ED charts. Factors associated with ADE nonrecognition were identified using multiple logistic regression analysis. RESULTS: Of the 465 included patients, 90 experienced an ADE at ED visit (19.4%; 95% confidence interval [CI] 15.9%-23.2%). Emergency physicians correctly recognized 36 of these cases (40.0%; 95% CI 29.8%-50.9%). On multivariate analysis, ADE nonrecognition was significantly associated with the following variables: nonrelation between the ADE and the patient's chief complaint; daily prescription of four drugs or more; and hospitalization ADE severity category. CONCLUSIONS: Our results emphasize the importance of searching for ADEs in patients with daily polypharmacy or whose chief complaint does not seem to be drug related.

Frequency and severity of adverse drug reactions due to self-medication: a cross-sectional multicentre survey in emergency departments.

BACKGROUND: Little is known about the relation of adverse drug reactions (ADRs) to self-use of medications. OBJECTIVE: The aim of this study was to determine the frequency and severity of ADRs related to self-medication (ADR-SM) among emergency department (ED) patients and to describe their main characteristics. METHODS: A prospective, cross-sectional, observational study was conducted over a period of 8 weeks (1 March to 20 April 2010), in the ED of 11 French academic hospitals. Adult patients presenting to the ED during randomization periods were included, with the exception of cases of self-drug poisoning, inability to complete self-medication questionnaire, or refusal. Clinical outcomes were assessed as well as history of self-medication behaviours and all drugs taken. All doubtful files and those related to ADR-SM were systematically reviewed by an expert committee. RESULTS: A total of 3,027 of 4,661 patients presenting to the ED met the inclusion criteria. Of these, 84.4 % declared a self-medication behaviour, 63.7 % took at least one non-prescribed drug during the previous 2 weeks and 59.9 % took a prescribed medication. A total of 296 patients experienced an ADR (9.78 %), of which 52 (1.72 %) were related to self-medication. Those ADRs related to self-medication included prescribed drugs (n = 19), non-prescribed drugs (n = 17), treatment discontinuation (n = 14), and interactions between non-prescribed and prescribed drugs (n = 2). The ADRs attributed to non-prescribed drugs represented 1 % of all patients taking non-prescribed drugs (n = 1,927). ADR severity was significantly lower for those related to self-medication (p = .032). CONCLUSION: Self-medication is frequent; its potential toxicity should not be neglected, taking into account the rate of adverse drug reactions in about 1 % of ED patient.

A questionnaire to document self-medication history in adult patients visiting emergency departments.

PURPOSE: To develop the first questionnaire to obtain a complete medication history by documenting self-medication history in adult patients admitted to a medical emergency department (ED). METHODS: A Questionnaire to document Self-Medicating Behaviours (QSMB) was developed between January and September 2008 (reference period), tested and refined between October and December 2008, and used routinely between January and December 2009 (routine period) in a tertiary care medical ED. The rate of SMBs measured with QSMB during the routine period was compared to the SMB rate measured with a spontaneous reporting method during the reference period. As survey teams changed every trimester, we also analysed the evolution of SMB rate over time. RESULTS: QSMB is divided into two parts. The first part consists of 20 closed-ended questions exploring all indications and dimensions of self-medication. The second part assesses the characteristics of each medication mentioned by the patient in the first 20 questions. The patients interviewed during reference and routine periods did not significantly differ. The routine period patients reported a third more SMBs (89.8% vs 57.6%, respectively; p < 0.0001) and twice more self-medication drugs than the reference period patients. SMB rate was significantly different between the survey teams during the reference period (p < 0.0001), but not during the routine period (p = 0.078). CONCLUSIONS: This questionnaire complements the traditional tools that are already available to collect medication histories of prescribed drugs. It may improve the recognition of iatrogenic conditions related to self-medication, and provide support to public health efforts and research programs on self-medication.

Relationship between hospital antibiotic use and quinolone resistance in Escherichia coli.

BACKGROUND: The relationship between the hospital use of various classes of antibiotics and resistance of Escherichia coli to quinolones remains debated. Our aim was to study the relationship between the hospital use of 16 classes of antibacterial agents and the incidence of quinolone-resistant E. coli isolates. METHODS: Antibiotic use and resistance data were collected from 36 hospitals. Incident rate ratios (IRR) were assessed using negative binomial regression. RESULTS: The incidence of quinolone-resistant isolates was independently associated with the consumption of tetracyclines (IRR 1.139, 95% CI 1.030-1.259), first- and second-generation cephalosporins (IRR 1.007, 95% CI 1.002-1.013), third-generation cephalosporins (IRR 1.029, 95% CI 1.010-1.048), and quinolones (IRR 1.007, 95% CI 1.000-1.014). These associations were independent from the type of patient served. CONCLUSIONS: The level of hospital use of quinolones influences the incidence of quinolone resistance in E. coli hospital isolates. The consumption of two other classes of antibiotics, cephalosporins and tetracyclines, is also associated with quinolone resistance.

Assessment of adverse drug event recognition by emergency physicians in a French teaching hospital.

OBJECTIVES: The frequency and the severity of drug-related visits in emergency department (ED) make the improvement of adverse drug event (ADE) recognition a crucial issue. As part of a research project aiming to improve the diagnosis and the management of ADEs in ED, the authors conducted a pilot study whose primary objective was to assess ADE recognition by emergency physicians. METHODS: The patients presenting to the ED were included at randomised time periods between 1 October 2007 and 31 March 2008 in this prospective cross-sectional study. The primary outcome was the frequency of ADEs that were attributed to a medication-related problem by the emergency physician. RESULTS: A total of 423 patients met the inclusion criteria, of which 95 experienced an ADE (22.5%; 95% CI 18.6% to 26.7%). Emergency physicians correctly attributed 33 of these cases (34.7%; 95% CI 25.3% to 45.2%) to a medication-related problem. Of the 28 cases in which the ADE was considered as a 'direct drug effect' (29.5%; 95% CI 20.6% to 39.7%), 16 were correctly identified by emergency physicians (57.1%; 95% CI 37.2% to 75.5%). Of the 67 cases in which the ADE was considered as a 'drug involvement in a multifactorial pathological condition' (70.5%; 95% CI 60.3% to 79.4%), 17 were correctly attributed (25.4%; 95% CI 15.5% to 37.5%). CONCLUSIONS: ADEs are frequent in EDs and are not well recognised by emergency physicians, especially when the drug is involved in a multifactorial pathological condition.

[Self-medicating behaviours in patients admitted to a medical emergency department]. / Étude des comportements d'automédication chez les patients admis dans un service d'urgences médicales.

OBJECTIVE: To describe the self-medicating behaviours (SMBs) in patients admitted to a tertiary care medical emergency department (ED); to study the factors associated with SMBs. METHODS: Observational cross-sectional study conducted in 2009. Included patients were interviewed about their SMBs using a standardized questionnaire. The search for factors associated with SMBs used multivariate logistic regression analysis. RESULTS: Among the 315 patients who were interviewed, 239 (75.9%) reported one SMBs or more in their lives and 105 (43.9%) within 7 days of admission to the ED. Some of the medications reported during interviews are known to be associated with adverse drug events. After adjustment, SMBs were conversely associated with an age ≥80 years, a number of prescribed medications ≥4 and a social vulnerability condition. CONCLUSION: The description of SMBs and the analysis of their determinants are necessary to improve the recognition of adverse events related to self-medication in ED patients.

Implementing a clinical pharmacy survey of adverse drug events in a French emergency department.

BACKGROUND: The prevalence of adverse drug events (ADEs) occurring in the ambulatory setting is high, requiring the development of a coherent and comprehensive patient-safety policy framework. Former experiences demonstrated that emergency department (ED) surveillance can help characterise the burden of outpatient ADEs. We developed a clinical pharmacy programme called the clinical pharmacy survey of adverse drug events (CPSA) to support interventions and research projects in the area of ADE prevention and management. OBJECTIVE: To design a survey to identify and describe ADEs in patients visiting the medical ED of our tertiary care hospital. We report the results of the first 2 years of CPSA implementation and an assessment of its performance. SETTING: The medical ED of a French 3,000-bed tertiary care hospital. METHOD: Between January 2008 and December 2009, adult patients visiting our medical ED were included during randomised time slots. Data were collected by pharmacy students. ADEs were documented by a trained physician pharmacist team using the chart review method. MAIN OUTCOME MEASURE: The primary outcome was the number of patients visiting our ED with an ADE. The CPSA attributes were assessed on the basis of the Centers for Disease Control and Prevention's 2001 updated guidelines for evaluating public health surveillance systems. RESULTS: Of the 1,035 included patients, 201 experienced an ADE at the ED visit (19.4 %; 95 % confidence interval 15.8-23.0 %). Forty-seven ADEs (23.4 %) were unrelated to the patient's chief complaint. An ADE was the leading cause of 154 in the 1,035 admissions (14.9 %). The assessment of our method on the basis of the Centers for Disease Control and Prevention guidelines showed good performances in terms of data quality, stability, flexibility, timeliness, and acceptability, but not in terms of simplicity and representativeness. The profile of patients with an ADE at admission and detected ADEs did not significantly differ between years 2008 and 2009. CONCLUSION: Our experience demonstrates that clinical pharmacists can successfully implement a survey process of ADEs in an ED over time. Our method seems basic enough to suit most health care facilities with pharmacy students.

[Grapefruit consumption and food-drug interaction hazard]. / Consommation de jus de pamplemousse et risque d'interactions médicamenteuses : étude transversale dans un service d'urgences médicales.

OBJECTIVE: To estimate the prevalence of grapefruit consumption in patients admitted to a tertiary care emergency department (ED) and its potential impact on the risk of fruit-drug interaction. METHODS: Observational cross-sectional study conducted in a medical ED between July and December 2009. Data analysis searched for the main drugs which can dramatically interact with grapefruit and for adverse drug events (ADEs). Among the 162 patients who were interviewed, 59 (36%) reported grapefruit consumption (regardless form or frequency) and 11 (7%) were prescribed a treatment with a risk of fruit-drug interaction. No ADE could be related to an interaction with grapefruit. Calcium channel blockers and HMG-coA-reductase inhibitors mostly accounted for drugs at risk of interaction in grapefruit consumers. CONCLUSION: These results give evidence of the sizeable risk of grapefruit-drug interaction in the prescriptions of patients admitted to a medical ED, with a high proportion of commonly used medicines but poor clinical consequences.

[Use of rapid diagnostic tests of tonsillitis in medical practice. Survey conducted from November 2006 to January 2007 in Pays de la Loire (France)]. / Utilisation des tests de diagnostic rapide de l'angine en médecine générale. Enquête réalisée de novembre 2006 à janvier 2007 dans les Pays de la Loire.

INTRODUCTION: The use of the rapid diagnostic test (RDT) and the strategy of management of pharyngitis in medical practice are little known. METHODS: During the 2006-2007 winter, a survey was conducted in the Pays de la Loire Region to evaluate the use of the RDT. A focus group was also organised. RESULTS: Data were collected from 525 patients (patients who were consulting for a sore throat, angina or patients for whom a RDT was made). RDT were performed on 245 patients (46%). The sixty positive RDT patients systematically received an antibiotic. Twenty negative RDT patients received an antibiotic. More than 75% of GPs considered the RDT useful or very useful. DISCUSSION: The guidelines for the management of pharyngitis are known but they are partially followed by physicians. Many countries have national guidelines for the management of tonsillitis and they are also not unanimous. When patients had pharyngitis symptoms, the frequency of antibiotic prescription was lower when the RDT was used as recommended by the French Medicines Agency (AFSSAPS). The treatment must be short in order to improve the compliance of outpatients and reduce the inappropriate use of antibiotics. CONCLUSION: A decrease in antibiotics prescription was recorded in the community. It was attributed to the availability of the RDT provided by the CNAMTS (French National Health Service). Moreover, the RDT are still free for practitioners and their reimbursement could be extended to hospital.

[Information for the patient in hospitals: the implicit shared role among professionals]. / L'information du patient à l'hôpital, un partage implicite des rôles entre professionnels?

OBJECTIVE: Perceived practices declared by physicians were assessed in order to determine the role of the different professionals in patient medical information, the communication methods and traceability practices used in patient files. Method Data were collected using an anonymous questionnaire sent by mail in April 2003 to the 794 physicians of the University Hospital of Nantes (France). RESULTS: The participation rate was of 38% (302 responses) and differed according to the medical categories: university professors (44%), young seniors (50%), hospital practitioners (43%) and practitioners under contract (21%). In outpatient departments, patient information was rarely shared between professionals: the senior practitioner only informed the patient in 80% of cases. In the case of hospitalisation, patient information concerned various health professionals: in general, senior practitioners, junior practitioners (50% of cases) and nursing staff (20 to 45%). Information for the patient was always oral, accompanied in 1/3 of cases by one or more documents. The traceability of the elements of information supplied to the patient was inadequate. CONCLUSION: This survey underlined the interest of the medical corps regarding information for the patient, and the important role played by junior practitioners and paramedical staff. Because they are all obviously implied in information supplied to the patient, quality improvement projects should target all the health professionals.

Quality control of antibiotics before the implementation of an STD program in Northern Myanmar.

BACKGROUND: The ready availability of poor-quality drugs in developing countries leads to treatment failure and, consequently, excess mortality and morbidity. Moreover, the widespread availability of substandard drugs plays a key role in increasing the resistance to antimicrobial drugs.GOAL As a prerequisite to the establishment of a sexually transmitted disease (STD) control program, this study aimed to evaluate the quality of antibiotics recommended for treatment of STDs that were locally available in the capital of a province of Northern Myanmar. STUDY DESIGN: In addition to the hospital pharmacy, we selected at random 5 of the 41 drug sellers and 5 of the 40 general practitioners who sell antibiotics in the city of Myitkyina. Twenty-one marketing products corresponding to nine different antibiotics used for STD treatment were purchased (benzathine benzylpenicillin, benzylpenicillin, ceftriaxone, chlortetracycline, ciprofloxacin, clotrimazole, co-trimoxazole, doxycycline, and erythromycin). Drugs were sent to France, where they were analyzed according to the WHO guidelines. Drugs were considered to be standard if their dosage remained in the 10% range of the expected value. RESULTS: Among the 21 different specialty products, only three displayed the official "registered" label. Three drugs were expired and the expiration date was not available for six others. One product did not contain the active drug declared (chlortetracycline; Lombisin, Unicorn, China) and did not show any in vitro activity against bacteria. Seven of 21 products (33%) did not contain the stated dosage (1, more than stated dosage; 6, less than stated dosage). The highest deficit observed was 48% in two products (co-trimoxazole, Yong Fong, Myanmar; benzylpenicillin, China [city and manufacturer unknown]). The dosage was not available for five drugs. As a result, only 8 of 21 products (38%) did not contain the stated dosage of active drug. CONCLUSION: These findings suggest that public health policies based on national treatment guidelines should rigorously include the monitoring of quality control of available antimicrobial products. In the absence of such measures, specific treatment strategies are likely to fail and to generate drug resistance.