Prosthetic joint infection: A pluridisciplinary multi-center audit bridging quality of care and outcome.

BACKGROUND: Care to patients with prosthetic joint infections (PJI) is provided after pluridisciplinary collaboration, in particular for complex presentations. Therefore, to carry out an audit in PJI justifies using pluridisciplinary criteria. We report an audit for hip or knee PJI, with emphasis on care homogeneity, length of hospital stay (LOS) and mortality. PATIENTS AND METHODS: Fifteen criteria were chosen for quality of care: 5 diagnostic tools, 5 therapeutic aspects, and 5 pluridisciplinary criteria. Among these, 6 were chosen: surgical bacterial samples, surgical strategy, pluridisciplinary discussion, antibiotic treatment, monitoring of antibiotic toxicity, and prevention of thrombosis. They were scored on a scale to 20 points. We included PJI diagnosed between 2010 and 2012 from 6 different hospitals. PJI were defined as complex in case of severe comorbid conditions or multi-drug resistant bacteria, or the need for more than 1 surgery. RESULTS: Eighty-two PJI were included, 70 of which were complex (85%); the median score was 15, with a significant difference among hospitals: from 9 to 17.5 points, P < 0.001. The median LOS was 17 days, and not related to the criterion score; 16% of the patients required intensive care and 13% died. The cure rate was 41%, lost to follow-up 33%, and therapeutic failure 13%. Cure was associated with a higher score than an unfavorable outcome in the univariate analysis (median [range]): 16 [9-18] vs 13 [4-18], P = 0.002. CONCLUSIONS: Care to patients with PJI was heterogeneous, our quality criteria being correlated to the outcome.

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

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

Antimicrobial stewardship program and quality of antibiotic prescriptions.

OBJECTIVE: National recommendations have been issued to define which optimal organization in hospitals could improve the quality of antibiotic prescription. Our aim was to check whether there was a link between applying these national recommendations and the quality of antibiotic prescriptions. PATIENTS AND METHODS: A prospective study was carried out in three French regional hospitals (A to C), to assess how recommendations were applied. Hospital organization was measured with the ICATB score (antimicrobial stewardship index) and the appropriateness of antibiotic prescription was assessed by an audit during 1 week by two investigators, who shadowed physicians during bedside visits, in various medical and surgical departments. RESULTS: There was a considerable difference in the organization of these three hospitals in terms of computerized prescriptions, formulary restriction, availability of recommendations, and antibiotic consumption defined as delivered daily-dose. Institution A had strictly followed recommendations for hospital organization, but these were less observed in institution B and C. The prevalence of antibiotic treatment was comparable in the three hospitals, and concerned over 25% of patients. In institution A, 60% of antibiotic prescriptions were inadequate, 23% were not appropriate and 17% were optimal. In institution B, these figures reached 36%, 34%, and 34%, while in institution C they reached 25%, 55%, and 20%, respectively. CONCLUSION: There is no clear link between applying national recommendations for antibiotic prescription and optimization of hospital organization and the quality of antibiotic prescriptions.

[Prospective evaluation of antibiotic combinations in a general hospital]. / Evaluation prospective des associations antibiotiques d'un centre hospitalier général.

INTRODUCTION: We previously reported a 30% rate of inadequate antibiotic therapy in a general hospital with optimal organization. This data led to implement a systematic weekly infectious diseases consultation. We report an evaluation of antibiotic combinations. PATIENTS AND METHODS: The infectious diseases consultation was scheduled half-a-day per week. Antibiotic combinations were collected by the pharmacist via computerized prescriptions. Discussion with the managing physician was systematic in order to evaluate the adequacy of the treatment both in terms of diagnosis and therapy. RESULTS: For 9 months, 381 patients were prescribed 486 antibiotic combinations, among which 116 were evaluated. The infectious diseases specialist suggested a similar diagnosis in 71 antibiotic treatments (61%), the diagnosis appeared doubtful in 36 cases (31%), and a true diagnostic discordance was noted in nine cases. The discussion between specialist and managing physician suggested that the antibiotic combination was justified in 35%, of limited usefulness in 22%, and inadequate in 43% of the cases. There was a significant correlation between the result of the discussion and the accuracy of the antibiotic combination (p<0.001). Respiratory infections were the main reason for inadequate or limited usefulness of antibiotic combinations (30/49, 61%). CONCLUSION: Computerized prescriptions allow the evaluation of antibiotic therapy even when the infectious diseases specialist intervention is short. The discussion with the managing physician on diagnosis and treatment appears to play a central role for a better use of antibiotherapy.