One Hundred Explicit Definitions of Potentially Inappropriate Prescriptions of Antibiotics in Hospitalized Older Patients: The Results of an Expert Consensus Study.

BACKGROUND: In geriatrics, explicit criteria for potentially inappropriate prescriptions (PIPs) are useful for optimizing drug use. OBJECTIVE: To produce an expert consensus on explicit definitions of antibiotic-PIPs for hospitalized older patients. METHODS: We conducted a Delphi survey involving French experts on antibiotic stewardship in hospital settings. During the survey's rounds, the experts gave their opinion on each explicit definition, and could suggest new definitions. Definitions with a 1-to-9 Likert score of between 7 and 9 from at least 75% of the participants were adopted. The results were discussed during consensus meetings after each round. RESULTS: Of the 155 invited experts, 128 (82.6%) participated in the whole survey: 59 (46%) infectious diseases specialists, 45 (35%) geriatricians, and 24 (19%) other specialists. In Round 1, 65 explicit definitions were adopted and 21 new definitions were suggested. In Round 2, 35 other explicit definitions were adopted. The results were validated during consensus meetings (with 44 participants after Round 1, and 54 after Round 2). CONCLUSIONS: The present study is the first to have provided a list of explicit definitions of potentially inappropriate antibiotic prescriptions for hospitalized older patients. It might help to disseminate key messages to prescribers and reduce inappropriate prescriptions of antibiotics.

Prevalence of anti-neutrophil cytoplasmic antibody-associated vasculitis in the south of France, using the capture-recapture method.

OBJECTIVES: This study aimed to estimate the prevalence of ANCA-associated vasculitis (AAV), ie granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangiitis (EGPA), in Southern France in 2018, and evaluate differences among Europeans and non-Europeans. METHODS: This population-based, cross-sectional study used four sources (hospitals, community-based physicians, laboratories, National Health Insurance) to identify adults ≥ 15 years diagnosed with GPA, MPA or EGPA, living in Hérault and Gard in 2018. Cases were defined using the ACR/EULAR classification criteria, and if necessary, the European Medicines Agency algorithm. Prevalence estimates were standardised to the world population and capture-recapture analysis was used to assess the comprehensiveness of the estimation. The influence of geographical origin was evaluated. RESULTS: 202 patients were selected, with 86 cases of GPA (42.6%), 85 cases of MPA (42.1%), and 31 cases of EGPA (15.3%). The standardised prevalence estimates per million inhabitants for 2018 were: 103 (95%CI 84 - 125) for AAV, 48 (95%CI 35 - 64) for GPA, 39 (95%CI 28 - 53) for MPA and 16 (95%CI 9 - 26) for EGPA, 36 (95%CI 25 - 50) for anti-PR3 positive AAV, 46 (95%CI 34 - 61) for anti-MPO positive AAV, and 16 (95%CI 9 - 26) for ANCA-negative AAV. The global estimation of comprehensiveness by capture-recapture analysis was 80.5%. The number of AAV cases was higher for non-European residents (P=0.001), particularly for MPA (P<0.0001). CONCLUSION: We provide a new estimate of AAV prevalence in France and show a higher prevalence of MPA in non-European patients.

The impact of transoesophageal echocardiography in elderly patients with infective endocarditis.

BACKGROUND: Infective endocarditis (IE) increasingly involves older patients. Geriatric status may influence diagnostic and therapeutic decisions. AIM: To describe transoesophageal echocardiography (TEE) use in elderly IE patients, and its impact on therapeutic management and mortality. METHODS: A multicentre prospective observational study (ELDERL-IE) included 120 patients aged ≥75 years with definite or possible IE: mean age 83.1±5.0; range 75-101 years; 56 females (46.7%). Patients had an initial comprehensive geriatric assessment, and 3-month and 1-year follow-up. Comparisons were made between patients who did or did not undergo TEE. RESULTS: Transthoracic echocardiography revealed IE-related abnormalities in 85 patients (70.8%). Only 77 patients (64.2%) had TEE. Patients without TEE were older (85.4±6.0 vs. 81.9±3.9 years; P=0.0011), had more comorbidities (Cumulative Illness Rating Scale-Geriatric score 17.9±7.8 vs. 12.8±6.7; P=0.0005), more often had no history of valvular disease (60.5% vs. 37.7%; P=0.0363), had a trend toward a higher Staphylococcus aureus infection rate (34.9% vs. 22.1%; P=0.13) and less often an abscess (4.7% vs. 22.1%; P=0.0122). Regarding the comprehensive geriatric assessment, patients without TEE had poorer functional, nutritional and cognitive statuses. Surgery was performed in 19 (15.8%) patients, all with TEE, was theoretically indicated but not performed in 15 (19.5%) patients with and 6 (14.0%) without TEE, and was not indicated in 43 (55.8%) patients with and 37 (86.0%) without TEE (P=0.0006). Mortality was significantly higher in patients without TEE. CONCLUSIONS: Despite similar IE features, surgical indication was less frequently recognized in patients without TEE, who less often had surgery and had a poorer prognosis. Cardiac lesions might have been underdiagnosed in the absence of TEE, hampering optimal therapeutic management. Advice of geriatricians should help cardiologists to better use TEE in elderly patients with suspected IE.

Chemsex in HIV pre-exposure prophylaxis users: Assessment of mood disorders and addictive behavior.

The assessment of mood disorders and addiction linked to the practice of chemsex is of interest given the psychoactive substances used. The aim of this study was to assess risky sexual and addictive behavior to chemsex and related anxiety/depression symptoms in individuals receiving HIV pre-exposure prophylaxis (PrEP). In this cross-sectional study, all adults presenting for PrEP renewal at French sexual health centers were enrolled from January 2018 to March 2019. Participants completed a questionnaire on chemsex (i.e., the use of psychoactive substances before/during sex), including adapted Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) to chemsex addiction (questions of ASSIST were modified to focus on chemsex). Anxiety/depression was assessed with the Hospital Anxiety and Depression Scale. In the last 3 months before enrollment, 39.8% (94/236) of participants reported chemsex. The main psychoactive substances consumed during chemsex were cathinones (74.6%), gamma-hydroxybutyrate (66.3%), and other psychostimulants (60%). The median score of the chemsex-focused ASSIST was 8 [IQR25-75 : 3-15]; 72.2% of participants had a score justifying at least a brief intervention (>4). In multivariate analyses, anxiety and cathinones consumption were associated with an ASSIST score >4: OR 13.65 (95% CI 1.68-662.7), P = 0.0062, and OR 8.468 (95% CI 2.066-43.059), P = 0.0014, respectively. The level of addiction to the practice of chemsex can be difficult to estimate for the user, and the ASSIST makes it possible to evaluate this addiction and to direct the subjects toward specialized consultations of addictology, sexual health, or PrEP renewals. The implementation of the modified ASSIST in these consultations can allow early systematic screening and counseling.

Tolerance of subcutaneously administered antibiotics: a French national prospective study.

Background/ Objective: Although poorly documented, subcutaneous (SC) administration of antibiotics is common practice in France especially in Geriatrics Departments. The aim of this study was to determine the tolerance of such a practice. Design: Prospective observational multicentre study. Methods: Sixty-six physicians accepted to participate from 50 French Infectious Diseases and Geriatrics Departments. From May to September 2014, patients treated at least one day with SC antibiotics could be included. Modalities of subcutaneous administration, occurrence of local and systemic adverse effects (AE) and clinical course were collected until the end of the treatment. Results: Two hundred-nineteen patients (83.0 [19­104] yo) were included. Ceftriaxone (n = 163, 74.4%), and ertapenem (n = 30, 13.7%) were the most often prescribed antibiotics. The SC route was mainly used because of poor venous access (65.3%) and/or palliative care (32.4%). Fifty patients (22.8%) experienced at least one local AE that led to an increased hospital stay for two patients (4.0%) and a discontinuation of the SC infusion in six patients (12.0%). A binary logistic regression for multivariate analysis identified the class of antibiotic (p = 0.002) especially teicoplanin and the use of rigid catheter (p = 0.009) as factors independently associated with AE. In over 80% of cases, SC antibiotics were well tolerated and associated with clinical recovery. Conclusions: SC administration of antibiotics leads to frequent but local and mild AE. Use of non-rigid catheter appears to be protective against AE. As it appears to be a safe alternative to the intravenous route, more studies are needed regarding efficacy and pharmacokinetics.

Managing infective endocarditis in the elderly: new issues for an old disease.

The incidence of infective endocarditis (IE) rises in industrialized countries. Older people are more affected by this severe disease, notably because of the increasing number of invasive procedures and intracardiac devices implanted in these patients. Peculiar clinical and echocardiographic features, microorganisms involved, and prognosis of IE in elderly have been underlined in several studies. Additionally, elderly population appears quite heterogeneous, from healthy people without past medical history to patients with multiple diseases or who are even bedridden. However, the management of IE in this population has been poorly explored, and international guidelines do not recommend adapting the therapeutic strategy to the patient's functional status and comorbidities. Yet, if IE should be treated according to current recommendations in the healthiest patients, concerns may rise for older patients who suffer from several chronic diseases, especially renal failure, and are on polypharmacy. Treating frailest patients with high-dose intravenous antibiotics during a prolonged hospital stay as recommended for younger patients could also expose them to functional decline and toxic effect. Likewise, the place of surgery according to the aging characteristics of each patient is unclear. The aim of this article is to review the recent data on epidemiology of IE and its peculiarities in the elderly. Then, its management and various therapeutic approaches that can be considered according to and beyond guidelines depending on patient comorbidities and frailty are discussed.

A cross sectional survey of the barriers for implementing rapid HIV testing among French general practitioners.

In France, almost 30,000 people are unaware of their HIV-positive status. Innovative screening strategies are essential to reach this population. The aim of this study was to describe the acceptability of rapid HIV testing (RHT) among French general practitioners (GPs) working in the south of France and barriers for implementing this strategy. We analysed an anonymous questionnaire sent by mail to GPs about demographic data, routine practice, knowledge of RHT and barriers to its use. Between 1 April and 30 September 2013, out of the 165 GPs contacted, 78 returned the questionnaires. The GPs' mean age was 52 years; 49 were men. Fifty-one GPs reported that their registered patients included at least one HIV-infected person and 70 GPs reported taking care of high-risk patients. Sixty-three percent of GPs reported being interested in using RHT in their daily practice. The main reasons reported by uninterested GPs were: greater confidence in standard HIV testing, difficulties including RHT during the routine consultation, difficulties to screen for other sexually transmitted infections simultaneously, and difficulties to deliver a positive result. French National Authorities for Health propose to screen the population at least once in their lifetime and high-risk people at least once a year. In order to achieve this aim, RHT should be included in the GPs' arsenal for HIV testing. We showed a high acceptability of RHT by GPs. If specific and adapted training is developed, and if solutions to barriers reported by GPs are found, RHT could be implemented in to their routine activity.

Aminoglycosides use in patients over 75 years old.

OBJECTIVE: to describe aminoglycoside use and nephrotoxicity in patients older than 75 years. DESIGN: retrospective multicenter study. SETTING: hospital department, rehabilitation, long-term care center. POPULATION: patients ≥75 years old treated by aminoglycosides. RESULTS: 184 patients, mean age: 84.4 years (range: 75-101). One hundred and twenty-seven patients received other nephrotoxic drug(s). Gentamicin (70%) and amikacin (30%) were used and the once-daily dosing was preferred (92%). Average treatment period was 2.75 (1-10) days for amikacin and 4.4 (1-30) for gentamicin with average dosage 13.5 and 3.5 mg/kg/day, respectively. The monitoring of maximal plasmatic concentration (Cmax) was done in 37 patients, 9 of them had probabilistic treatment. Only one had a Cmax fulfilling the objective of French recommendations (gentamicin >30 mg/l, amikacin >60 mg/l). When infection was documented, the objective of Cmax >10 × minimal inhibitory concentration of the strain was reached for 27%. Minimal plasmatic concentration was checked in 38% of cases, with adequate value (gentamicin <0.5 mg/l, amikacin <2.5 mg/l) for 37%. At the end of aminoglycoside course, 40 patients increased their serum creatinine >25% of the baseline value. In multivariate analysis, this was associated with treatment length ≥3 days and concomitant use of nephrotoxic drugs. CONCLUSION: aminoglycosides dosing used in elderly patients probably need therapeutic drug monitoring and dose adjustment. Aminoglycosides are used to treat severe infections. One of the most important side effects is nephrotoxicity in oldest patients. To minimise nephrotoxicity, short treatments are necessary and avoiding others nephrotoxic drugs could be relevant.

Candiduria in those over 85 years old: a retrospective study of 73 patients.

OBJECTIVE: Candiduria is a common finding in the growing population of very old patients that has not been previously studied. The objective was to study candiduria in the population aged 85 and over, including an estimation of the incidence, factor of acquisition, and evaluation of treatment and mortality. METHODS: Retrospective monocentric study. Materials medical charts of patients aged of 85 and over who have candiduria diagnosed at Nimes University Hospital. RESULTS: The prevalence of candiduria in the hospitalized very old patients was 8.9%. More than half of strains isolated were C. albicans (59%). Mean age was 89.7 years old with 53 women and 20 men. Urinary catheter (55%) and prior antibiotic use (67%) were commonly found. Fifteen patients with candiduria were treated, consistently with fluconazole. Patients treated had higher Mini Mental Test score than the others. A high C-reactive protein level, Mac Cabe score or Charlson's score >7 were associated with 6 months mortality. CONCLUSION: Episodes of candiduria in oldest old were associated with frailty and vulnerability of the patient. The medical decision for antifungal treatment is usually difficult to make but it did not seem to influence mortality.

[Myasthenia gravis in the elderly: diagnosis, comorbidity and course: 45 cases]. / Myasthénie du sujet âgé: diagnostic, comorbidité et évolution: à propos de 45 cas.

OBJECTIVE: Analyze the clinical presentation, laboratory indicators, and outcome of patients with late-onset myasthenia gravis (after 60 years). METHOD: This retrospective cohort design with prospective follow-up included 45 patients with late-onset myasthenia gravis diagnosed in hospitals in Avignon, Montpellier, and Nimes between 1993 and 2000. Prospective data collection of their subsequent course took place in 2001. RESULTS: Median age at onset was 72 years and median follow-up 35.5 months. Initial symptoms were ocular (38/45, 95%) and bulbar (31/45, 69%). Initial Osserman grades were distributed as follows: 10 grade I, 2 grade IIA, 25 grade IIB, 8 grade III and no grade IV. Anticholinesterase antibodies were positive in 39 patients (91%), response to anticholinesterase positive in 31/33 (94%), and electrophysiological abnormalities observed in 20/33 (61%). Thoracic computed tomography, performed in 42 patients (93%), found thymic abnormalities in 7. At least one comorbid disease was diagnosed in 41/43 patients (93%) and an autoimmune disorder in 18/43 (42%). In all, 42 patients (93%) received anticholinesterase and 36 (80%) immunosuppressive therapy. Sixteen patients (36%) died during follow-up, 8 of causes directly related to the myasthenia gravis. The relative risk of death estimated by odds ratios (OR) was highest for patients with comorbid cancer (OR 8.6 [1.8-40.6]) and those with the highest Osserman scores: grades I-II OR: 0.05 [0.01-0.29] versus grades III-IV OR: 15.5 [2.9-83.0]. CONCLUSION: Late-onset myasthenia gravis is specific in many aspects (presentation, autoimmune and other comorbid conditions, and course) that require attentive care.

[Evaluation of self-medication by scuba divers]. / Evaluation de la pratique de l'automédication chez les plongeurs en scaphandre autonome.

AIM: The aim of the study was to evaluate drug use amongst French scuba divers. METHODS: An anonymous questionnaire was distributed to 220 people, out of which 106 responded. RESULTS: Fifteen percent of respondents were receiving long-term medication whereas 60.33% of respondents reported taking medication only occasionally when diving. Thirty-seven percent of respondents were taking prescribed medicines. Drugs consumed occasionally included analgesics (43.5%), corticosteroids (14.5%) and antiemetics. A detailed study of aspirin and steroid consumption revealed their misuse for performance-enhancing purposes, the level of risk varying with the type of diving activity. The influence of drug use on personal performance was recognised by 72.6% of divers, but only 59.4% considered that they were putting themselves at risk by self-medicating.

Acute respiratory failure secondary to dilatation of herniated stomach.

We report the case of a patient who presented acute respiratory failure (ARF) due to gastric distension secondary to hiatus hernia. This clinical condition may have been induced by an interaction between fluphenazine and ipratropium bromide. This exceptional diagnosis needs to be considered when discussing compressive pneumothorax.