Appropriateness of aminoglycoside prescriptions in a French university hospital.

INTRODUCTION: Aminoglycosides are a major class of antibiotics. Their use is particularly interesting in the treatment of severe infections but their toxicity is well known. They are mostly prescribed combined with other agents and as first-line treatments. We aimed to assess the appropriateness of aminoglycoside prescriptions in a French university hospital on the basis of the latest French recommendations published in 2011. METHOD: We conducted a prospective study between January 17th and February 4th, 2014 to assess prescription modalities of aminoglycosides on the basis of the following criteria: indication, duration of treatment, dosing schedule, administration modalities, and drug level monitoring. Prescriptions were then compared to the 2011 national guidelines. RESULTS: A total of 68 consecutive prescriptions were analyzed and only 47.8% complied with guidelines. Most physicians complied with recommendations, particularly with the indication for severe infections (95.6%), the administration of a single daily dose (92.6%), and the slow intravenous infusion (30minutes) administration (84%). However, physicians tended to prescribe lower doses than recommended (40.3%), especially to patients presenting with renal insufficiency, and drug level monitoring was not optimal. CONCLUSION: Although new and accurate national recommendations were recently published, aminoglycoside prescription is still not optimal, in particular for dosing and plasma concentration monitoring.

Appropriate use of carbapenems in the Besançon university hospital.

INTRODUCTION: The excessive and inappropriate use of carbapenems is responsible for the development of resistance. The scientific community has been requiring caution and using these agents in specific cases only. OBJECTIVES: The authors had for aim to evaluate the appropriate use of carbapenems in a French university hospital. DESIGN: A retrospective survey was made over two months as a clinical audit to assess professional practices. The evaluation criteria for this audit were: the appropriateness of the indication, the possibility of alternative therapeutic strategies, the choice of an antibiotic combination, duration of treatment and dosage. RESULTS: During the audit period, 103 carbapenem prescriptions were included. Ninety-nine cases were analyzed. Among the carbapenem prescriptions, 28.3% (28/99) did not meet the criterion "appropriateness of the indication". Carbapenems were mostly prescribed empirically (60/99 [60%]) and most often for lung infections or nosocomial urinary tract infections. Finally, 66.7% (66/99) of all prescriptions were considered inappropriate for at least one criterion. The rate of inappropriateness ranged around 30% for each criterion. CONCLUSIONS: This study allowed us to assess professional practices for carbapenem prescriptions. The overall rate of inappropriateness was quite important. Carbapenems were not always used appropriately. These findings highlight the need of new regional guidelines and regular updating of local best practices recommendations. Finally, a stricter validation of carbapenem prescriptions will be implemented at the hospital pharmacy level.

[Antibiotics in elderly patients: Impact of clinical practice evaluation]. / Antibiothérapie chez le sujet âgé : impact d'une démarche d'évaluation des pratiques professionnelles.

OBJECTIVE: Improving the use of antimicrobial drugs is a national objective. To this end an evaluation of clinical practice was implemented on prescribed antibiotics in elderly patients, in the Besançon Teaching Hospital. DESIGN: In 2005, a clinical audit compared the adequacy of antibiotic prescriptions to national guidelines in 37 patients. An improvement plan was implemented, including the drafting of local guidelines (adapted national guidelines) "Antibiotic prescription in elderly patients" by a multidisciplinary team. The Antibiotics Committee approved it. A retrospective study compared antibiotic prescription of 62 patients to these guidelines. The methodology was based on Gyssen's algorithm. The assessment criteria were: relevance of the indication, absence of a better alternative, respect of recommended dose, duration, and timing. RESULTS: The rate of overall conformity was 26% in 2005, 57% in 2007. Antibiotic choice was adequate in 61% of cases in 2005, 78% in 2007. In 63% of cases, a more efficient alternative was advised in 2005, 10% of cases in 2007. Treatment duration, dose, and timing were adequate in 54 - 92 - 96% in 2005 respectively and 86 - 92 - 100% of cases in 2007. Ciprofloxacin was prescribed in first line for 42% of urinary infections in 2005, 0% in 2007. CONCLUSIONS: This approach improved antibiotic prescriptions because of better guideline observance by physicians. The main improvement concerned fluoroquinolones. It should be continued to confirm antibiotic good use and protect our hospital bacterial ecology.

Ribosomal and mitochondrial DNA target for real-time PCR diagnosis of invasive aspergillosis.

The aim of the present study was to assess the diagnostic efficacy of a combination of two quantitative Aspergillus PCR assays, targeting a mitochondrial and a ribosomal target, in patients with risk factors for invasive aspergillosis (IA) and positive galactomannan (GM) antigen. Forty-four patients with hematological malignancies and risk factors for IA according to revised European Organization for Research on Treatment of Cancer and the Mycoses Study Group criteria (EORTC/MSG) criteria and presenting at least two sequential GM-positive sera were included in the study. Mitochondrial PCR was carried out prospectively on all GM-positive serum samples. Ribosomal PCR was carried out retrospectively on frozen stored sera. The sensitivities of mitochondrial and ribosomal PCRs were 58% and 50%, respectively. The diagnostic test performance was improved by using a combination of both PCR assays and by considering a patient PCR positive when at least two positive results were obtained. The sensitivity, specificity, and positive and negative likelihood ratios were 65%, 94%, and 11.8 and 0.37, respectively. A significant association between fatal outcome at 90 days and positive results of ribosomal PCR assays was observed (adjusted hazard ratio = 8.2; 95% confidence interval [CI] = 1.0 to 65.8; P = 0.048). Our results showed that the combination of two PCR assays targeting mitochondrial and ribosomal Aspergillus DNA improves the sensitivity of PCR in the diagnosis of IA in hematological patients with risk factors and positive GM results. This study also confirms that a positive PCR result is associated with a poor prognosis in these patients and should lead to specific antifungal therapy being introduced immediately.

[Regional audit on fluoroquinolones usage in the hospital and the community: are these antibiotics over-used?]. / Audit régional de l'usage des fluoroquinolones à l'hôpital et en ville : y a-t-il une surconsommation de ces antibiotiques ?

AIM OF THE STUDY: The ecological impact of an over-use or a mis-use of fluoroquinolones (FQs) appears of great importance according to published data. With the objective to set up a regional antibiotic stewardship program, we conducted a regional audit on FQs usage. MATERIAL AND METHODS: [corrected] Ninety general practionners and 15 health care facilities participated to this prospective study. Overall, 511 prescriptions were evaluated (276 from hospital physicians and 235 [46%] from general practionners). The compliance of FQs prescription with national recommendations and with a regional referential was assessed. This regional referential was established in order to preserve FQs. RESULTS: Only 14,3% of the prescriptions complied with the regional referential, even if the choice of FQs were in accordance with national recommendations in 56,8% of the prescriptions. Urinary tract infections (mostly non-complicated) were the most common indication for FQs prescription. CONCLUSION: Analysis of FQs prescriptions shows that there is a significant potential for FQs preservation in Franche-Comté.

[Clinical audit on the use of expensive systemic antifungals in the Besançon University Hospital]. / Audit clinique des prescriptions d'antifongiques systémiques couteux au centre hospitalier universitaire de Besançon.

UNLABELLED: The continuous improvement policy for healthcare quality requires practice evaluation. The principle of a clinical audit is to compare practice to guidelines. Prescription guidelines on antifungal agent use has been available in our hospital since 2003. It was updated in 2005 and 2006. OBJECTIVE: The aim of this study was to assess compliance to guidelines, with an audit of prescriptions: amphotericin B lipid formulation, voriconazole and caspofungin, expensive antifungals concerned by the budget allowance correlated to activity, subject to supplementary reimbursement to the coded Homogeneous Group of Diseases. METHOD: The assessment criteria were: relevance of the indication, absence of a better alternative, complying to recommended dosage, loading dose and timing. This retrospective study dealt with all prescriptions of all departments, from January to May 2007. RESULTS: Hundred and eighteen prescriptions were retrospectively analyzed for 81 patients. The rate of overall conformity was 54%. Antifungal therapy was justified for 113 prescriptions (96%). In 30% of the cases, a more efficient alternative was advised, cheaper or less toxic. The dosage and the charge dosing were right in 92% and 80% of the cases respectively. CONCLUSION: This audit allowed assessing good-use of antifungals. We showed an over-prescription of caspofungin and sometimes insufficient regimen of voriconazole dosages for children. Reporting these audit results and development of new international guidelines stress the need to update local recommendations regularly.

[Evaluation of antibiotic prescription in a French university hospital]. / Evaluation de la prescription antibiotique dans un centre hospitalier universitaire français.

OBJECTIVE: The aim of this study was to evaluate antibiotic prescription in a French university hospital. DESIGN: Our hospital participated in an international European Surveillance of Antimicrobial Consumption (ESAC) project study, including a longitudinal survey of monthly antibiotic use between 1998 and 2005, and a point prevalence study in 2006. All patients in the hospital on the day of survey were included in the study. Antibiotic treatments were assessed according to local antibiotic guidelines. RESULTS: Between 1998 and 2005, antibiotic use increased from 551.9 to 628.5 defined daily doses per 1000 patient-days. This increase was linked to the increase of penicillin and fluoroquinolone consumption. In the point prevalence survey, 251 (27.0%) of the 930 included patients received one or several antibiotics for a total of 395 antibiotic prescriptions. Community-acquired infections were the first indication of treatment (41.8% of prescriptions), hospital-acquired infections accounted for 34.9% of prescriptions, surgical and medical antibiotic prophylaxis for 22.4%. The assessment of antibiotic prescriptions showed that 73.7% of them were in conformity with local recommendations. CONCLUSIONS: This type of study is relevant to identify critical points of inadequate antibiotic use so as to suggest corrective measures to prescribers.

[Risk factors for Abacavir-induced hypersensibility syndrome in the "real world"]. / Facteurs de risque de syndrome d'hypersensibilité à l'Abacavir en pratique clinique de routine.

UNLABELLED: Abacavir (ABC) is a generally well-tolerated NRTI. However, up to 5% of patients may develop hypersensitivity syndrome (HSS) within the first weeks of treatment. The objectives of this study were to describe the side effects of ABC, to evaluate the incidence of the ABC-HSS, and to identify the risk factors of HSS after first exposure to ABC in a cohort of patients followed up in a university HIV clinic. METHODS: The charts of all HIV-infected patients who started ABC between February 1998 and May 2002 were reviewed. HSS was defined as the onset, within 8 weeks of ABC initiation, of either a skin rash associated with at least one of the following symptoms (fever, gastrointestinal symptoms, respiratory symptoms, myalgia, malaise) or at least three of the above symptoms in the absence of rash. A multivariate logistic regression analysis was performed to identify risk factors of HSS. RESULTS: Of the 191 patients studied (134 M, 57 F, mean age 39 years), 53 (27.8%) presented with manifestations that were regarded as potential side-effects of ABC. Ten (5.2%) developed HSS, none of whom died. Two factors were independently associated with an increased risk of HSS: history of allergy to nevirapine (OR 8.1, 95% CI 1.6-40.5, p = 0.02), and being naïve to ART (OR 5.8, 95% CI 1.2-28.5, p = 0.04). CONCLUSION: This study "in the real world" confirms that the incidence of ABC-induced HSS is of about 5%. It also confirms that HSS occurs more frequently in patients with a history of allergy to nevirapine and in ART-naïve patients.

[Prescriptions of aerosol therapy. A survey of practices at the Besançon University Hospital]. / Les conditions de prescription de l'aérosolthérapie. Une enquête de pratique réalisée au CHU de Besançon.

OBJECTIVE: Prescriptions of aerosol sprays concomitantly with other drugs can raise problems of incompatibility. METHODS: Medical practices in the clinical units of the Besançon University Hospital were analyzed to assess the therapeutic indications, the most frequently prescribed drugs, possible admixtures, the nature and volume of solvents used, drug protocols and type of aerosol therapy and nebulizer used. Sixty questionnaires were sent to all the units of the University Teaching Hospital of Besançon. RESULTS: Analysis of 48 questionnaires completed by head nurses showed that 28 different drugs and 26 different admixtures were prescribed. Only 2 of the admixtures had undergone prior validation. Only 7 (26%) of the drug formulations prescribed had received marketing approval. Recognized clinical practices for the administration of aerosol therapy were not applied and the aerosol sessions were not standardized. CONCLUSION: Many prescriptions are carried out without knowledge of the chemical compatibility of co-administered medicines.

[Incomplete prescription: a potential medication error]. / Prescription incomplète: erreur de médication potentielle.

OBJECTIVE: According to the American Society of Health System Pharmacists, an incomplete or imprecise medial order comprises a prescription error. Such errors have potential consequences in terms of mortality, morbidity, prolonged hospital stay and, finally, in health care expenditure. The aim of this study was to determine the rate of incomplete prescriptions observed in a university hospital setting and identify the causes of such imprecisions. METHODS: A prospective analysis of prescriptions for oral medicines ordered by an internal medicine unit of a university hospital was conducted on a daily basis by a pharmaceutical team immediately after the orders were written. A complete prescription was defined as one with the following information: unit dose, formulation, number of doses per day, hour of administration, particular instructions for use. RESULTS: Among the 241 prescription lines analyzed during a 20 day period, 131 (54.2%) were incomplete. The number of doses per day was missing for 7.9%, unit dose for 6.2%, particular instructions for 4.9% and the formulation for 2.9%. DISCUSSION: These findings demonstrated the lack of quality of the prescriptions studied. A treatment scheme totally incompatible with quality prescriptions and a poor understanding of prescription quality were the most probable causes. These two elements reflect the gap between the outdated organizational scheme currently in use and appropriate implementation of the hospital drug distribution circuit.

[Myocardial infarction treated within 4 hrs: comparison of the cost-benefit ratio of 3 thrombolytic treatments: APSAC, rt-PA and streptokinase in 270 patients]. / L'infarctus du myocarde traité avant la 4e heure: comparaison chez 270 patients du rapport coût-efficacité de 3 traitements thrombolytiques: l'APSAC, le rt-PA et la streptokinase.

Two hundred and seventy patients under 71 years of age with myocardial infarction less than 4 hours old, defined by clinical and electrocardiographic criteria, were included in this trial and followed up for 1 year: two groups of 89 and 92 patients were randomised to receive APSAC (30 mg i.v. over 5 minutes) or rt-PA (10 mg bolus + 5000 IU of heparin as a bolus, followed by 90 mg rt-PA over 3 hours) and compared with a control series of 89 consecutive patients treated with streptokinase (1.5 MU in 1 hour). Heparin and aspirin (250 mg/day) were prescribed systematically. A score of efficacy was established from the following 4 parameters: patency of the infarct-related artery on coronary angiography at day 6 +/- 2 (N = 252), dyssynergic score on radiological ventriculography, infarct size on resting Thallium myocardial scintigraphy performed between day 15 and 21 (N = 242) and radionuclide ejection fraction performed at the same time. This score (0-24) was respectively 17.8 +/- 6.4 for rt-PA, 17.7 +/- 6.0 for APSAC and 18.1 +/- 6.0 for streptokinase (NS). The costs of hospital treatment were assessed by including: the cost of thrombolytic therapy (ranging from 1.7% of total cost for streptokinase to 16% for rt-PA), the cost of other treatments and biological investigations (10% of total cost); the cost of followed coronary angiography, in 33% of patients, by an angioplasty (21% of total cost), the cost of hospital stay averaging 17 days (49% of total cost in the rt-PA and APSAC groups and 56% in the streptokinase group NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Cost effectiveness of thrombolytic treatment for myocardial infarction: comparison of anistreplase, alteplase and streptokinase in 270 patients treated within 4 hours.

Two hundred and seventy patients, under 71 years of age and suffering from a less than 4 h infarction diagnosed according to clinical and electrocardiographic criteria, were included: two 90-patient groups were randomized and then treated with either anistreplase (30 mg iv over 5 min) or alteplase (10 mg bolus injection + 5000 IU heparin bolus injection, followed by 90 mg alteplase over 3 h), and compared with a consecutive control series of 90 patients treated with streptokinase (1.5 million U over 1 h). Intravenous heparin and aspirin (250 mg day-1) were then prescribed routinely. The three groups were comparable as regards age (55.2 +/- 10 years), male/female ratio (10.4), the site of the infarction (42% anterior, 55% inferior) and initial clinical seriousness (Killip I = 90%, II = 8%, III = 2%). The patients were thrombolysed in 17 community hospitals, and then referred to a university hospital with catheterization facilities. An efficacy score was determined, based on four parameters: two obtained from coronary angiography and left ventriculography performed on day 6 +/- 2 (N = 252) (asynergic score and patency of the infarct-related artery), one from Tl-tomography performed at rest (infarct size) and one from radionuclide angiography (global left ventricular ejection fraction) performed between day 15 and day 21 (N = 242). The score (range: 0-24 per patient) was 17.8 +/- 6.4 for alteplase, 17.7 +/- 6.0 for anistreplase and 18.1 +/- 6.0 for streptokinase respectively (NS).(ABSTRACT TRUNCATED AT 250 WORDS)