Implementation of antibiotic stewardship programmes in French ICUs in 2018: a nationwide cross-sectional survey.

BACKGROUND: Antibiotic stewardship programmes have a pivotal role in ICUs, but the level of implementation of these programmes at the regional or national level is not well known. OBJECTIVES: The aim of our study was to assess the level of implementation of antibiotic stewardship programmes in French ICUs. METHODS: We conducted a nationwide cross-sectional survey from January to March 2018 using an online questionnaire sent as an E-mail link to ICU specialists (one questionnaire per ICU). RESULTS: Overall, 113 out of 206 (55%) ICUs participated. Access to local epidemiology regarding bacterial resistance and antibiotic consumption data was reported in 84% and 65% of ICUs, respectively. Local guidelines for antibiotic use were available in 54% of ICUs. The duration of empirical antibiotic therapy was limited in 46% of cases, following the recommendation of an external expert in 33%. An antibiotic stewardship programme leader was reported at the hospital level by 94% of respondents, being an infectious disease physician in 80%. His/her role in the ICU was mostly to discuss specific cases (50%) and to provide advice on antibiotic prescriptions (26%). Regarding microbiological diagnosis, blood cultures were not processed at night or during weekends in 57%. Molecular biology and MS techniques were available in 62% and 59% of cases, respectively. Therapeutic drug monitoring of ß-lactams was available in 46% of cases. Forty-three percent of respondents knew the expression 'antimicrobial/antibiotic stewardship'. CONCLUSIONS: Antibiotic stewardship programmes are not optimally implemented in French ICUs. Improvement efforts and regular monitoring of the level of implementation are needed.

The ANTIBIOPERF study: a nationwide cross-sectional survey about practices for ß-lactam administration and therapeutic drug monitoring among critically ill patients in France.

Our objective was to assess current practices about the administration (intermittent, extended, or continuous infusions) and therapeutic drug monitoring (TDM) of ß-lactam antibiotics and vancomycin in France. We conducted a nationwide cross-sectional survey in May-August 2015, using an online questionnaire, sent as an e-mail link to infectious disease specialists and intensive care specialists through national mailing lists. We used clinical vignettes of critically ill patients to assess physicians' practices about administration and TDM practices for amoxicillin, cloxacillin, piperacillin/tazobactam, cefotaxime, ceftazidime, cefepime, meropenem and vancomycin. In all, 507 physicians participated (507/1200, response rate 42%). TDM was rarely available for ß-lactams (from 16.5% (81/490) for cloxacillin to 30% (145/490) for ceftazidime), whereas vancomycin TDM was available in 97% (477/490) of the cases. In the clinical vignettes, ceftazidime and piperacillin/tazobactam were the ß-lactams administered most frequently by extended or continuous infusions (76% (336/440) and 57% (252/444), respectively). Gaps in knowledge about the duration of stability of intravenous ß-lactams were common (correct answers ranged from 8% (35/432) for cloxacillin to 33% (146/438) for ceftazidime). Most physicians (77%, 339/442) were convinced of the value of extended or continuous infusions for ß-lactams in critically ill patients, but 48% (211/442) did not have access to practical guidelines. Our survey found that most infectious disease and intensive care specialists are favourable to optimized administration of ß-lactams in critically ill patients. But the lack of guidelines and limited TDM availability for ß-lactams in hospitals are potential barriers to its implementation.

Neurological complications of infective endocarditis: new breakthroughs in diagnosis and management.

Neurological complications are frequent in infective endocarditis (IE) and increase morbidity and mortality rates. A wide spectrum of neurological disorders may be observed, including stroke or transient ischemic attack, cerebral hemorrhage, mycotic aneurysm, meningitis, cerebral abscess, or encephalopathy. Most complications occur early during the course of IE and are a hallmark of left-sided abnormalities of native or prosthetic valves. Ischemic lesions account for 40% to 50% of IE central nervous system complications. Systematic brain MRI may reveal cerebral abnormalities in up to 80% of patients, including cerebral embolism in 50%, mostly asymptomatic. Neurological complications affect both medical and surgical treatment and should be managed by an experimented multidisciplinary team including cardiologists, neurologists, intensive care specialists, and cardiac surgeons. Oral anticoagulant therapy given to patients presenting with cerebral ischemic lesions should be replaced by unfractionated heparin for at least 2 weeks, with a close monitoring of coagulation tests. Recently published data suggest that after an ischemic stroke, surgery indicated for heart failure, uncontrolled infection, abscess, or persisting high emboli risk should not be delayed, provided that the patient is not comatose or has no severe deficit. Surgery should be postponed for 2 to 3 weeks for patients with intracranial hemorrhage. Endovascular treatment is recommended for cerebral mycotic aneurysms, if there is no severe mass effect. Recent data suggests that neurological failure, which is associated with the location and extension of brain injury, is a major determinant for short-term prognosis.

[Traumatic injuries of the descending thoracic aorta apart from the isthmus: diagnosis and therapeutic approach]. / Les lésions traumatiques de l'aorte descendante en dehors de l'isthme: particularités diagnostiques et thérapeutiques.

Lesions involving the descending thoracic aorta apart from isthmus are rare and less known by anesthetists. We report the clinical course of two severely injured patients who sustained a thoracic aortic rupture in whom favorable outcome was achieved with endovascular treatment. Mechanisms, diagnosis and therapeutics aspects of these rare lesions are discussed according to literature.

[Inadvertent peripheral nerve catheter shearing occurring during ultrasound guidance]. / Cisaillements accidentels de cathéters périnerveux lors de poses échoguidées.

We report two cases of inadvertent peripheral nerve catheter (PNC) shearing that occurred during placement under ultrasound guidance. Same PNC kits were used in two different hospitals. The possible causes of PNC shearing are exposed. Differences and mechanical properties of different PNC kits are discussed. The management of retained PNC carried out in these cases is presented.