Relevance of fluoroquinolone use in a French teaching hospital.

OBJECTIVE: The objective of our study was to assess the good use of fluoroquinolone (FQ) in a French teaching hospital by a two round relevance review before and after proposal for better use of FQ prescriptions. PATIENTS AND METHODS: The relevance of FQ prescription according to regional guidelines was assessed using a standard card filled out retrospectively by physicians in the 3 previous months, in volunteer hospital wards. Then, two experts checked the relevance of prescriptions according to the regional antibiotherapy guidelines, a book called "Antibioguide", and determined a therapeutic index of adequacy for each card. The first survey (R1) took place in January 2008. The second survey (R2) took place in June 2009 to evaluate the impact of corrective measures, adopted at a meeting of the regional antibiotics commission in January 2009. RESULTS: Physicians in 18 wards completed 475 cards in R1 and physicians in 16 wards completed 263 in R2. The inappropriateness of FQ indication was significantly improved by 57% (P<0.001) between the two rounds and the rate of adequate cards was 33% in R1 and 55% in R2, giving an improvement of 66% (P<0.001). CONCLUSIONS: The improvement of FQ prescriptions and observance of guidelines demonstrate the importance of assessing the state of things before introducing corrective actions. "Antibioguide" was updated at the end of this study.

Antibiolor, the Lorraine antibiology network: update on 7 years of activity.

OBJECTIVE: The objective of the study was to assess the activity of the Antibiolor network, created in 2003, to promote antibiotic stewardship in Lorraine, and comply with the French Ministry guidelines issued in May 2002. METHODS: The authors described the objectives and structure of the network, actions implemented with physicians, pharmacists, community or hospital biologists, and evaluation. RESULTS: The network is made up of five committees supervised by a pilot committee. Over the previous 7 years, various actions were undertaken such as the drafting of guidelines for the hospitals and general practitioners, the creation of a hotline for advice on antibiotic treatment, the creation of a website, and giving information on infectious diseases via a quarterly letter sent to healthcare professionals. The network participated in continuous medical education for practitioners and organized the evaluation of professional practice in Lorraine hospitals. It also helped set up a network of community private laboratories for the study of resistance in the most frequently isolated bacteria, and implemented the monitoring of antibiotic consumption in hospitals. CONCLUSION: After 7 years, the Lorraine antibiology network has proved its beneficial role in terms of communication and scientific information for antibiotic stewardship. The Antibiolor network would like to follow other indicators in the future, such as the evolution of community antibiotic consumption in partnership with the public healthcare insurance.

[Impact of corrective measures on fluoroquinolones prescriptions for urinary tract infections during a 2-round relevance study]. / Amélioration de la prescription des fluoroquinolones dans les infections urinaires. Revue de pertinence à deux tours.

OBJECTIVES: Evaluating the impact of corrective measures on fluoroquinolones (FQ) prescriptions for urinary tract infections (UTI) during a 2-round relevance study on a regional scale. METHODS: FQ prescriptions of voluntary hospitals were checked by an infectious diseases physician and a pharmacist according to regional guidelines. A first round (R1) took place in January 2008, with feedback and proposal for personalized corrective measures in January 2009. A second round (R2) was organized in June 2009. UTI data were extracted and the results of the two rounds were compared. RESULTS: Four hundred and thirty-five and 302 FQ prescriptions for UTI, coming from 28 and 24 different hospitals, were analyzed at R1 and R2, respectively. Thirty-six percent and 55% of these prescriptions were entirely in accordance with regional guidelines, at respectively R1 and R2 (P<0.001). All the analyzed criteria (choice of the molecule, dosage, duration of the treatment) significantly improved between R1 and R2. The route of administration non-significantly deteriorated. The rate of FQ prescriptions for non conform indications decreased from 24% to 12% between R1 and R2 (P<0.05). CONCLUSION: Most hospitals of Lorraine took part in this study, confirming its feasibility on a regional scale. The regional guidelines were reviewed at the end of R2, taking into account the last national guidelines. There was a significant improvement of FQ prescriptions for UTI through better adhesion to the regional guidelines between the two rounds. This is probably due to first turn results feedback, and corrective measures suggestion.

[Relevance of fluoroquinolone use in Nancy's hospital. Results of the first turn]. / Revue de pertinence de la prescription des fluoroquinolones au CHU de Nancy : résultats du premier tour.

OBJECTIVES: The objective was to evaluate the good use of fluoroquinolones in a hospital with a relevance review in the context of an approach to evaluation of professional practices at the regional level initiated by the Antibiolor network. METHOD: In February 2008, in each volunteer service, practitioners filled out a standardized form indicating indication, the name of the fluoroquinolone, route of administration and duration of treatment, retrospectively from 20 medical records on the last 3 months. Each one was analyzed by a binomial (doctors and pharmacists) according to the local Antibioguide. The degree of compliance requirements has been appreciated by a global index of adequacy of therapeutic consisting of six criteria. RESULTS: Eighteen units of Nancy's hospital filled 475 cards. The most frequent indications were pulmonary infections (38 %; 181/475) and urinary (23 %; 111/475). The fluoroquinolone indication was non-conform for 28 % of the cards (133/475). When the fluoroquinolone indication was justified, the association with another antibiotic was considered non-compliant in 20 % of cases (70/342), the choice of the molecule in 18 % (62/342), duration of treatment in 17 % (57/342), the dose in 13 % (45/342) and route of administration in 9 % (30/342). The requirements were entirely conform in 34 % of cases (160/475). CONCLUSION: The results were communicated to each participating service with corrective actions and then this experience has been repeated in May 2009.

[Relevance of fluoroquinolone use in Lorraine: results of the first survey]. / Revue de pertinence des fluoroquinolones en Lorraine: résultats de la première évaluation.

OBJECTIVES: The Antibiolor network assessed the good use of fluoroquinolones (FQ) in the French Lorraine region by a relevance review. METHODS: At the beginning of 2008, the experts in voluntary hospitals filled out a standard card mentioning the indication, FQ name, route, and duration according to prescriptions in the last 3 months. Two experts checked the relevance of prescriptions according to the local Antibioguide, and determined a score of therapeutic adequacy index for each card. Each establishment was given its results. Corrective measures were adopted at a meeting of the regional antibiotics commission in January 2009. RESULTS: One hundred and twenty-four units (61 medical, 33 surgical, 17 ICU, 2 ER, 11 long-stay hospital) in 28 hospitals filled 1538 cards. The most frequent indications were: pulmonary (632), urinary (445), digestive (130). The FQ indication was non-conform for 36% of the cards (n=554). When the FQ indication was justified (984 cards), the chosen molecule was non-conform in 222 cases (23%), dose in 115 cases (12%), duration in 250 cases (25%), and route of administration in 83 cases (8%). The prescriptions were entirely conform for 425 cards (28%). CONCLUSION: The Lorraine hospitals massively took part in this study. The second survey will use the same methodology. The objective will be to reduce the number of unjustified FQ prescriptions and to increase the number of conform cards.

Occult hepatitis B infection in patients infected with HIV: report of two cases of hepatitis B reactivation and prevalence in a hospital cohort.

Patients co-infected with human immunodeficiency virus (HIV) and hepatitis B virus (HBV) are particularly at risk of hepatitis B reactivation. Two cases of patients infected with HIV with isolated anti-HBc antibodies who had experienced an HBV reactivation are described. In the two cases HBV reactivation occurred after withdrawal of anti-retroviral treatment with anti-HBV activity from the patients' highly active antiretroviral therapy (HAART), in accordance with HIV genotypic resistance profiles. Consequently, plasma samples from 383 patients infected with HIV were tested to assess the prevalence of occult HBV infection in the Infectious Diseases Department Unit of Nancy Hospital by investigating serological patterns and HBV replication. Forty-five percent (172/383) of patients had had previous contact with HBV. Isolated anti-HBc antibodies were observed in 48 patients (48/383, 12%) and, among these, 2 were HBV-DNA positive. Since 75% (288/383) of the patients were treated with HAART, including at least one drug active against HBV, occult HBV infection was perhaps unrecognized. In cases of HIV infection, all patients should be screened for HBV infection and the knowledge of HBV status as well as the monitoring of HBV viral load are essential in preventing HBV reactivation. Consideration should be given to the continuation of drugs with anti-HBV activity in co-infected patients receiving HAART, as cessation of therapy is associated with a risk of HBV reactivation. At least, close monitoring of the HBV viral load is warranted in such situations.

Liver-related deaths in HIV-infected patients between 1995 and 2005 in the French GERMIVIC Joint Study Group Network (Mortavic 2005 study in collaboration with the Mortalité 2005 survey, ANRS EN19).

BACKGROUND: More than 10 years after the introduction of combination antiretroviral therapy (cART), we examined the trend in the proportion of deaths caused by end-stage liver disease (ESLD) in HIV-infected adults in France between 1995 and 2005. DESIGN AND METHODS: In 2005, 34 departments prospectively recorded all deaths in HIV-infected patients who were followed in those departments (around 24 000). RESULTS: were compared with those of four previous cross-sectional surveys conducted since 1995 using the same methodology. Results Among 287 reported deaths in 2005, 100 (35%) were related to AIDS, and 48 (17%) to ESLD. Three out of four patients who died from ESLD-related causes had chronic hepatitis C. Excessive alcohol consumption was reported in approximately half of the patients (48%). At death, 62% of patients had undetectable HIV viral load and the median CD4 count was 237 cells/microL. From 1995 to 2005, the proportion of deaths caused by ESLD increased from 2 to 17% (P<0.001). The proportion of deaths caused by hepatocellular carcinoma increased from 5% in 1995 to 25% in 2005 (P=0.0337). CONCLUSIONS: Over the 10 years from 1995 to 2005, the proportion of deaths caused by hepatitis C virus-related ESLD has increased in HIV-infected patients. ESLD is currently a leading cause of death in this population, with hepatocellular carcinoma representing a quarter of liver-related deaths. Recommendations for the detection of hepatocellular carcinoma should be strictly applied in these patients.

[Isolation of an acid-alcohol resistant bacillus (BAAR) in the febrile HIV infected patients: Mycobacterium tuberculosis (MT) or Mycobacterium avium complex (MAC)?]. / Isolement d'un bacille acido-alcoolorésistant (BAAR) chez le patient VIH+ fébrile: bacille de Koch (BK) ou Mycobacterium avium complex (MAC)?

The detection of BAAR in HIV infected patients with CD4 < 100/mm3 and with an infectious syndrome urge on beginning an effective treatment against Mycobacterium tuberculosis and/or Mycobacterium avium Complex, before the results of the culture are known. Our purpose was to search clinical and biological features to angle directly the diagnosis towards a tuberculosis or not, and to start the most suitable treatment. This retrospective study, from 1986 to 1993, stated on 54 patients who had at least one sample with positive BAAR (blood, marrow, stools, sputum or urine cultures). From these cultures, MAC was isolated on 37 patients and BK on 17. The both groups were similar for age, sex, risk factor, number of opportunistic infections, delay between the date of AIDS and the discovery of a positive BAAR, and Ag p24. However, a significant difference in favor of a MAC disease exists regarding about: disseminated infections (92% vs 53%), digestive troubles (57% vs 23.5%), anterior or concomitant CMV infection (49% vs 9%), isolation of BAAR in blood culture (54% vs 20%) or in stools culture (76% vs 33%), leucopenia (2850/mm3 +/- 1520 vs 4124/mm3 +/- 2232), anémia (Hb 9.1 g/dl +/- 1.5 vs 10.1 g/dl +/- 1.6). The univariated analysis of results allowed us to conclude that the presence of one among those parameters must induce the prescription of a suitable treatment against MAC.

[Nutritional and trace elements status in cardiomyopathies in the elderly]. / Statut nutritionnel et en oligo-éléments dans les cardiomyopathies du sujet âgé.

Nutritionnal status remain poor in hospitalized elderly for cardiopathy compared to healthy controls, secondary to bad general status. Selenium rate appears significantly lower in ischemic cardiomyopathy than in valvular or hypertension cardiopathy.