Presentation, management and outcome of heparin-induced thrombocytopenia after valvular heart surgery.

OBJECTIVES: The use of heparin exposes patients to heparin-induced thrombocytopenia, which is a challenging issue for both diagnosis and patient management. We sought to describe the clinical presentation, management and outcome of a series of patients diagnosed with heparin-induced thrombocytopenia after heart valve surgery. METHODS: All consecutive patients diagnosed with heparin-induced thrombocytopenia during the postoperative period of heart valve surgery over a 6-year period were prospectively enrolled in a single-centre registry. Clinical and biological data were collected. In-hospital and mid-term outcomes were assessed. Information regarding the occurrence of all medical events including death, recurrence of thromboembolic events and/or thrombocytopenia was collected. RESULTS: We identified 93 patients (incidence proportion = 2.8%). Most patients (82%) were asymptomatic with isolated thrombocytopenia at the time of diagnosis. The other main circumstance of diagnosis was the occurrence of thromboembolic events in 17 patients (6 strokes, 10 prosthetic valve thrombosis and 1 peripheral embolic event). The in-hospital mortality rate was 1%. No thrombolysis, interventional procedure or redo surgery was performed. Danaparoid sodium was used as heparin replacement therapy in most cases (96%) and leading to complete and uneventful thrombus resolution in all cases with only one possibly related major bleeding complication. During a mean follow-up of 36 ± 20 months, no patient presented recurrence of any heparin-induced thrombocytopenia-related complication. CONCLUSIONS: In this contemporary series of patients, heparin-induced thrombocytopenia incidence was low and isolated thrombocytopenia was the most frequent presentation. Conservative management with early diagnosis and substitutive anticoagulation therapy introduction was associated with a low rate of clinical events and a remarkably good outcome with a low mortality rate.

Predictors of insufficient amikacin peak concentration in critically ill patients receiving a 25 mg/kg total body weight regimen.

PURPOSE: Amikacin requires pharmacodynamic targets of peak serum concentration (Cmax) of 8-10 times the minimal inhibitory concentration, corresponding to a target Cmax of 60-80 mg/L for the less susceptible bacteria. Even with new dosing regimens of 25 mg/kg, 30% of patients do not meet the pharmacodynamic target. We aimed to identify predictive factors for insufficient Cmax in a population of critically ill patients. METHODS: Prospective observational monocentric study of patients admitted to a general ICU and requiring a loading dose of amikacin. Amikacin was administered intravenously at the dose of 25 mg/kg of total body weight. Independent determinants of Cmax < 60 mg/L were identified by mixed model multivariate analysis. RESULTS: Over a 1-year period, 181 episodes in 146 patients (SAPS 2 = 51 [41-68]) were included. At inclusion, the SOFA score was 8 [6-12], 119 (66%) episodes required vasopressors, 150 (83%) mechanical ventilation, and 81 (45%) renal replacement therapy. The amikacin Cmax was 69 [54.9-84.4] mg/L. Overall, 60 (33%) episodes had a Cmax < 60 mg/L. The risk of Cmax < 60 mg/L associated with BMI < 25 kg/m(2) varied across quarters of inclusion. Independent risk factors for Cmax < 60 mg/L were a BMI < 25 kg/m(2) over the first quarter (odds ratio (OR) 15.95, 95% confidence interval (CI) [3.68-69.20], p < 0.001) and positive 24-h fluid balance (OR per 250-mL increment 1.06, 95% [CI 1.01-1.11], p = 0.018). CONCLUSIONS: Despite an amikacin dose of 25 mg/kg of total body weight, 33% of patients still had an amikacin Cmax < 60 mg/L. Positive 24-h fluid balance was identified as a predictive factor of Cmax < 60 mg/L. When total body weight is used, low BMI tended to be associated with amikacin underdosing. These results suggest the need for higher doses in patients with a positive 24-h fluid balance in order to reach adequate therapeutic targets.

Medication reconciliation: a prospective study in an internal medicine unit.

BACKGROUND: Medication reconciliation has proved its effectiveness at improving drug-prescription safety. This study was undertaken to assess the impact of an intervention aimed at decreasing the discrepancies between a patient's usual treatment(s) and medications prescribed at admission. METHODS: Our study was conducted from November 2010 to May 2011. Discrepancies between home medication( s) and drugs prescribed to every patient aged C65 years, transferred from the Emergency Department and hospitalized in the Internal Medicine Unit, were analyzed. RESULTS: During this 6-month period, 170 patients were prospectively included, with a total of 1,515 medicines reconciled. The unintentional discrepancy rate declined from 4.3 to 0.9 % after the intervention. The main sources of discrepancies concerned alimentary tract and metabolism (25.7 %), cardiovascular (24 %), and nervous system drugs (19.4 %). CONCLUSIONS: The results of this study demonstrated that acquisition of patients' medication history is often incomplete or incorrect. Pharmacists seem to be especially well suited to help medical teams rectify this situation. However, the cost effectiveness of this intervention needs further assessment.

Variability of intestinal colonization with third-generation cephalosporin-resistant Enterobacteriaceae and antibiotic use in intensive care units.

OBJECTIVES: Healthcare-associated infections due to third-generation cephalosporin-resistant Enterobacteriaceae (CRE) have become a major public health threat, especially in intensive care units (ICUs). We assessed and compared ß-lactam use, the prevalence of colonization with CRE at admission and the incidence of CRE acquisition across ICUs. PATIENTS AND METHODS: A cohort study was conducted in 10 ICUs of the Paris (France) metropolitan area between November 2005 and February 2006. Antibiotic use was recorded prospectively in all patients admitted during the study period. Rectal swabs were collected at admission, twice weekly thereafter, before ß-lactam prescription and before discharge. RESULTS: A total of 893 patients provided 3453 rectal swabs; 793 of the patients were newly admitted, mostly for medical reasons (80.7%). On admission, 74 patients (9.6%) were colonized with CRE, including 32 with an extended-spectrum ß-lactamase (ESBL)-producing strain. Among the remaining 694 naive patients, 94 acquired CRE during their follow-up, including 31 with an ESBL-producing strain. Incidence rates of colonization ranged from 8.8 to 21.0/1000 patient-days for all CRE, and from 1.4 to 10.9/1000 patient-days for ESBL producers. A majority of patients (68.3%) were prescribed ß-lactams during their ICU stay, with defined daily doses ranging from 428 to 985/1000 patient-days. Across ICUs, prescriptions of all antibiotics, ß-lactams and carbapenems were significantly correlated to incidence rates of colonization with ESBL-producing CRE. CONCLUSIONS: The standardized and systematic follow-up of patients in 10 ICUs revealed great heterogeneity in the rates of colonization with ESBL- and non-ESBL-producing CRE, as well as in antimicrobial prescription practices.

Do case vignettes accurately reflect antibiotic prescription?

BACKGROUND: Antibiotic prescription is frequently inappropriate in hospitals. Our objective was to evaluate whether the quality of antibiotic prescription could be measured using case vignettes to assess physicians' knowledge. METHODS: The study was conducted in 2 public teaching hospitals, where 33/41 units and 206/412 physicians regularly prescribing antibiotics to inpatients agreed to participate. A cross-sectional survey of knowledge was performed using 4 randomly assigned case vignette sets. Curative antibiotic prescriptions were then evaluated using standard criteria for appropriateness at initiation (day 0), after 2-3 days of treatment (days 2-3), and at treatment completion. We compared knowledge of the physicians with their observed prescriptions in the subset of 106 physicians who completed the case vignettes and prescribed antibiotics at least once. RESULTS: The median global case vignette score was 11.4/20 (interquartile range, 8.9-14.3). Of the 483 antibiotic prescriptions, 314 (65%) were deemed appropriate at day 0, 324 (72%) on days 2-3, and 227 (69%) at treatment completion. Prescriptions were appropriate at all 3 time points in only 43% of patients. Appropriate prescription was positively and independently associated with emergency prescription on day 0, documented infection on days 2-3, and 1 of the 2 hospitals at treatment completion. In addition, appropriateness at the 3 evaluation times was positively associated with prescription in anesthesiology or the intensive care unit. Case vignette scores above the median were significantly and independently associated with appropriate antibiotic prescription on days 2-3 and at treatment completion. CONCLUSIONS: Case vignettes are effective for identifying physicians or hospitals whose knowledge and practice regarding antibiotic prescription require improvement.

Antibiotic use: knowledge and perceptions in two university hospitals.

OBJECTIVES: To investigate knowledge and perceptions about antibiotic prescription in two university hospitals. METHODS: Physicians completed four case vignettes describing infections and a questionnaire. For each vignette, the physicians were asked to determine whether hospital admission and antibiotic treatment were needed; whether a treatment change was needed; and the duration of antibiotic treatment. The questionnaire collected data on beliefs and perceptions regarding antibiotic prescription. RESULTS: Of 412 eligible physicians, 206 agreed to participate. Factors associated with a vignette score above the median were anaesthesiologist/intensivist (adjusted odds ratio, 3.09; P=0.02), perception of inappropriate antibiotic use as risky for the patient (adjusted odds ratio, 2.84; P=0.03) and self-efficacy (adjusted odds ratio, 2.18; P=0.02), whereas being a surgeon was associated with a vignette score lower than the median (adjusted odds ratio, 0.14; P<0.0001). CONCLUSIONS: The high participation rate suggested awareness of antibiotic use. Educational programmes specifically targeted at surgeons are needed. We identified cognitive factors that affect knowledge of antibiotic prescription, and may help in the design of education programmes and interventions aimed at improving antibiotic use.

The pharmacokinetic profile of voriconazole during continuous high-volume venovenous hemofiltration in a critically ill patient.

In critically ill patients, dosage adjustment of voriconazole could be helpful when high-volume continuous venovenous hemofiltration is needed. Voriconazole pharmacokinetics were studied in an anuric critically ill patient, under high-volume continuous venovenous hemofiltration, over an interval period after a 4-mg/kg dose of voriconazole. Arterial and effluent voriconazole concentrations were measured after liquid phase extraction using a high-pressure liquid chromatography. The extrapolate area under the curve(0-12h) of voriconazole was 65 mg/h/L. The total body clearance of voriconazole was 5.4 L/h with a half-life of 16.5 hours and a distribution volume of 128.6 L. The estimated sieving coefficient was 0.58 and the filtration clearance 1.39 L/h. High-volume continuous venovenous hemofiltration could affect voriconazole disposition in contrast with other techniques. Besides, we observed voriconazole accumulation consequence of the saturation of the metabolic clearance resulting from multiple organ failure. Dosage adjustment seems to be required in these conditions, but this observation must be confirmed by a clinical study.

Care related pain in hospitalized patients: a cross-sectional study.

CONTEXT: Care-related pain includes pain occurring during transportation, movement, diagnostic imaging, physical examination, or treatment. Its prevalence has never been assessed in a large adult inpatient population. OBJECTIVE: To identify the procedures likely to induce or increase pain in hospital patients, attempting to separate the most painful from those reported as most frequently inducing pain. DESIGN: A single-day cross-sectional survey conducted in two large French teaching hospitals, including all hospitalized patients, free of communication problems. One third was randomly selected and interviewed about the painful episodes that had occurred or were associated with the procedures performed during the previous two weeks. Patients were interviewed using a structured questionnaire. RESULTS: Six-hundred-eighty-four patients were randomly selected. Six-hundred-seventy-one painful events were reported in 55% of the patients, with an average of 1.8 events/patient. Fifty-two percent of the painful events were associated with procedures performed by non-medical staff; 38% of the painful episodes occurred during procedures involving vascular puncture and 24% during patients' mobilization. In 57% of painful procedures, pain was rated as severe or extremely severe. The most painful procedures were invasive procedures, other than vascular and non vascular punctures (74% of severe and extremely severe painful episodes). Maximum pain intensity was rated higher for procedures that were repeated than for those experienced only once (62% versus 53%, p=0.02). CONCLUSION: This survey gives new insight into our daily practice. Proper management of care-related pain should be a major concern of all hospital staff to improve the quality of our health care.