Family physicians' practices and attitudes towards HPV vaccination since extension of HPV vaccination to males.

OBJECTIVES: To describe family physicians' (FP) practices and attitudes towards HPV vaccination guidelines since its extension to males in 2021, and to identify levers to promote HPV vaccination in all adolescents. PATIENTS AND METHODS: Cross-sectional study among FPs established in France in 2021. We collected sociodemographic data, practices, opinions, and attitudes towards vaccination, and FPs' demands regarding training and information about HPV. We used logistic regression models to identify the variables associated with HPV vaccination proposal. RESULTS: Of 530 FPs included, 469 (88.5%) reported that they systematically proposed HPV vaccines to girls vs 335 (63.2%) to boys. A total of 366 (69.0%) FPs reported an increase in HPV vaccines proposal to all adolescents since the extension of HPV vaccination to males recommended by French guidelines. However, factors associated with HPV vaccination proposal differed by target females and target males. Setting and mode of practice, opinion about the number of recommended vaccines and HPV vaccines, and demands of training on HPV vaccines were associated with HPV vaccination proposal to target females. Whereas academic status, opinion about HPV vaccination guidelines extension to males, using continuing medical education as the main source of information on HPV vaccines, and demands for training on HPV vaccines were associated with HPV vaccination proposal to target males. CONCLUSIONS: Extension of HPV vaccination to males in French guidelines might have had a favorable impact on HPV vaccination proposal by FPs to adolescents. However, levers to promote HPV vaccination might differ according to the target population sex.

Harnessing the wisdom of crowds can improve guideline compliance of antibiotic prescribers and support antimicrobial stewardship.

Antibiotic overprescribing is a global challenge contributing to rising levels of antibiotic resistance and mortality. We test a novel approach to antibiotic stewardship. Capitalising on the concept of "wisdom of crowds", which states that a group's collective judgement often outperforms the average individual, we test whether pooling treatment durations recommended by different prescribers can improve antibiotic prescribing. Using international survey data from 787 expert antibiotic prescribers, we run computer simulations to test the performance of the wisdom of crowds by comparing three data aggregation rules across different clinical cases and group sizes. We also identify patterns of prescribing bias in recommendations about antibiotic treatment durations to quantify current levels of overprescribing. Our results suggest that pooling the treatment recommendations (using the median) could improve guideline compliance in groups of three or more prescribers. Implications for antibiotic stewardship and the general improvement of medical decision making are discussed. Clinical applicability is likely to be greatest in the context of hospital ward rounds and larger, multidisciplinary team meetings, where complex patient cases are discussed and existing guidelines provide limited guidance.

Antibiotic use and resistance: a nationwide questionnaire survey among French dentists.

The aim of this survey was to describe the attitudes and self-reported practices of French dentists towards antibiotic use and resistance and to compare practices with national guidelines. A nationwide cross-sectional internet-based survey was conducted among the 41,800 French dentists. The online questionnaire was distributed through professional networks from April 2017 to April 2018. Seven-hundred seventy-five dentists participated but only 455 questionnaires were complete enough to be included in the analyses. Amoxicillin was the most frequently prescribed antibiotic (65.8%, 1783/2711), followed by spiramycin + metronidazole fixed-dose combination (11.6%, 312/2711) and amoxicillin-clavulanic acid (10.3%, 279/2711). The main indications for use were abscess (349/423, 82.5%), cervicofacial cellulitis (74.2%, 314/423), and pericoronitis (58.6%, 239/408). Most dentists (90.5%, 381/421) considered that antibiotic resistance is of concern but only half of them (56.3%, 238/423) felt adequately informed about antibiotic use. Many dentists did not comply with the national guidelines: the majority of them declared inappropriate antibiotic prescriptions for 11/17 clinical situations. They did not prescribe antibiotics for 5/6 clinical situations requiring prophylaxis. They reported that the publication of clinical guidelines is the main factor influencing their prescriptions (71.0%, 299/421). They wished to receive regular updates of national guidelines in the form of practical sheets (93.0%, 172/185). French dentists should urgently be targeted by antibiotic stewardship initiatives.

Antibiotic therapy in case of positive cultures of kidney transplant preservation fluid: a nationwide survey of prescribing practices.

Our survey aimed to describe current prescribing practices for perioperative antibiotic prophylaxis in French kidney transplant centers. We conducted a nationwide cross-sectional clinical vignette-based survey that we sent via email to hospital practitioners involved in perioperative management of kidney transplant patients (KTR). Nearly half of practitioners contacted (182/427, 42.6%) were respondents. A total of 167 getting enough kidney transplant activity were eligible for the survey. The response rate was 50.7% (68/134) among interns and 33.8% (99/293) among seniors. Positive perfusion fluids (PF) cultures for methicillin-susceptible Staphylococcus aureus were associated with antibiotic prescribing in 35% of cases, with no difference in prescribing in patients with diabetes, obesity, or delayed graft function. Antibiotic prescribing was most frequent with Pseudomonas aeruginosa (67%) and Klebsiella pneumoniae strains producing extended spectrum ß-lactamases (57%). About 77%, 16%, and 13% of respondents, respectively, reported the existence of local practice guidelines for surgical antibiotic prophylaxis, a standardized approach for antibiotic prescribing in case of positive kidney transplant PF cultures, and local practice guidelines for systematical antibiotic prophylaxis in the early post-transplant period. In France, antibiotic prophylaxis practices in the perioperative kidney transplant period are very heterogeneous. To prevent unnecessary prescribing and bacterial resistance, evidence-based practice guidelines should be developed.

Proxy indicators to estimate the appropriateness of medications prescribed by paediatricians in infectious diseases: a cross-sectional observational study based on reimbursement data.

BACKGROUND: We previously developed proxy indicators (PIs) that can be used to estimate the appropriateness of medications used for infectious diseases (in particular antibiotics) in primary care, based on routine reimbursement data that do not include clinical indications. OBJECTIVES: To: (i) select the PIs that are relevant for children and estimate current appropriateness of medications used for infectious diseases by French paediatricians and its variability while using these PIs; (ii) assess the clinimetric properties of these PIs using a large regional reimbursement database; and (iii) compare performance scores for each PI between paediatricians and GPs in the paediatric population. METHODS: For all individuals living in north-eastern France, a cross-sectional observational study was performed analysing National Health Insurance data (available at prescriber and patient levels) regarding antibiotics prescribed by their paediatricians in 2017. We measured performance scores of the PIs, and we tested their clinimetric properties, i.e. measurability, applicability and room for improvement. RESULTS: We included 116 paediatricians who prescribed a total of 44 146 antibiotic treatments in 2017. For all four selected PIs (seasonal variation of total antibiotic use, amoxicillin/second-line antibiotics ratio, co-prescription of anti-inflammatory drugs and antibiotics), we found large variations between paediatricians. Regarding clinimetric properties, all PIs were measurable and applicable, and showed high improvement potential. Performance scores did not differ between these 116 paediatricians and 3087 GPs. CONCLUSIONS: This set of four proxy indicators might be used to estimate appropriateness of prescribing in children in an automated way within antibiotic stewardship programmes.

Microbiological epidemiology of preservation fluids in transplanted kidney: a nationwide retrospective observational study.

OBJECTIVES: Kidney transplant recipients are at high-risk for donor-derived infections in the early post-transplant period. Transplant preservation fluid (PF) samples are collected for microbiological analysis. In case of positive PF cultures, the risk for the recipient is unknown and there is no consensus for prescribing prophylactic antibiotics. This nationwide observational study aimed to determine the epidemiology of bacterial and fungal agents in kidney transplant PF cultures and identify risk factors associated with positive PF cultures. METHODS: We performed a retrospective observational study on the following data collected from a national database between October 2015 and December 2016: characteristics of donor, recipient, transplantation, infection in donor and PF microbiological data. RESULTS: Of 4487 kidney transplant procedures, including 725 (16.2%, 725/4487) from living donors, 20.5% had positive PF cultures (living donors: 1.8%, 13/725; deceased donors: 24.1%, 907/3762). Polymicrobial contamination was found in 59.9% (485/810) of positive PF cultures. Coagulase-negative staphylococci (65.8%, 533/810) and Enterobacteriaceae (28.0%, 227/810) were the most common microorganisms. Factors associated with an increased risk of positive PF cultures in multivariable analysis were (for deceased-donor kidney transplants): intestinal perforation during procurement (OR 4.4, 95% CI 2.1-9.1), multiorgan procurement (OR 1.4, 95% CI 1.1-1.7) and en bloc transplantation (OR 2.5, 95% CI 1.3-4.9). Use of perfusion pump and donor antibiotic therapy were associated with a lower risk of positive PF cultures (OR 0.4, 95% CI 0.3-0.5 and OR 0.6, 95% CI 0.5-0.7, respectively). CONCLUSION: In conclusion, 24% of deceased-donor PF cultures were positive, and PF contamination during procurement seemed to be the major cause.

Impact of the French Infectious Diseases Society's (SPILF) proposals for shorter antibiotic therapies.

OBJECTIVE: To compare the practices of French infection specialists related to antibiotic therapy duration between 2016 and 2018. METHODS: We conducted two identical surveys (in 2016 and 2018) targeting hospital-based infection specialists (medical physicians, pharmacists) who gave at least weekly advice on antibiotic prescriptions. The questionnaire included 15 clinical vignettes. Part A asked about the durations of antibiotic therapies they would usually advise to prescribers, and part B asked about the shortest duration they would be willing to advise for the same clinical situations. RESULTS: We included 325 specialists (165 in 2016 and 160 in 2018), mostly infectious disease specialists (82.4%, 268/325), members of antibiotic stewardship teams in 72% (234/325) of cases. Shorter antibiotic treatments (as compared with the literature) were advised to prescribers in more than half of the vignettes by 71% (105/147) of respondents in 2018, versus 46% (69/150) in 2016 (P<0.001). Guidelines used by participants displayed fixed durations for 77% (123/160) of cases in 2018 versus 21% (35/165) in 2016. Almost all respondents (89%, 131/160) declared they were aware of the 2017 SPILF's proposal. CONCLUSION: The release of guidelines promoting shorter durations of antibiotic therapy seems to have had a favourable impact on practices of specialists giving advice on antibiotic prescriptions.

Perceptions, attitudes, and practices of French junior physicians regarding antibiotic use and resistance.

OBJECTIVES: To assess the perceptions, attitudes, and practices of French junior physicians regarding antibiotic use and resistance, and then to identify the characteristics of junior physicians associated with appropriate practices of antibiotic use. METHOD: European junior physicians received an email invitation to complete a 49 item web questionnaire between September 2015 and January 2016. We present the French data. Multivariate regression models were used to identify the characteristics of junior physicians associated with appropriate prescription practices and with consideration of the antibiotic prescription consequences. RESULTS: The questionnaire was completed by 641 junior physicians: family medicine (37%), other medical specialties (e.g., pediatrics, internal medicine, neurology: 45%), surgical specialties (11%), and anesthesiology-intensive care specialty (7%). Most respondents (93%) declared being aware of the risk of bacterial resistance and 41% acknowledged prescribing antibiotics more often than necessary. Two factors were independently associated with appropriate prescription practices: a high perceived level of education on antibiotic use (OR=1.51; 95% CI [1.01-2.30]) and a medical specialty (OR=1.69; 95% CI [1.16-2.46]). Factors independently associated with taking into account adverse events of antibiotics were a good perceived knowledge of antibiotics (OR=3.71; 95% CI [2.09-6.61]), and a high perceived education level on antibiotics (OR=1.70; 95% CI [1.11-2.58]). CONCLUSION: Our data can help better define interventions targeting junior physicians in antibiotic stewardship programs.

Ultrasound assessment of gastric content in the immediate postpartum period: a prospective observational descriptive study.

INTRODUCTION: Pulmonary aspiration of gastric contents in pregnant women undergoing general anesthesia or sedation/analgesia in the peripartum period is a feared complication in obstetric anesthesia. We assessed the changes in antral cross-sectional area (CSA) with ultrasonography in laboring women and in the immediate postpartum period. PATIENTS AND METHODS: In an observational study in a university-affiliated maternity, gastric ultrasonography examinations were performed in non-consecutive laboring women, after epidural analgesia insertion and after childbirth. Assessment of antral CSA, difficulty of performance on a numerical scale, and factors that could influence gastric content were noted. A cut-off value of 381 mm2 was taken for the diagnosis of empty stomach. RESULTS: One hundred women were enrolled in the study. Median antral CSA was 469 mm2 [25th-75th] [324-591] after epidural insertion and 427 mm2 [316-574] after delivery. Antral CSA was ≥ 381 mm2 in 59 of 90 women (65%) after epidural insertion vs. 48 of 100 women (48%) after delivery (P = 0.59). Median variation of antral CSA between two measurements was 36 mm2 [-42 to 114]. Gastric ultrasonography was significantly more difficult to perform during labor than immediately post-delivery (median difficulty score 5 [2-7] vs. 2 [1-4], P < 0.0001). No risk factors (pain, anxiety, diabetes, smoking) were significantly associated with the occurrence of full stomach post-delivery. CONCLUSION: This study demonstrated that 48% of parturients in the immediate postpartum period presented an antral CSA ≥ 381 mm2 , cut-off being accepted for diagnosis of empty stomach and emphasizes the need for re-assessing before any general anesthetic procedure.

Reliability of self-reported recent antibiotic use among the general population: a cross-sectional study.

OBJECTIVES: This study aimed at evaluating the reliability of self-reported recent antibiotic use, including ability to name the antibiotic, among pharmacy customers from the general population. METHODS: This cross-sectional observational study of adults took place in pharmacies in northeastern France from January to April 2016. Participants were asked if they had used any antibiotics in the preceding 4 months and if so, to name them. Their reports were compared with an electronic pharmacy dispensing record listing all of the medication dispensed to them in France. RESULTS: The study included 653 individual customers from 15 pharmacies. Antibiotics had been dispensed 325 times, according to the records, but the patients reported only 237 courses of treatment. Agreement between self-report and the electronic record about whether or not they had used an antibiotic was 80% (κ 0.60). Among the discordant responses, 57% (81/143) involved underreporting. Only 24% (79/325) of the patients could name the antibiotic for each course of treatment; 49% (160/325) could not. The multivariate analysis showed that patients who had purchased an antibiotic in the previous 30 days were 2.5 times more likely to know its name (p 0.01). CONCLUSIONS: Participants' self-reports were relatively reliable for recent use of an antibiotic, but not for its name. Because physicians cannot base prescription decisions on these self-reports only, an electronic pharmacy dispensing file shared among prescribers would be useful.

[Evaluation of the theoretical teaching of postgraduate medical students in France]. / Évaluation nationale de l'enseignement théorique du troisième cycle des études médicales en France.

OBJECTIVES: In France, medical students regularly complain about the shortcomings of their theoretical training and the necessity of its adaptation to better fit the needs of students. The goal was to evaluate the theoretical teaching practices in postgraduate medical studies by: 1) collecting data from medical students in different medical faculties in France; 2) comparing this data with expected practices when it is possible; 3) and proposing several lines of improvement. METHODS: A survey of theoretical practices in the 3rd cycle of medical studies was conducted by self-administered questionnaires which were free of charge, anonymous, and administered electronically from July 3 to October 31, 2013 to all medical students in France. RESULTS: National, inter-regional, regional and field internship educational content was absent in respectively 50.5%, 42.8%, 26.0% and 30.2% of cases. Medical students follow complementary training due to insufficient DES and/or DESC 2 training in 43.7% of cases or as part of a professional project in 54.9% of cases. The knowledge sought by medical students concerns the following crosscutting topics: career development (58.9%), practice management (50.7%), medical English (50.4%) and their specialty organization (49.9%). Fifty-four point one percent would like to be evaluated on their theoretical training on an annual basis. CONCLUSION: The results of this first national survey give insights into the theoretical teaching conditions in postgraduate medical education in France and the aspirations of medical students.

[Enhanced recovery following uncomplicated elective caesarean section in France: a survey of national practice]. / Réhabilitation périopératoire des césariennes programmées non compliquées en France : enquête de pratique nationale.

INTRODUCTION: Enhanced recovery is a concept currently recognised and adopted in a number of surgical specialties. In obstetrics however, this concept remains surprisingly underdeveloped. The purpose of this survey was to study the practice of obstetric anaesthetists in France as regards the recovery of women undergoing uncomplicated, elective caesarean section. MATERIAL AND METHOD: An online 39-point questionnaire was displayed for 2months on the Caro (Club d'anesthesie réanimation en obstétrique) website. The questionnaire related to uncomplicated, elective Caesarean sections and aimed to define the following: preoperative information given regarding the recovery period, intraoperative care - both anaesthetic and surgical, postoperative analgesia, measures taken to prevent post-partum haemorrhage, reintroduction of fluids and diet, return to mobility, local practices designed to promote bonding between mother and baby. RESULTS: The overall response rate for our survey was 45%. Forty-nine percent of practitioners report that patients are provided with specific information on the recovery period preoperatively. Sixty percent of those surveyed state the absence of any specific recovery protocol for this patient population in their hospital. Eighty-one percent of respondents state that, in the majority of cases, patients are admitted on the eve of surgery and remain hospitalised for more than 72hours (89%). Ninety-nine percent of practitioners employ a regional technique to deliver anaesthesia for elective section and 44% rely on intrathecal morphine for postoperative analgesia. The concept of 'Patient Controlled Oral Analgesia' (PCOA), although widely recognised, is used by only 17% of practitioners. Forty-one percent of practitioners report the reintroduction of fluids as soon as patients return to the ward following surgery and at the same time as the urinary catheter is removed (51%). Diet is commenced 4 to 6hours following surgery amongst 40% of those surveyed. Fifty-one percent of practitioners report removal of the intravenous catheter 24hours postoperatively. Finally, 49% of practitioners feel patients are independently functioning and mobile within 24hours of surgery. CONCLUSION: This survey of national practice shows that the concept of 'enhanced recovery' following elective caesarean section can be again developed. Standardisation of practice with the design of local protocols relating to postoperative analgesia, timing of removal of the intravenous access and urinary catheter, time to first mobilisation and to commencement of diet would appear to be warranted. Surely this surgery, more than any other, merits an expeditious and effective return to normal and independent function, allowing mother to better look after baby.

15 years of antibiotic stewardship policy in the Nancy Teaching Hospital.

OBJECTIVES: The authors report the results of a 15-year antibiotic stewardship policy in the Nancy Teaching Hospital and assess the impact of reinforcing this policy on antibiotic consumption. METHODS: Antibiotic stewardship policy was initiated in the mid 90s and then reinforced from 2006 onwards. It was completed by prescription guidelines, nominative prescription of antibiotics, and an operational infectious diseases team (OIDT). The objectives were to promote antibiotic stewardship and decrease the use of extended broad spectrum or costly molecules and intravenous administration. Antibiotics consumption, as defined daily dose per 1000 patient days (DDD/1000PD) and in euros, was monitored from 2005 onwards. RESULTS: Between 2005 and 2008, overall yearly cost of antibiotics dropped by 34% (-€1,308,902) and consumption in DDD/1000PD by 10%. This drop in consumption concerned all antibiotic classes. Teicoplanin prescription dropped by more than 50% and use of fluoroquinolone IV decreased by 15% in 3years. The operational team's interventions were effective since nearly 80% of suggested prescription amendments were accepted by prescribers. CONCLUSIONS: This experiment shows that it is possible to implement antibiotic stewardship policy. Our results prove a significant decrease in overall consumption of antibiotic, a change in prescribing patterns, with a shift towards the use of cheaper antibiotics.

[Medical care of chronic kidney disease after kidney transplantation]. / Prise en charge de la maladie rénale chronique après transplantation rénale.

Kidney transplantation is the treatment of choice to enhance survival, morbidity and quality of life perceived by the patient. Despite improvements in short-term outcomes, a gap persists comparing with health of general population. A stringent collaboration between the family physician, the community nephrologists, the transplant center and others specialists is required. Recent recommendations have been published in France.

Factors associated with anemia among incident pre-dialysis patients managed within a French care network.

BACKGROUND AND AIMS: Despite guidelines concerning the management of renal anemia, the international literature reports that a large proportion of pre-dialysis patients have hemoglobin values lower than the recommended level. The present study analyzed the evolution of pre-dialysis Hb levels and erythropoietin use over a 4-year period and investigated factors associated with anemia. METHODS: A total of 1315 patients initiating dialysis in Lorraine, France, were enrolled since 2001-2004. For each year, anemia, defined by Hb <11 g/dl, and erythropoietin use were investigated in three groups: all patients, patients whose dialysis was planned and patients whose dialysis was unplanned. RESULTS: At initiation of dialysis, all groups showed increases over time in mean hemoglobin levels, proportion of patients without anemia and with erythropoietin therapy. Among patients whose first dialysis was planned in 2004, 43.8% had anemia and 67.9% had received erythropoietin, compared with 75.4% and 29.4%, respectively, when dialysis was unplanned. Patients receiving unplanned dialysis were more likely to have anemia (odds ratio (OR) = 2.6), as were those with a serum albumin level < 3.5 g/dl (OR = 2.1), body mass index < 30 kg/m2 (OR = 1.9) (all p < 0.001) or glomerular filtration rate < 10 ml/min/1.73 m2 (OR = 1.4, p = 0.04). The year of dialysis initiation was also associated with anemia (p = 0.024). CONCLUSION: The proportion ofpatients starting dialysis with anemia might be reduced by earlier nephrology referral leading to erythropoietin administration, planned first dialysis while residual renal function remains, and greater attention to nutritional status.

[Prophylaxis of venous thromboembolism in medical patients: from medical decision tools to the use of low molecular weight heparin]. / Prévention de la maladie thromboembolique veineuse en milieu médical: de l'aide à la décision à l'utilisation des héparines de bas poids moléculaire.

In France, low molecular weight heparins are largely used for prophylaxis of venous thromboembolic disease in medical patients. Although clinical trials show their efficacy in some particular clinical situations, there is no consensus about their use in non-surgical patients. A consequence is a wide disparity of prophylaxis of venous thromboembolic disease regimens: such a situation was observed during a practice survey in two medical units of the general hospital of Lunéville. So, prior assessment for pharmacists and physicians was carried out to determine tools which guide decision-making. These comprise clinical practice guidelines, a record card which allows the scoring of risk for venous thromboembolic disease and a clinical algorithm leading to the appropriate prescription according to the risk and the haematological results. A second concomitant practice survey was organized in the same two units in order to measure the appropriateness of the decision-making tools in medical practice. The four-month study included 108 medical patients. The process was successful because: (1) validated practices are improved, particularly in respect of biological monitoring during treatment, and (2) the disparity of therapeutic strategies is highly reduced, the clinical practice guidelines being followed in 81 per cent of all cases. Despite the lack of consensus, heightened awareness of the attendant risk in many medical conditions allows appropriate prophylactic measures to be taken. These measures need decision-making tools that are easy to use and that improve heparin prescribing and thus healthcare quality.