[Long-term usefulness of an information programme on practices in surgical antimicrobial prophylaxis]. / Efficacité à long terme d'une action d'information sur les pratiques d'antibioprophylaxie chirurgicale.

INTRODUCTION: In France, numerous concordant studies show that there are some discrepancies between guidelines on surgical antibiotic prophylaxis and the current practice. In a previous study, conducted in April-June 2001, we found that the rate of appropriateness of surgical antimicrobial prophylaxis was approximately 40%. An information programme was implemented and the purpose of this paper was to present the short- and long-term usefulness of this campaign. METHODS: A total of 13 pairs of surgeons/anaesthetists participated in data collection during the three periods of the study. Prescriptions were observed in order to answer to five questions. Five variables describing practices concerning antibiotic prophylaxis in surgery were compared to national recommendations (updated in 1999): did the surgical procedure require antibiotic prophylaxis and was this carried out? Was the antibiotic used appropriate? Was the timing of the first injection optimal? Was the total duration of the treatment correct? Was the dose correct? RESULTS: The overall compliance with recommendations was significantly improved during the third period (P = 0.0002). This improvement was particularly marked for antimicrobial prophylaxis duration. CONCLUSION: It seems that sequential surveillance of antimicrobial prophylaxis, including numerous surgical teams, could considerably improve the practices, if it was associated to informations that allowed physicians to appropriate the procedures.

[Evaluation of practices in surgical antimicrobial prophylaxis in the Franche-Comté before and after implementation of an information program]. / Evaluation des pratiques d'antibioprophylaxie chirurgicale en Franche-Comté avant et après une action d'information.

OBJECTIVES: To assess the practices of surgical antimicrobial prophylaxis in the Franche-Comté region of France before and after the implementation of information program. STUDY DESIGN: Prospective multicenter transversal study type before/after. The information program included a feedback on the observed results during the period before and a meeting with opinion leaders. PATIENTS AND METHODS: Data were collected by 28 pairs of surgeons/anaesthetists. Prescriptions were analysed to answer five questions about antibiotic prophylaxis practices in surgery: did the surgical procedure require antibiotic prophylaxis and was this carried out? Was the appropriate antibiotic used? Was the timing of the first injection optimal? Was the total duration of the treatment correct? Was the dose correct? Our data were compared to national recommendations (updated in 1999). RESULTS: The overall frequency of conformity was about 40% both before and after the implementation of an information/awareness campaign. Only the conformity of the total duration of the prophylaxis was significantly higher after the action, but only for interventions that lasted less than two hours. [RR = 2.09 (1.32-3.31), p = 0.001]. This improvement in the total duration of regulation seemed to be related to the more frequent use of written protocols in the surgical units. CONCLUSION: Our study confirms that information campaign have little effect within the framework of the good use of antibiotics. We agree with the experts who claim that only an overall strategy including organization, education and restriction will really improve the frequency of conformity of the practices of surgical prophylaxis.

[Correct and incorrect usage of antibiotics. Prevalence study in Franche-Comté]. / Bon et mauvais usage des antibiotiques. Enquête de prévalence en Franche-Comté.

OBJECTIVE: To report the results observed regarding the prescription of antibiotics according to various indications in the Franche-Comté area: curative for a community infection, curative for a nosocomial infection and prophylactic. METHOD: A total of 6,038 patients hospitalized in 32 hospital centers of the Franche-comté area were surveyed. RESULTS: Among the 1,016 (16.8% of the total) patients receiving anti-infection products, 47.7% received anti-infection agents for the treatment of a community infection, 25.9% for a nosocomial infection and 26.4% for prophylaxis. Multiple antibiotherapy was more frequent for the treatment of community infections than for nosocomial infections [p = 0.067, Relative Risk = 1.11, (confidence interval: 95%: 1.00-1.24)]. Sixty percent of the prescriptions of 3rd generation cephalosporines were within the community framework. This class of antibiotics was widely prescribed for the treatment of E. coli infections, multi-sensitive to antibiotics, not only before but after bacteriological documentation. Among the 83 patients treated with fluoroquinolone for a nosocomial infection, 47 (56.6%) were treated with monotherapy. Regarding prophylaxis, 3rd generation cephalosporine and fluoroquinolone, which are not indicated for this, were widely used, in contradiction with the recommendations of the Société Française d'Anesthésie et de Réanimation (French Society of Anesthesia and Reanimation). CONCLUSION: This survey, despite the limits related to the prevalence method, shows the high frequency of antibiotic prescriptions that do not conform to the recommendations of the ANDEM (French agency for the assessment of medical practice) and the scientific societies.

[Antibiotic prophylaxis and surgery. Prescription compliance in Franche-Comté with the national reference system]. / L'antibioprophylaxie en chirurgie. Conformité des prescriptions en Franche-Comté par rapport au référentiel national.

AIM OF THE STUDY: To evaluate the practice of antibiotic prophylaxis for surgery in the Franche-Comté region of France. MATERIALS AND METHODS: A total of 36 surgical teams (72 pairs surgeons/anaesthesists) participated in data collection. Five variables describing practices concerning antibiotic prophylaxis for surgery were compared to national recommendations: did the surgical procedure require antibiotic prophylaxis and was it carried out? Was the antibiotic used appropriately? Was the timing of the first injection optimal? Was the total duration of the treatment correct? Was the dose correct? RESULTS: Among the 687 operations for which data were collected, 513 (74.7%) that corresponded to class 1 or 2 Altemeier operations for which the Société Française d'Anesthésie et Réanimation (SFAR) had drawn up recommendations were analysed in order to answer these questions. The overall frequency of conformity with the regulations was 40% for these 513 operations. Of the 156 patients who did not receive the recommended antibiotic, 133 (85.5%) received an antibiotic with an activity range wider than that of the recommended antibiotic. The duration of prophylaxis was longer than recommended in 80 (87.9%) out of the 91 patients for whom the duration of antibiotic prophylaxis did not respect the recommendations. CONCLUSIONS: This prospective surveillance showed that less than 50% of patients received an antibiotic prophylaxis that was conformed to the regulations. To ensure the efficiency of prophylaxis and to prevent deleterious effects, such as the emergence of antibiotic-resistant bacteria, the recommendations must be regularly respected. Frequent audits of practices should be carried out by the teams responsible for fighting nosocomial infections.

D-dimer test and diagnosis of deep vein thrombosis: a comparative study of 7 assays.

The current D-Dimer ELISA methods provide high sensitivity and negative predictive value for the diagnosis of deep vein thrombosis but these methods are not suitable for emergency or for individual determination. We have evaluated the performance of 3 newly available fast D-Dimer assays (Vidas D-Di, BioMérieux; Instant IA D-Di, Stago; Nycocard D-Dimer, Nycomed) in comparison with 3 classic ELISA methods (Stago, Organon, Behring) and a Latex agglutination technique (Stago). One-hundred-and-seventy-one patients suspected of presenting a first episode of deep vein thrombosis were investigated. A deep vein thrombosis was detected in 75 patients (43.8%) by ultrasonic duplex scanning of the lower limbs; in 11 of them the thrombi were distal and very limited in size (< 2 cm). We compared the performance of the tests by calculating their sensitivity, specificity, positive and negative predictive value for different cut-off levels and by calculating the area under ROC curves. The concordance of the different methods was evaluated by calculating the kappa coefficient. The performances of the 3 classic ELISA and of the Vidas D-Di were comparable and kappa coefficients indicated a good concordance between the results provided by these assays. Their sensitivity slightly declined for detection of the very small thrombi. Instant IA D-Di had a non-significantly lower sensitivity and negative predictive value than the 4 previous assays; however its performance was excellent for out-patients. As expected, the Latex assay had too low a sensitivity and negative predictive value to be recommended. In our hands, Nycocard D-Dimer also exhibited low sensitivity and negative predictive value, which were significantly improved when the plasma samples were tested by the manufacturer. Thus significant progress has been made, allowing clinical studies to be planned to compare the safety and cost-effectiveness of D-Dimer strategy to those of the conventional methods for the diagnosis of venous thrombosis.