[Cutaneous adverse drug reactions: enhanced imputation score by skin testing]. / Réactions cutanées médicamenteuses: la réalisation de tests cutanés augmente le score d'imputabilité

INTRODUCTION: A careful diagnosis and the identification of the causative drug after a cutaneous adverse reaction can avoid relapses. Skin tests facilitate the identification of the causative molecule by producing a hypersensitivity reaction at the application site. Adverse drug reactions are reported to Pharmacovigilance Centres who determine the imputation score of the suspected drugs. The aim of this study was to assess to what extent skin testing after a suspected allergic drug reaction can be helpful to identify the causative drug and whether an impact on the final imputation score could be evidenced. METHOD: A 18-month prospective study was performed. All patients with a history of cutaneous adverse drug reaction of suspected immunoallergic origin were included provided skin tests could be performed within 6 to 12 weeks after the adverse drug reaction. The imputation score was determined using the French imputation method prior to and after skin testing. RESULTS: Thirthy-nine patients were included in the study. Positive skin tests were observed in 11 of 20 patients with a C2S2 (I2: plausible) initial imputation score and in 6 of 15 patients with a C2S1 (I1: doubtful) initial imputation score. One patient with a C1S1 (I1: doubtful) initial imputation score had positive skin tests. DISCUSSION: The results of skin tests helped change the imputation score of the suspected drug in 18 patients out of 39. In 55 p. 100 of cases, the imputation score was increased from C2S2 (I2) to C2S3 (I3: likely) and from C2S1 (I1) to C2S3 (I3) in 40 p. 100 of cases. The increase in imputation scores was helpful to improve warning signals after an immunoallergic reaction. Skin tests led to a more accurate diagnosis in 50 p. 100 of cases. Thus, more adequate advices for further drug treatment were possible, particularly in avoiding the irrelevant prohibition of innocent drugs.

[The circulation of anesthetic agents at Edouard-Herriot Hospital]. / Le circuit du médicament en anesthésie à l'hôpital Edouard-Herriot.

In order to improve quality, practice evaluation is a major tool for hospital management. For many years anaesthesia has been monitored by some form of quality assurance programme. However, despite the improvement in anaesthetic techniques, major problems persist, particularly with the use of anaesthetic agents. Drug administration is the first cause for malpractice and death in anaesthesia. The aim of this study was to analyse drug circuits in anaesthesia, with special reference to French regulations. In 13 theatres, doctors and nurse anaesthetists were interviewed by a pharmacist with a focus on following items: prescription, preparation, administration, management, storage, conservation, information, and regulations. Results demonstrated that practice organisation and information transfers were mainly by oral route. The low proportion of written information, especially for preoperative prescription, did not comply with regulations. Nurse anaesthetists were the main actors in drug handling. Common practice patterns throughout the hospital were non existing. In each theatre, a storage of usual drugs for four weeks was found, whereas in pharmacies drugs were stocked for a 2-week period only. Standardised and written procedures, as well as pharmaceutical practice guidelines, are essential for decreasing the risk and improving quality. Such a procedure requires the full participation of anaesthetists and nurses.

Pefloxacin and vancomycin vs. gentamicin, colistin sulphate and vancomycin for prevention of infections in granulocytopenic patients: a randomised double-blind study.

To test the value of pefloxacin for the prevention of infections in patients with chemotherapy-induced neutropenia, oral pefloxacin plus vancomycin (PV) (n = 76) or gentamicin, colistin sulphate and vancomycin (GCV) (n = 74) were administered in a randomised double-blind study. Infections were significantly less severe in the PV than in the GCV group. Patients receiving PV had significantly fewer episodes of bacteraemia and central venous line infections than patients treated with GCV. Gram-positive and gram-negative infections were significantly less frequent in patients receiving PV, because of fewer infections with Staphylococcus species and enterobacteriaceae. Stool culture detected significantly more gram-positive organisms in the PV group and more gram-negative organisms in the GCV group. Thus, PV was more efficacious than GCV for the prevention of gram-positive and gram-negative infections in the neutropenic patients, despite lower efficacy in eradicating gram-positive organisms from the lower intestinal tract.

Intestinal decontamination in a polyvalent ICU. A double-blind study.

A double blind, placebo-controlled trial was performed to test the efficacy of prevention of nosocomial infections by selective digestive decontamination. Placebo or tobramycin (80 mg) and colistin (100 mg) was given four times daily via the gastric tube. Amphotericin B (500 mg/6 h) was administered to all patients. As our ICU is divided into two separate subunits, intestinal decontamination or placebo was administered alternatively to patients of the two subunits during two 3-month periods, separated by a 2-month period without prevention. The decontamination (n = 97) and placebo groups (n = 84) were similar with respect to age, sex, severity score and diagnostic categories on admission. Intestinal decontamination alone failed to significantly reduce the number of infected patients (26% vs 34.5%, p = 0.20), but was effective on ICU-acquired infections (0.33 vs 0.60, p = 0.02) especially gram-negative infection rates (0.17 vs 0.43, p = 0.01). The onset of the first ICU-acquired infection was delayed (9 vs 13 days, p less than 0.001) and incidence of pneumonia (2 vs 13 cases, p less than 0.01) including bacterial pneumonia (0 vs 8 cases, p less than 0.01) was significantly decreased. However, mean ICU stay and mortality were not significantly modified by intestinal decontamination.