Tratamiento antimicrobiano de las infecciones bronquiales en los servicios de urgencias hospitalarios / Antimicrobial treatment of bronchial infections in hospital emergency rooms

Objetivo: Analizar los hábitos de prescripción de antimicrobianos en los niños atendidos en servicios de urgencias hospitalarios y diagnosticados de infecciones bronquiales. Métodos: Estudio descriptivo de una muestra aleatoria de niños diagnosticados de bronquitis aguda y bronquiolitis en los servicios de urgencias de 11 hospitales españoles. Se recogió información sobre el tipo de infección bronquial diagnosticada y el tratamiento antimicrobiano prescrito mediante un cuestionario estructurado. Se evaluó la idoneidad del tratamiento prescrito según un patrón de referencia elaborado mediante la revisión de las evidencias científicas y la opinión de un grupo de expertos. Resultados: Se seleccionaron 731 niños, 531 (73 por ciento) diagnosticados de bronquitis aguda y 200 (27 por ciento) de bronquiolitis, y se prescribió un tratamiento antimicrobiano a 234 (32 por ciento; intervalo de confianza del 95 por ciento [IC 95 por ciento], 29-35). Los antimicrobianos más prescritos fueron las aminopenicilinas, en 138 niños (19 por ciento; IC 95 por ciento, 16-22), las cefalosporinas en 54 (7 por ciento; IC 95 por ciento, 5-9) y los macrólidos en 45 (6 por ciento; IC 95 por ciento, 4-8). El tratamiento prescrito fue inadecuado en el 26 por ciento (IC 95 por ciento, 23-29) de los casos (31,5 por ciento [IC 95 por ciento, 27-35] en las bronquitis aguda y 11,5 por ciento [IC 95 por ciento, 7-16] en las bronquiolitis). Se observó una gran variabilidad en el uso inadecuado de los antimicrobianos entre los distintos hospitales, tanto en las bronquitis agudas (14-80 por ciento) como en las bronquiolitis (0-71 por ciento). Conclusión: Se prescribe un tratamiento antimicrobiano inadecuado en una proporción relevante de los niños con infecciones bronquiales atendidos en los servicios de urgencias hospitalarias, aunque existe una gran variabilidad interhospitalaria. Es necesario desarrollar programas de mejora de la calidad de la prescripción de antimicrobianos que combinen medidas reguladoras y educativas dirigidas a los profesionales sanitarios y a la población (AU)

[Antimicrobial treatment of bronchial infections in hospital emergency rooms]. / Tratamiento antimicrobiano de las infecciones bronquiales en los servicios de urgencias hospitalarios.

OBJECTIVE: To analyze antimicrobial prescribing habits in children diagnosed with bronchial infections in hospital emergency rooms. METHODS: A descriptive study was performed in a random sample of children diagnosed with acute bronchitis and bronchiolitis in the emergency rooms of 11 Spanish hospitals. Information about the type of bronchial infection diagnosed and the antimicrobial treatment prescribed was gathered. The appropriateness of antibiotic prescriptions was assessed by comparing clinical practice in the use of antibiotics for bronchial infections with consensus guidelines developed for this study. RESULTS: A total of 731 children were selected. The diagnosis was acute bronchitis in 531 (73 %) and bronchiolitis in 200 (27 %). Antimicrobial treatment was prescribed to 234 children (32 %; 95 % CI: 29-35 %). The most commonly prescribed antimicrobials were the aminopenicillins in 138 children (19 %; 95 % CI 16-22 %), cephalosporins in 54 (7 %; 95 % CI 5-9 %) and macrolides in 45 (6 % 95 % CI 4-8 %). The prescribed treatment was inappropriate in 26 % (95 % CI 23-29 %) of patients [31.5 % (95 % CI 27-35 %) of cases of acute bronchitis and 11.5 % (95 % CI 95 % 7-16 %) of cases of bronchiolitis]. Wide variability was observed in the inappropriate use of antimicrobial agents among the different hospitals, both in acute bronchitis (14-80 %) and in bronchiolitis (0-71 %). CONCLUSION: Inappropriate antimicrobial treatment is prescribed to a considerable proportion of the children with bronchial infections attended in hospital emergency rooms, although there is wide variability among different hospitals. Programs to improve the quality of antimicrobial prescription should be developed. These should combine regulatory and educational measures directed at health professionals and the general public.

[Drug utilization and recommended conditions for use in children]. / Utilización de medicamentos y condiciones de uso recomendadas en pediatría.

BACKGROUND: Studies carried out in other countries show that drugs are used in children outside the approved conditions, in a context in which investigation, information and authorization of medications in the pediatric population are scarce. OBJECTIVES: To evaluate the conditions of drug use recommended in children and variability in sources of drug information. METHODS: We performed a descriptive, retrospective study. Data on medication consumption in 1997 were obtained from a pediatric university hospital. Information on conditions of drug use in children was analyzed using a Spanish catalog of medications. This information was compared with that of a North American catalog for international reference. RESULTS: Most of the drugs used were of unrestricted (43; 47 %) or restricted (26; 28 %) pediatric use, but drugs that are not recommended (8; 9 %) or those with unspecified conditions of use in children were also used (15; 16 %). Approximately 12 % of the drugs were not identified in the North American catalog; of the remaining drugs, 60 % were of unrestricted pediatric use, 35 % of restricted use and 5 % were not recommended. CONCLUSIONS: A substantial proportion of drugs administered to hospitalized children are not recommended or their possible use in this population is not specified. It is worth encouraging research, having sources of information that help to make decisions, especially in conditions that have not been approved, and adapting regulatory attitudes, as far as possible, to the evidence and therapeutic needs.

Hemorragias en pacientes tratados con heparinas de bajo peso molecular / Hemorrhages among patients treated with low-molecular-weight heparins

Objetivo. Se han descrito diversos casos de pacientes con hemorragias graves por heparinas de bajo peso molecular (HBPM). El objetivo del estudio fue analizar los factores de riesgo hemorrágico de los pacientes diagnosticados de hemorragia por HBPM. Método. Estudio retrospectivo (1989-1999) de los pacientes diagnosticados de hemorragias por HBPM en un hospital universitario de tercer nivel. Se revisaron: a) las historias clínicas de los archivos hospitalarios y b) las notificaciones de reacciones adversas a medicamentos de un programa de monitorización intensiva de reacciones adversas hospitalarias. Se recogió información de las variables clínicas de los pacientes, del tratamiento, de la localización y de la gravedad de la hemorragia. Resultados. Se identificaron 36 pacientes diagnosticados de hemorragias por HBPM. La edad mediana de los pacientes fue de 76 años (mínimo 39 y máximo 94 años). En 11 (31 por ciento) pacientes la hemorragia se originó durante un tratamiento ambulatorio que motivó ingreso hospitalario. Todos los pacientes presentaban uno o más factores de riesgo hemorrágico: edad 65 años (34; 94 por ciento); comorbilidad de riesgo hemorrágico (28; 78 por ciento); uso de antiagregantes plaquetarios o antiinflamatorios no esteroideos (AINE) (17; 47 por ciento); duración del tratamiento > 7 días (17; 47 por ciento), y uso de dosis anticoagulantes (16; 44 por ciento). Las hemorragias más frecuentes fueron las gastrointestinales y las musculares (24; 67 por ciento). La mayoría de pacientes presentaron hemorragias mayores (26; 72 por ciento), y en 5 casos fueron mortales. En ningún paciente se ajustó la dosis mediante la monitorización de la actividad anti-Xa. Conclusiones. La mayoría de pacientes con hemorragias por HBPM tienen diversos factores de riesgo hemorrágico. Es necesaria una valoración cuidadosa de los factores de riesgo hemorrágico de los pacientes cuando se utilizan HBPM, y en especial en los tratamientos ambulatorios. Se deberían ajustar la dosis de las HBPM en los pacientes con factores de riesgo hemorrágico (AU)

Utilización de medicamentos y condiciones de uso recomendadas en pediatría / Drug utilization and recommended conditions for use in children

Antecedentes: Estudios realizados en otros países indican que en niños se utilizan fármacos en condiciones distintas a las aprobadas, en un contexto en que son escasas la investigación, información y autorización de medicamentos en población pediátrica. Objetivos: Evaluar las condiciones de uso recomendadas en pediatría para los fármacos utilizados en niños y la variabilidad de las fuentes de información sobre éstos. Métodos: Estudio descriptivo y retrospectivo. Se seleccionaron los datos de consumo de medicamentos en un hospital universitario pediátrico durante el año 1997. Se analizó la información sobre las condiciones de uso en pediatría de los fármacos utilizados a partir de un catálogo de medicamentos español. Esta información se comparó con la de un catálogo norteamericano de referencia internacional. Resultados: La mayor parte de los fármacos utilizados fueron de uso pediátrico no restringido (43 [47%]) o restringido (26 [28%]), pero también se utilizaron fármacos no recomendados (8 [9%]) o para los que no se especificaban condiciones de uso en niños (15 [16 %]). Alrededor del 12% de los fármacos no se identificaron en el catálogo norteamericano; de los restantes, el 60% de los fármacos fueron de uso pediátrico no restringido, el 35% de uso restringido y el 5% no recomendados. Conclusiones: En niños hospitalizados, una proporción relevante de los fármacos que se utilizan no se recomiendan o no se especifica su posible uso en población pediátrica. Sería conveniente incentivar la investigación, disponer de fuentes de información sobre terapéutica que ayuden a tomar decisiones, sobre todo en las condiciones no aprobadas, y que la actitud reguladora se ajuste en la medida de lo posible a las evidencias y necesidades terapéuticas (AU)

[Hemorrhages among patients treated with low-molecular-weight heparins]. / Hemorragias en pacientes tratados con heparinas de bajo peso molecular.

OBJECTIVE: Several cases have been reported of patients with severe hemorrhages caused by low-molecular-weight heparins (LMWH). The objective of the present report was to analyse risk factors for hemorrhage among patients diagnosed of hemorrhage due to LMWH. METHODS: Retrospective study (1989-1999) of patients diagnosed of LMWH hemorrhages in a third-level teaching hospital. A review was made of: a) clinical records from hospital files; b) reports of adverse drug reactions from a program on intensive surveillance of hospital adverse reactions. Information was collected of clinical perameters of patients, treatment, site, and severity of hemorrhage. RESULTS: A total of 36 patients diagnosed of LMWH hemorrhages were identified. The median age of patients was 76 years (range: 39 to 94 years). In 11 (31%) patients, hemorrhage originated during an ambulatory treatment, which prompted hospital admission. All patients had one or more risk factors for hemorrhage: age > or = 65 years (34; 94%); co-morbidities with hemorrhagic risk (28; 78%); use of platelet anti-aggregants or NSAIDs (17; 47%); length of treatment > 7 days (17; 47%) and use of anticoagulant doses (16; 44%). Hemorrhages occurred most commonly in the gastrointestinal tract and muscles (24; 67%). Most patients had major hemorrhages (26; 72%); and in 5 cases hemorrhages were fatal. In no patient was the dose adjusted by anti-Xa activity monitoring. CONCLUSIONS: Most patients with LMWH hemorrhages have different risk factors for hemorrhage. A careful assessment of hemorrhagic risk factors on patients is needed when LMWH are used, particularly in the ambulatory setting. LMWH doses should be adjusted in patients with hemorrhagic risk factors.

[The evolution of use of anti-Parkinson drugs in Spain]. / Evolución del consumo de fármacos antiparkinsonianos en España.

INTRODUCTION: In recent years new anti Parkinson drugs have been marketed and there has been controversy over the safety of some drugs. OBJECTIVE: To analyze the evolution of the consumption of anti Parkinson drugs and the effect of the newer drugs. PATIENTS AND METHODS: A study of the consumption of anti Parkinson drugs (1989 1998). Data were obtained from the ECOM database of the Ministry of Health and TEMPUS of the National Statistics Institute. The drugs were classified using the Anatomo Therapeutic Clinical Classification (ATC). Consumption was expressed in defined daily dosage (DDD) and the costs in euros. The drugs marketed since 1990 were classified as new drugs and the others as classical drugs. RESULTS: The total consumption of drugs increased from 1.92 DDD/1,000 inhabitants/day in 1989 to 3.64 DDD/1,000 inhabitants/day in 1998. The drugs showing the greatest increase were selegiline, pergolide and levodopa. The total pharmaceutical expenses tripled. There was a smaller increase in the consumption of new drugs (1.2% of the total in 1991 and 6.6% in 1998) than in their costs (6.7% of the total in 1991 and 38.8% in 1998). The cost per DDD of the new drugs increased five times (1989: 2.55 euros and 1998: 13.59 euros) and that of the classical drugs was similar (1989: 0.54 euros and 1998: 0.62 euros). CONCLUSIONS: The total consumption of anti Parkinson drugs has progressively increased. The consumption of selegiline has also increased in spite of controversy over its safety. The new drugs have a major economic effect.

[Antibiotic prescription in acute respiratory infections in adults: its variability and appropriateness in 10 Spanish hospitals]. / Prescripción antibiótica en las infecciones respiratorias agudas del adulto: su variabilidad e idoneidad en diez hospitales españoles.

OBJECTIVE: To report the variability in antibiotic prescribing habits for patients diagnosed of non-specified acute respiratory infections (ARI) (according to the International Classification of Diseases 9MC) at Emergency Departments of ten Spanish hospitals, and to evaluate the appropriateness of antimicrobial prescription for such patients, after specifically elaborating some reference patterns for appropriate antimicrobial use. DESIGN: Descriptive study of variability in clinical practice by means of a prospective series of cases. Study of appropriateness by means of elaborating reference standards for appropriate use and comparison with the data from the descriptive study with such standards. DURATION: six months. SETTING: Emergency Department in ten Spanish hospitals from different autonomic communities: Andalucía, Islas Canarias, Castilla-León, Cataluña, Galicia, Madrid, Murcia and Valencia for a 6-month period. PATIENTS: Patients with the diagnosis of community ARI attended at emergency departments. SAMPLE SIZE: 903 cases. INTERVENTIONS: Collection of cases in a unified database with the following variables: age, sex, ARI type, diagnosis of comorbidity, prescribed antimicrobial, hospital admission and type of prescriber. A panel of experts was commissioned to elaborate the gold standards for the appropriate use of antibiotics or the lack of indication for the different locations of ARI. RESULTS: The adjusted proportion of the inappropriate prescription for the group with laryngo-tracheal-influenza-rhinopharyngitis-multiple ARI or non specified infections was 67.9%. CONCLUSIONS: Concerning antibiotic prescription, significant inter-center variability and relevant heterogeneity were observed.