Evaluation of an intervention to improve blood culture practices: a cluster randomised trial.

This study aimed to evaluate an intervention to improve blood culture practices. A cluster randomised trial in two parallel groups was performed at the Grenoble University Hospital, France. In October 2009, the results of a practices audit and the guidelines for the optimal use of blood cultures were disseminated to clinical departments. We compared two types of information dissemination: simple presentation or presentation associated with an infectious diseases (ID) specialist intervention. The principal endpoint was blood culture performance measured by the rate of patients having one positive blood culture and the rate of positive blood cultures. The cases of 130 patients in the "ID" group and 119 patients in the "simple presentation" group were audited during the second audit in April 2010. The rate of patients with one positive blood culture increased in both groups (13.62 % vs 9.89 % for the ID group, p = 0.002, 15.90 % vs 13.47 % for the simple presentation group, p = 0.009). The rate of positive blood cultures improved in both groups (6.68 % vs 5.96 % for the ID group, p = 0.003, 6.52 % vs 6.21 % for the simple presentation group, p = 0.017). The blood culture indication was significantly less often specified in the request form in the simple presentation group, while it remained stable in the ID group (p = 0.04). The rate of positive blood cultures and the rate of patients having one positive blood culture improved in both groups. The ID specialist intervention did not have more of an impact on practices than a simple presentation of audit feedback and guidelines.

Prospective study of telephone calls to a hotline for infectious disease consultation: analysis of 7,863 solicited consultations over a 1-year period.

To respond to the increasing requests of non-infectious disease physicians for access to infectious diseases expertise, a hotline was created in the infectious diseases consultation (IDC) unit of the Grenoble university-affiliated hospital (GUH). This study describes the patterns of solicited consultations provided by the hotline during a 1-year period. We conducted a prospective study of consecutive solicited IDCs requested by physicians in 2008. A total of 7,863 consultations were requested by physicians over 1 year; 4,407 (56.0%) by ambulatory physicians, 2,933 (37.3%) by GUH physicians, and 523 (6.7%) by physicians in public or private hospitals. The majority of consultations were requested via cell phone (58.7%). The main reasons for requesting a consultation were related to antimicrobial treatment for hospital-based physicians and prophylaxis for ambulatory physicians (p < 0.001). Recommendations to perform diagnostic or monitoring tests were less frequent in ambulatory medicine (16%) than in the GUH (59%) or other hospitals (63%, p < 0.001). The route of consultation for patients with nosocomial infections was more likely to be formal (p < 0.001). The activity of the IDC hotline attests to an important need for such expertise consultation, both in hospitals and in ambulatory medicine.

[Evaluation of a remote infectious disease consultation]. / Evaluation d'une consultation mobile d'infectiologie.

OBJECTIVES: The aims of our study were to characterize the activity of a remote infectious diseases consultation (RIDC) in a teaching hospital and to assess physician observance to advice. DESIGN: All demands received by the RIDC for initial advice and the given answers were recorded during one month. Advice given for inpatients was followed up 72 hours after to evaluate the physician's observance. RESULTS: Six hundred and nineteen demands were recorded: 47% came from our teaching hospital and 53% came from community practice. Hospital demands came mostly from surgical (47%) and medical (41%) units. Most of them (92%) were related to the treatment of an infection or diagnostic help. Outside calls came from doctors (85%) either private or working in a health care institution. Prophylaxis (47%) and treatment of an infection or a diagnostic help (43%) were the most frequent issues. Among the 176 pieces of advice requested for inpatients, 87% were completely observed. Advice was more followed when it was given by experienced specialists (p=0.02) or by phone (p=0.03) and less followed for patients presenting a nosocomial infection (p=0.03). CONCLUSIONS: The RIDC is very useful for the medical community and its advice is usually followed. Informal consultations account for an important part of its activity.

[Adequacy of new systemic antifungal agents prescriptions in a teaching hospital]. / Revue de pertinence des prescriptions des nouveaux antifongiques systémiques dans un hôpital universitaire.

OBJECTIVES: The aim of this study was to evaluate the adequacy and the conformity of prescriptions of new systemic antifungal drugs to guidelines and scientific data. PATIENTS AND METHODS: Each prescription of liposomal amphotericin B (lip Amb), voriconazole, and caspofungin made between May 2003 and May 2004 in a teaching hospital were reviewed by an infectious diseases specialist. He used criteria based on marketing authorization, national recommendations, and scientific data. RESULTS: One hundred and fifteen files were studied during the 12-month period and 203 prescriptions analyzed. Most patients were immunodepressed. The indication of the treatment was appropriate for 127 prescriptions (62.6%). Dose and drug interactions were compliant with prescription rules for 158 prescriptions (77.8%). Among the causes of misuse, 16.3% concerned combinations of antifungals. Prescriptions of liposomal amphotericin B, voriconazole and caspofungin complied with guidelines respectively in 69.7, 60.6 and 36.8% of the cases. Among the 127 appropriate prescriptions, the use of cheaper molecules with an equivalent clinical effectiveness would have allowed saving 13.6% of the total cost of these prescriptions. CONCLUSIONS: This study will lead us to implement policies for new antifungal prescription.

Prospective assessment of fluoroquinolone use in a teaching hospital.

The aim of this study was to review the use of fluoroquinolone (FQ) drugs in a teaching hospital and to bring to light the factors associated with FQ misuse. A prospective observational study of FQ prescriptions was conducted in a 2,200-bed teaching hospital. Every hospitalized patient receiving a FQ drug during the 3-week survey period was included. A questionnaire was filled out using medical records and face-to-face interviews with FQ prescribers. An infectious diseases specialist reviewed the questionnaires and analyzed FQ therapy according to local guidelines for FQ prescription. Among the group of 174 patients included, FQ therapy was inappropriate in 88 cases (50.6%; 95% CI 43-58) for the following reasons: inappropriate clinical setting, 43; non-first-line recommendation, 24; inappropriate choice of FQ agent, 9; and inappropriate combination of FQs, 12. FQ prescriptions did not comply with prescription rules in 45 cases (25.9%; 95% CI 20-33). Appropriateness and compliance overlapped for 17 of these 45 patients who received an inappropriate FQ course that did not comply with prescription rules. Finally, FQ therapy was misused for 116 of the 174 patients (66.6%; 95% CI 59-74). Characteristics linked with FQ misuse were hospitalization in surgical wards (p = 0.03), intravenous therapy (p < 0.01), and presumptive therapy (p = 0.05). The FQ misuse rate progressively decreased during the survey period (p = 0.04). FQ misuse was a common phenomenon in the teaching hospital studied. The significant improvement in FQ prescribing practices observed during the study period demonstrates that frequent review of antibiotic use with prescribers is warranted.

[Adequacy of antibiotic therapy to guidelines for urinary tract infection in hospital]. / Conformité des prescriptions d'antibiotiques dans les infections urinaires de l'adulte en milieu hospitalier.

OBJECTIVE: We estimated the adequacy of antibiotic therapy to guidelines for nosocomial and community-acquired urinary tract infections in hospital. DESIGN: For 4 weeks, all adult patients hospitalized with positive bacteriuria were included in our retrospective study. Data was collected from urine culture results and from patient medical files. Adequacy to guidelines was analyzed by two infectious disease specialists, focusing on the indication, antibiotic choice, dosage, route of administration, and duration of treatment. RESULTS: Overall 202 patients were enrolled in the study (63.9% women). The decision of initiating or not antibiotic therapy was appropriate in 66.8% of cases. Antibiotherapy indication and antibiotic choice were adequate in 94 cases in empiric prescription (50.8%) and in 123 cases (60.9%) after receiving culture antibiogram results. Route of administration was adequate in 94.4% and dosage in 70.8% of prescriptions. This poor compliance with guidelines was mainly due to unnecessary prescriptions in asymptomatic bacteriuria, unnecessary biotherapies and spectrum errors. CONCLUSIONS: It seems important to remind prescribers of recommendations for urinary tract infections.