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Background The increased use of new costly antifungal agents has led to a considerable increase in pharmaceutical expenditure. In December 2011, the Lorraine Regional Health Agency commissioned the Antibiolor network to evaluate costly antifungal agent stewardship using as reference regional, French, and international recommendations. Methods We performed a regional retrospective multicenter study. The criteria for evaluation were the appropriateness of the indication for treatment, the choice of the agent or of a combination, compliance with dose and treatment duration, and the absence of any alternative. Results One hundred and fourteen prescriptions were analyzed, in 7 intensive care units, 4 hematology units, and 1 infectious diseases unit. The indication for costly antifungal treatment was appropriate in 110 cases (96.5%), the choice of the antifungal agent in 102 cases (93%), the dose in 98 cases (89%), treatment duration in 102 cases (93%), and an alternative antifungal treatment was possible in 10 cases (9%). Eighty-two prescriptions (74.5%) complied with the marketing authorization, 19 (17%) were related to a protocol for temporary use, and 9 (8%) were considered as inappropriate. Conclusion Our results show a high rate of appropriate prescriptions. The easily accessible and regularly updated local recommendations probably resulted in the standardization and optimization of costly antifungal agent prescriptions. [ABSTRACT FROM AUTHOR]

Résumé: Objectifs: Évaluer l’adéquation de nos pratiques avec les recommandations (17e conférence de consensus, SPILF 2008) et identifier les facteurs associés aux délais des principaux temps de prise en charge. Méthodes: Étude rétrospective observationnelle (2009–2011) portant sur les méningites bactériennes aiguës (MBA) de l’adulte. Les données ont été recueillies par questionnaire standardisé à partir des dossiers médicaux et infirmiers. Résultats: Sur 31 MBA admises aux urgences, 29 (93,5 %) y ont reçu ceftriaxone ou céfotaxime. Les indications de corticothérapie et d’imagerie étaient conformes dans 71,0 % et 83,9 % des cas. Les délais médians (IQR) ont été : admission/ponction lombaire (PL), 2h43 (1h09–5h57) ; admission/antibiothérapie, 3h21 (1h34–5h11). La mention de suspicion de méningite dans le courrier d’admission était associée à une PL plus précoce (p =0,01), et une tendance à l’instauration plus rapide de l’antibiothérapie (p =0,05). Conclusions: La mention de suspicion de MBA dans le courrier d’admission est associée à une meilleure prise en charge aux urgences. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: The excessive and inappropriate use of carbapenems is responsible for the development of resistance. The scientific community has been requiring caution and using these agents in specific cases only. Objectives: The authors had for aim to evaluate the appropriate use of carbapenems in a French university hospital. Design: A retrospective survey was made over two months as a clinical audit to assess professional practices. The evaluation criteria for this audit were: the appropriateness of the indication, the possibility of alternative therapeutic strategies, the choice of an antibiotic combination, duration of treatment and dosage. Results: During the audit period, 103 carbapenem prescriptions were included. Ninety-nine cases were analyzed. Among the carbapenem prescriptions, 28.3% (28/99) did not meet the criterion “appropriateness of the indication”. Carbapenems were mostly prescribed empirically (60/99 [60%]) and most often for lung infections or nosocomial urinary tract infections. Finally, 66.7% (66/99) of all prescriptions were considered inappropriate for at least one criterion. The rate of inappropriateness ranged around 30% for each criterion. Conclusions: This study allowed us to assess professional practices for carbapenem prescriptions. The overall rate of inappropriateness was quite important. Carbapenems were not always used appropriately. These findings highlight the need of new regional guidelines and regular updating of local best practices recommendations. Finally, a stricter validation of carbapenem prescriptions will be implemented at the hospital pharmacy level. [Copyright &y& Elsevier]

Abstract: The medical dashboard (DB) recording our clinical practices indicated on one hand the use of two different diagnosis terms, acute dermohypodermitis (ADH) or cellulitis, and on the other hand, an important antibiotic prescription heterogeneity. Our aim was to define these two diagnosis groups and to document compliance to our antibiotic therapy protocol. Method: ADH and cellulitis were selected in our medical DB that records all patient data. Our local antibiotic therapy protocol was designed in April 2009; the prescription of recommended antibiotic agents defined the compliance to recommendations. The patient files indicating non-consensual therapy were analyzed to determine the reasons for inappropriate prescription. Results: Three hundred and four cases of ADH and 82 of cellulitis were diagnosed over 6.5years. ADH was associated with older age (P =0.007), a higher frequency of venous insufficiency (P =0.015), a lower frequency of cancer (P =0.007), and was more often located on lower limbs (P <0.001), compared to cellulitis. The diagnosis of ADH was associated with higher compliance to our antibiotic therapy protocol, compared to cellulitis: 68% versus (vs.) 24%, P <0.001, and after April 2009: 53% vs. 64%, P =0.033. Among the 162 inappropriate antibiotic prescriptions (42%), 75 were deemed justified after analyzing the patient file, but less frequently for ADH compared to cellulitis: 49% vs. 11,5%, P <0.001. Conclusion: ADH presents different clinical characteristics compared to cellulitis. The antibiotic therapy protocol for ADH cannot be applied to cellulitis. [Copyright &y& Elsevier]

Abstract: Objective: Improving the use of antimicrobial drugs is a national objective. To this end an evaluation of clinical practice was implemented on prescribed antibiotics in elderly patients, in the Besançon Teaching Hospital. Design: In 2005, a clinical audit compared the adequacy of antibiotic prescriptions to national guidelines in 37 patients. An improvement plan was implemented, including the drafting of local guidelines (adapted national guidelines) “Antibiotic prescription in elderly patients” by a multidisciplinary team. The Antibiotics Committee approved it. A retrospective study compared antibiotic prescription of 62 patients to these guidelines. The methodology was based on Gyssen''s algorithm. The assessment criteria were: relevance of the indication, absence of a better alternative, respect of recommended dose, duration, and timing. Results: The rate of overall conformity was 26% in 2005, 57% in 2007. Antibiotic choice was adequate in 61% of cases in 2005, 78% in 2007. In 63% of cases, a more efficient alternative was advised in 2005, 10% of cases in 2007. Treatment duration, dose, and timing were adequate in 54 – 92 – 96% in 2005 respectively and 86 – 92 – 100% of cases in 2007. Ciprofloxacin was prescribed in first line for 42% of urinary infections in 2005, 0% in 2007. Conclusions: This approach improved antibiotic prescriptions because of better guideline observance by physicians. The main improvement concerned fluoroquinolones. It should be continued to confirm antibiotic good use and protect our hospital bacterial ecology. [Copyright &y& Elsevier]

Abstract: The evaluation of clinical practice includes three successive phases: demonstration of suboptimal clinical practice, proposals for improvement, and assessment of effective changes. We present a medical computerized database used for this evaluation. Patient and methods: Our database includes 24 parameters for all hospitalized patients among which diagnosis and antibiotherapy. The first assessment phase indicated an unjustified heterogeneous antibiotherapy for community-acquired pneumonia (CAP). The second phase was the drafting of our own consensus for CAP treatment, aiming at reducing the use of fluoroquinolones and third generation cephalosporin. The computerized database was used in the third phase to check observance of our consensus. Results: Two hundred and fifty patients were hospitalized for CAP before the consensus, from October to January 2005, 2006, and 2007, compared to 113 patients from October 2008 to March 2009. The rate of adequate prescriptions improved from the first period to the second one: 58% versus 69%, p =0.045. The inadequate use of fluoroquinolones and third generation cephalosporins was more frequent during the first period, compared to the second one: 49% versus 38%, p =0.048. The mean hospital stay was longer before applying our consensus: 9±5 days versus 7±4 days, p =0.009. Evolution was unfavorable in 15/250 cases (6%) and 3/113 cases (<1%), respectively. Conclusion: A medical database allows for a rapid implementation of two out of three phases of clinical evaluation, through the appropriation of a new consensus, with a reduction of antibiotic misuse without impact on infectious morbidity and mortality. [Copyright &y& Elsevier]

Abstract: Introduction: Methods used for the assessment of professional practices must be dependable and reproducible. The aim of this study was to assess a method used in our hospital to assess antibiotic therapy for acute community-acquired pneumonia (CAP). Method: In this study, a pharmacist and two infectious disease specialists retrospectively and independently evaluated the compliance to local antibiotic guidelines for 124 patients. The assessment tool was a Medical Appropriateness Index (MAI) (nine items). The kappa agreement index (K) among experts was calculated. Results: The agreement among experts was poor for the initial antibiotic treatment (K =0.16) and route of administration (K =0.14), low for the duration of treatment (K =0.34), and null for the dose and adjustment to 72hours. Conclusion: Differences between experts can be explained by the complexity of medical records, the number of items assessed, the complexity of the MAI, but also by the specialization and experience of experts. Thus, the assessment of CAP antibiotic therapy requires the use of appropriate methods targeting reliable criteria. [Copyright &y& Elsevier]

Abstract: Objectives: Imogam rage® (IgR) prescriptions were assessed in the rabies prophylaxis centre of Poitiers (France). Material and methods: All medical records closed between January 1 and June 1, 2005 were retrospectively analyzed. An infectious disease specialist examined the pertinence of IgR prescription according to WHO references adapted to the epidemiological situation by the Pasteur Institute French rabies center. The indicator used was the proportion of patients treated by IgR among all patients treated by vaccination or vaccination with IgR. Results: During the study period, 69 medical records have bewereen analyzed: 48 (70%) patients were treated including 22 (46%) with IgR. Imogam rage® indication was not appropriate for 21 (95%) patients (one contact with a rodent, 8 low gravity contact, 12 contacts with a French animal) that is to say 86 IgR® vials. The direct cost was 8,032 euros. Conclusion: This assessment permitted to underline an overprescription of IgR®, to adapt guidelines to the local situation, and to improve care quality by adaptating medical record files, improving the prescription decisional tree and the local guidelines, and improving the training of interns. [Copyright &y& Elsevier]

Abstract: 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. [Copyright &y& Elsevier]

Abstract: Objectives: The Saint-Antoine Orchestra Program aims at improving the clinical management of HIV-infected patients through access to care, prevention and early diagnosis of comorbidities. Methods: The program was initiated in December 2004 on the whole database. The following topics were concerned: cardiovascular risk factors, gynecological follow-up, anti-HBV vaccinal coverage, sexuality and prevention of STIs, therapeutic adherence and counsels to travelers. The program included several actions: diffusion of information to patients, development of a computerized chart (alert pop-ups), individualized prescription advice and recommendations for specialist referral. Results: The program was applied to 1959 patients whose initial characteristics were: mean age: 43±10 years; ratio M/W: 1466/493; European origin: 69%; sub-Saharan: 19%; mean duration of HIV infection: 9.3±6 years; naïve of antiretrovirals: 14%; mean CD4+count: 494±277/mm3; HIV viral load inferior to 50 cp/ml: 62%. Among 1347 patients for whom cardiovascular risk factors were completely informed, 42% had two or more factors. In particular, 31% of them were smokers, 7% had an arterial pressure superior to 140/90 mmHg and 11% had LDL-cholesterolemia superior to 4.1 mmol/l. Among 1448 untreated patients, 70% were initially considered as adherent. Half of the concerned women had neither cervical smear nor mammography up to date. Among 67% patients with an informed complete HBV serology, 27% were seronegative among which 310 (86%) were eligible for the vaccine. Problems of sexual difficulties or prevention were initially discussed for 11% of patients. Among them, 14% had a problem of prevention and 148 (66%) recognized sexual difficulties. Conclusion: The initiation of the Saint-Antoine Orchestra program has provided a unique opportunity to assess and improve the prevention and management of comorbidities in HIV patients. Also, this program aimed to improve professional practices. [Copyright &y& Elsevier]