1. Strategies of initiation and streamlining of antibiotic therapy in 41 French intensive care units
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Philippe Montravers, Herve Dupont, Remy Gauzit, Benoit Veber, Jean-Pierre Bedos, Alain Lepape, The CIAR Study Group, Service d'anesthésie - réanimation chirurgicale, Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-AP-HP - Hôpital Bichat - Claude Bernard [Paris], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Pôle d'Anesthésie Réanimation, CHU Amiens-Picardie, Affectations Mineralisantes du Systeme Cardiovasculaire : Calcifications Arterielles et Valvulaires Aortiques, Université de Picardie Jules Verne (UPJV)-Institut National de la Santé et de la Recherche Médicale (INSERM), Service d'anesthésie-réanimation [Hôtel-Dieu], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpital Hôtel-Dieu [Paris], Service de réanimation médicale [CHU Rouen], Hôpital Charles Nicolle [Rouen]-CHU Rouen, Normandie Université (NU)-Normandie Université (NU)-Université de Rouen Normandie (UNIROUEN), Normandie Université (NU), Service de réanimation [CH Versailles], Centre Hospitalier de Versailles André Mignot (CHV), Service d'anesthésie-réanimation [Centre Hospitalier Lyon Sud - HCL], Centre Hospitalier Lyon Sud [CHU - HCL] (CHLS), Hospices Civils de Lyon (HCL)-Hospices Civils de Lyon (HCL), This research was supported by Wyeth Pharmaceuticals France, CIAR (Club d'infectiologie en Anesthésie-Réanimation) Study Group, Assistance publique - Hôpitaux de Paris (AP-HP)-AP-HP - Hôpital Bichat - Claude Bernard [Paris], Université de Picardie Jules Verne ( UPJV ) -Institut National de la Santé et de la Recherche Médicale ( INSERM ), Assistance publique - Hôpitaux de Paris (AP-HP)-Hôpital Hôtel-Dieu [Paris], Service de réanimation médicale [Rouen], Hôpital Charles Nicolle [Rouen]-CHU Rouen-Université de Rouen Normandie ( UNIROUEN ), Normandie Université ( NU ) -Normandie Université ( NU ), Service de Reanimation Polyvalente, Centre Hospitalier de Versailles (CHV), Centre Hospitalier Lyon Sud [CHU - HCL] ( CHLS ), Hospices Civils de Lyon ( HCL ) -Hospices Civils de Lyon ( HCL ), Hôpital Charles Nicolle [Rouen], CHU Rouen, Normandie Université (NU)-Normandie Université (NU)-CHU Rouen, and BMC, Ed.
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Male ,[SDV.MHEP.PHY] Life Sciences [q-bio]/Human health and pathology/Tissues and Organs [q-bio.TO] ,MESH : Prospective Studies ,MESH : Aged ,Bacteremia ,Critical Care and Intensive Care Medicine ,MESH : Intensive Care ,MESH : Intraabdominal Infections ,law.invention ,MESH: Clinical Protocols ,MESH : Physician's Practice Patterns ,0302 clinical medicine ,Clinical Protocols ,law ,MESH: Risk Factors ,Risk Factors ,MESH : Female ,030212 general & internal medicine ,Hospital Mortality ,Prospective Studies ,MESH : Anti-Bacterial Agents ,Practice Patterns, Physicians' ,Prospective cohort study ,MESH: Bacteremia ,MESH: Aged ,MESH: Intraabdominal Infections ,MESH: Middle Aged ,[ SDV.MHEP.PHY ] Life Sciences [q-bio]/Human health and pathology/Tissues and Organs [q-bio.TO] ,MESH : After-Hours Care ,MESH : Adult ,Middle Aged ,MESH : Risk Factors ,Intensive care unit ,3. Good health ,Anti-Bacterial Agents ,Intensive Care Units ,SAPS II ,Cohort ,SOFA score ,Female ,France ,MESH : Intensive Care Units ,MESH: After-Hours Care ,Adult ,medicine.medical_specialty ,MESH: Pneumonia ,Critical Care ,MESH : Male ,MESH : Drug Administration Schedule ,MESH: Drug Administration Schedule ,Drug Administration Schedule ,MESH : Hospital Mortality ,03 medical and health sciences ,After-Hours Care ,Intensive care ,MESH: Anti-Bacterial Agents ,medicine ,[SDV.MHEP.PHY]Life Sciences [q-bio]/Human health and pathology/Tissues and Organs [q-bio.TO] ,Humans ,MESH : Middle Aged ,MESH : Clinical Protocols ,MESH: Intensive Care ,MESH: Hospital Mortality ,MESH : France ,MESH: Physician's Practice Patterns ,Aged ,MESH: Humans ,business.industry ,MESH : Pneumonia ,Research ,MESH : Humans ,030208 emergency & critical care medicine ,MESH: Adult ,Odds ratio ,Pneumonia ,MESH : Bacteremia ,medicine.disease ,MESH: Male ,MESH: Prospective Studies ,MESH: France ,Emergency medicine ,Intraabdominal Infections ,MESH: Intensive Care Units ,business ,MESH: Female - Abstract
CIAR (Club d'infectiologie en Anesthésie-Réanimation) Study Group: Pr B Allaouchiche (HCL, CHU Lyon), Pr C Arich (CHU Nimes), Pr C Auboyer (CHU St-Etienne), Dr JP Caramella (CHG Nevers), Dr JF Cochard (CHU Bordeaux), Dr A Combes (CHG Meaux), Dr P Courant (CHG Avignon), Dr J Durand-Gasselin (CHG Toulon), Pr J Duranteau (APHP, CHU Bicetre), Dr H Floch (CHU Nantes), Dr F Fraisse (CHG St Denis), Pr M Freysz (CHU Dijon), Dr B Garrigues (CHG Aix-en-Provence), Dr B Georges (CHU Toulouse), Pr F Gouin (APHM, CHU Marseille), Pr L Jacob (APHP, CHU St Louis), Pr P Juvin (APHP, CHU Beaujon), Dr J Keinlen (CHU Montpellier), Dr AM Korinek (APHP, CHU Pitie Salpetriere), Dr C Lamer (Institut Mutualiste Montsouris, Paris), Pr JY Lefrant (CHU Nimes), Dr O Lesieur (CHG La Rochelle), Dr Yazine Mahjoub (CHU Amiens), Pr Y Malledant (CHU Rennes), Pr C Martin (APHM, CHU Marseille), Pr O Mimoz (CHU Poitiers), Pr C Paugam-Burtz (APHP, CHU Beaujon, Clichy), Dr PF Perrigault (CHU Montpellier), Pr T Pottecher (CHU Strasbourg), Pr JL Pourriat (APHP, CHU Hotel Dieu), Dr JF Poussel (CHG Metz), Dr A Rabbat (APHP, CHU Hotel Dieu), Dr J Reignier (CHG La Roche sur Yon), Dr P Sichel (CHG Cherbourg), Dr JP Sollet (CHG Argenteuil), Dr D Thevenin (CHG Lens), Dr G Viquesnel (CHU Caen).; International audience; INTRODUCTION: Few studies have addressed the decision-making process of antibiotic therapy (AT) in intensive care unit (ICU) patients. METHODS: In a prospective observational study, all consecutive patients admitted over a one-month period (2004) to 41 French surgical (n = 22) or medical/medico-surgical ICUs (n = 19) in 29 teaching university and 12 non-teaching hospitals were screened daily for AT until ICU discharge. We assessed the modalities of initiating AT, reasons for changes and factors associated with in ICU mortality including a specific analysis of a new AT administered on suspicion of a new infection. RESULTS: A total of 1,043 patients (61% of the cohort) received antibiotics during their ICU stay. Thirty percent (509) of them received new AT mostly for suspected diagnosis of pneumonia (47%), bacteremia (24%), or intra-abdominal (21%) infections. New AT was prescribed on day shifts (45%) and out-of-hours (55%), mainly by a single senior physician (78%) or by a team decision (17%). This new AT was mainly started at the time of suspicion of infection (71%) and on the results of Gram-stained direct examination (21%). Susceptibility testing was performed in 261 (51%) patients with a new AT. This new AT was judged inappropriate in 58 of these 261 (22%) patients. In ICUs with written protocols for empiric AT (n = 25), new AT prescribed before the availability of culture results (P = 0.003) and out-of-hours (P = 0.04) was more frequently observed than in ICUs without protocols but the appropriateness of AT was not different. In multivariate analysis, the predictive factors of mortality for patients with new AT were absence of protocols for empiric AT (adjusted odds ratio (OR) = 1.64, 95% confidence interval (95%CI): 1.01 to 2.69), age ≥60 (OR = 1.97, 95% CI: 1.19 to 3.26), SAPS II score >38 (OR = 2.78, 95% CI: 1.60 to 4.84), rapidly fatal underlying diseases (OR = 2.91, 95% CI: 1.52 to 5.56), SOFA score ≥6 (OR = 4.48, 95% CI: 2.46 to 8.18). CONCLUSIONS: More than 60% of patients received AT during their ICU stay. Half of them received new AT, frequently initiated out-of-hours. In ICUs with written protocols, empiric AT was initiated more rapidly at the time of suspicion of infection and out-of-hours. These results encourage the establishment of local recommendations for empiric AT.
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- 2011