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Résumé: Introduction: Il s’agit d’une évaluation des pratiques professionnelles (EPP) sur l’antibiothérapie dans un service de médecine interne. Matériels et méthodes: Un recueil prospectif sur six mois des prescriptions antibiotiques et leur comparaison avec les recommandations locales et nationales (molécule, dose journalière, modalité d’administration, durée) ont été réalisés. Résultats: Deux cent vingt-sept antibiothérapies ont été recueillies. Par rapport aux recommandations locales, on retrouvait 56 % de schémas totalement respectés (STR) (infections bronchopulmonaires [IBP] : 38 %, urinaires : 88 % et cutanées : 73 %), 33 % de schémas partiellement respectés (SPR) et 11 % de schémas différents (SD). En prenant comme référentiel les recommandations nationales relatives aux IBP, les résultats étaient : STR : 81 % (dont IBP : 80 %), SPR : 16 %, et SD : 3 %. Conclusion: Ce retour sur les prescriptions a permis de mettre en place des actions pérennes d’amélioration des pratiques. Cette démarche anticipe les EPP qui seront nécessaires pour l’accréditation des établissements et souligne l’intérêt de la prise en compte de plusieurs sources de recommandations pour l’interprétation des résultats. [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]

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Abstract: Objectives: The objective was to evaluate the good use of fluoroquinolones in a hospital with a relevance review in the context of an approach to evaluation of professional practices at the regional level initiated by the Antibiolor network. Method: In February 2008, in each volunteer service, practitioners filled out a standardized form indicating indication, the name of the fluoroquinolone, route of administration and duration of treatment, retrospectively from 20 medical records on the last 3 months. Each one was analyzed by a binomial (doctors and pharmacists) according to the local Antibioguide. The degree of compliance requirements has been appreciated by a global index of adequacy of therapeutic consisting of six criteria. Results: Eighteen units of Nancy''s hospital filled 475 cards. The most frequent indications were pulmonary infections (38 %; 181/475) and urinary (23 %; 111/475). The fluoroquinolone indication was non-conform for 28 % of the cards (133/475). When the fluoroquinolone indication was justified, the association with another antibiotic was considered non-compliant in 20 % of cases (70/342), the choice of the molecule in 18 % (62/342), duration of treatment in 17 % (57/342), the dose in 13 % (45/342) and route of administration in 9 % (30/342). The requirements were entirely conform in 34 % of cases (160/475). Conclusion: The results were communicated to each participating service with corrective actions and then this experience has been repeated in May 2009. [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]