Les infections sur prothèses vasculaires (IPV) sont rares mais mettent en jeu le pronostic vital et fonctionnel des patients. Leur épidémiologie et les facteurs pronostiques ne sont pas bien connus notamment depuis l'émergence de bactéries multirésistantes (BMR). Étude prospective dans un hôpital universitaire. Tous les patients ayant présenté une IPV de janvier 2015 à octobre 2017 ont été inclus. Nous avons colligé les caractéristiques cliniques, le type de chirurgie, les données microbiologiques et l'évolution. La définition utilisée pour les IPV était celle de Fitzgerald et al., et la définition de BMR était celle de Magiorakos et al. La guérison était définie par l'absence de signe clinique, biologique et radiologique d'infection sans nouvelle intervention chirurgicale pour sepsis ni antibiothérapie additionnelle à l'épisode index lors de la dernière visite de suivi. Au total, 70 patients ont été inclus, l'âge moyen était de 72,3 ± 11,9 ans et le sexe ratio de 3,7, le BMI moyen était de 25,7. Les principales comorbidités étaient l'immunodépression (n = 27 ; 38,6 %) et le diabète (n = 21 ; 30,0 %). Les topographies des interventions chirurgicales étaient périphériques (n = 44 ; 62,9 %), aorto-périphériques (n = 16 ; 27,1 %), aortiques (n = 5 ; 7,1 %), et carotidiennes (n = 1 ; 1,4 %) ; 44 (62,9 %) d'entre elles étaient des infections précoces (< 3 mois). Lors du diagnostic 46 (65,7 %) patients étaient fébriles, 39 (55,7 %) présentaient une fistule, et 22 (31,4 %) un abcès. Par ailleurs, 4 (5,7 %) patients étaient en choc septique. Le geste chirurgical était : une excision complète du matériel (n = 21 ; 30,0 %), une excision incomplète (n = 13 ; 18,6 %), un lavage sans excision (n = 29 ; 41,4 %). Finalement, 57 patients présentaient des infections à bactéries non BMR : Entérobactéries (n = 20 ; 28,6 %), Entérocoques (n = 15 ; 21,4 %), Staphylococcus aureus (n = 14 ; 20,0 %) and Staphylocoques à coagulase-négative (n = 12 ; 17,1 %). Treize (18,6 %) patients présentaient des IPV à BMR : Entérobactéries (n = 8 ; 11,4 %), Staphylocoques à coagulase-négative (n = 3 ; 4,3 %), Entérocoques (n = 3 ; 4,3 %), et Pseudomonas aeruginosa (n = 2 ; 2,9 %). Les IPV étaient plurimicrobiennes dans 35 (50,0 %) cas. L'évolution était : la guérison dans 35 cas (50,0 %), l'échec dans 27 (38,6 %), et 9 (12,9 %) étaient perdus de vue. La durée moyenne de suivi était de 195 ± 226 jours Les facteurs pronostic péjoratifs étaient la présence d'un choc (0,0 vs. 0,5 ; p < 10–5), d'infection à Entérobactéries (0,25 vs. 0,5 ; p = 0,04), d'infection due à une BMR (0,3 vs. 0,5 ; p = 0,035) et d'infection polymicrobienne (0,4 vs. 0,5 ; p = 0,03). Le pronostic des IPV est sombre, en particulier en cas de choc, d'infections à Entérobactéries ou à BMR ou d'infection polymicrobienne.

Background STOPP and START criteria were developed to identify potentially inappropriate prescription (PIP) and potentially prescribing omission (PPO), and to improve the use of medication in older people. Purpose The aim of this study was to evaluate the medical care for elderly patients in an acute geriatric department with the STOPP and START criteria. Material and methods This study included patients admitted to the acute geriatric department in an academic hospital from July to October 2015. Using pre-admission treatment, a pharmacist used STOPP and START criteria version 2 to identify PIPs and PPOs. After the patient’s discharge, a geriatrician and a pharmacist assessed how many STOPP and START criteria were followed according to the discharge prescription. The reason for not following STOPP/START criteria was investigated using clinical records. Results Among 81 patients included, 224 PIPs were identified according to STOPP criteria, of which 168 (75%) were followed by the geriatricians. Among 56 cases of non-adherence to STOPP criteria, 50 cases (90%) presented a justified reason for this decision. Among 262 inappropriate prescriptions identified by geriatricians, 94 (36%) prescriptions were supplementary and not identified by STOPP criteria. Supplementary drugs stopped the most by geriatricians were drugs related to the cardiovascular system (n=28), mostly because the treatment was ineffective (n=7). According to START criteria, 90 PPOs were identified, of which 56 (62%) were followed by the geriatricians. Among 34 cases of non-adherence to START criteria, 27 cases (79%) presented a justified reason for this decision. Among 273 omission prescriptions identified by geriatricians, 217 prescriptions were supplementary and not identified by START criteria. The drugs started most by geriatricians were drugs related to the central nervous system (n=79), mostly because patients presented moderate pain (n=36). Conclusion In this study, PIP and PPO STOPP and START criteria were usually followed by geriatricians. The reasons for not following the criteria were usually justified. However, cases of non-adherence to START criteria were more important than cases of non-adherence to STOPP criteria. In these cases, geriatricians added more drugs than the START criteria. More studies about following these criteria should be performed in older patients admitted to hospital, especially in others wards, without geriatricians. No conflict of interest

Au cours des infections ostéoarticulaires (IOA), les fluoroquinolones (FQ), sont les molécules antibiotiques de choix. Cependant au vu de l’émergence de résistance à cette classe elles sont moins souvent utilisables. Le cotrimoxazole (CTX) est une alternative mal étudiée dont l’efficacité et la tolérance sont peu documentées. Nous nous sommes intéressés à évaluer le traitement par CTX IOA dans un centre de référence des infections ostéoarticulaires. Étude rétrospective bicentrique de 2013 à 2016 au sein d’un centre de référence, portant sur les dossiers des patients hospitalisés en chirurgie orthopédique et ayant bénéficié d’une prescription de cotrimoxazole durant leur séjour, identifiée à partir du logiciel de prescription. Critères d’inclusion : patients hospitalisés pour prise en charge d’une IOA traités par du CTX per os en antibiothérapie définitive de relais. Critères d’exclusion : traitement par antibiothérapie suppressive au long cours, absence d’IOA, un traitement par CTX inférieur à 10 jours. L’efficacité et les effets indésirables du CTX ont été évalués à j7 de la date opératoire, à j45, et à j90. Le succès était défini par l’absence de signes locaux et généraux de sepsis, pas d’incident cicatriciel, régression du syndrome inflammatoire biologique motivant une reprise chirurgicale ou une antibiothérapie additionnelle. Au total 100 dossiers ont été revus et 34 inclus. L’âge moyen = 62 ± 20 ans. Sexe ratio H/F = 1. Score de Charlson médian = 4. Parmi eux, 76,5 % (n = 26) possédaient du matériel étranger, dont 44,1 % une prothèse (n = 15), 32,3 % du matériel d’ostéosynthèse (n = 11) ; 23,5 % (n = 8) présentaient une IOA sur articulation native. La prise en charge consistait en ablation/changement du matériel (n = 18 ; 69,2 %). Les IOA étaient pour un tiers des cas (n = 11) polymicrobiennes. Les micro-organismes les plus fréquemment retrouvés étaient : entérobactéries (n = 14), SCN (n = 13) et staphylocoque doré (n = 13), dont 30,7 % (n = 4) de SARM. La durée médiane de traitement était de 45 jours (21–45) et la posologie utilisée allaient de 800 mg × 2 (n = 27) à 800 mg × 3/j (n = 7). La plupart des molécules associées étaient : 35,3 % des FQ (n = 12) et 23,5 % rifampicine (RFP) (n = 8). Aucune utilisation en monothérapie. Effets indésirables : 8,8 % (n = 4) dont une allergie cutanée, une diarrhée sévère, une hépatite non grave et une fièvre aux ATB. Tous les cas ayant conduit à l’arrêt du CTX. On note 29,4 % de perdu de vue (n = 10) à j90. On retrouve un succès en ITT/per-protocole : à j7, de 97,0 % ; j45 de 88,2 %/90,9 % (n = 30) ; j90 de 58,8 %/83,3 % (n = 20). En analyse Kaplan-Mayer (log-rank test), pas de différence significative d’efficacité entre les associations : CTX/RFP et CTX/FQ (p = 0,73). Notre étude retrouve une efficacité de 83,3 % du CTX à j90 au cours des IOA, qui constitue donc une alternative de choix lorsque les FQ et la RFP ne sont pas utilisables en association.

Background Antimicrobial stewardship programmes (ASPs) have been effective in optimizing antibiotic use for inpatients. However, an emergency department's fast-paced clinical setting can be challenging for a successful ASP. Aim In April 2015, an ASP was implemented in our emergency department and we aimed to determine its impact on antimicrobial use for outpatients. Methods This was a single-centre study comparing the quality of antibiotic prescriptions between a one-year period before ASP implementation (November 2012 to October 2013) and a one-year period after its implementation (June 2015 to May 2016). For each period, antimicrobial prescriptions for all adult outpatients (hospitalized for <24h) were evaluated by an infectious disease specialist and an emergency department physician to assess compliance with local prescribing guidelines. Inappropriate prescriptions were then classified. Findings Before and after ASP, 34,671 and 35,925 consultations were registered at our emergency department, of which 25,470 and 26,208 were outpatients. Antimicrobials were prescribed in 769 (3.0%) and 580 (2.2%) consultations, respectively (P < 0.0001). There were 484 (62.9%) and 271 (46.7%) (P < 0.0001) instances of non-compliance with guidelines before and after ASP implementation. Non-compliance included unnecessary antimicrobial prescriptions, 197 (25.6%) vs 101 (17.4%) (P<0.0005); inappropriate spectrum, 108 (14.0%) vs 54 (9.3%) (P=0.008); excessive treatment duration, 87 (11.3%) vs 53 (9.1%) (P>0.05); and inappropriate choices, 11 (1.4%) vs 15 (2.6%) (P>0.05). Conclusion The implementation of an ASP markedly decreased the number of unnecessary antimicrobial prescriptions, but had little impact on most other aspects of inappropriate prescribing.

Objectives. - The proper use of antibiotics is a public health priority to preserve their effectiveness. Little data is available on outpatient antibiotic prescriptions, especially in the emergency department. We aimed to assess the quality of outpatient antibiotic prescriptions in our hospital.Patients and methods. - Retrospective monocentric study of antibiotic prescriptions written to adult patients managed at the emergency department without hospitalization (November 15th, 2012-November 15th, 2013). Prescriptions were evaluated by an infectious disease specialist and an emergency physician on the basis of local recommendations compiled from national and international guidelines.Results. - A total of 760 prescriptions were reviewed. The most frequent indications were urinary tract infections (n = 263; 34.6%), cutaneous infections (n = 198; 26.05%), respiratory tract infections (n = 101; 13.28%), and ENT infections (n = 62; 8.15%). The most frequently prescribed antibiotics were fluoroquinolones (n = 314; 40.83%) and amoxicillin clavulanic acid (n = 245; 31.85%). Overall, 455 prescriptions (59.86%) did not comply with guidelines. The main reasons for inadequacy were the absence of an indication for antibiotic therapy (n = 197; 40.7%), an inadequate spectrum of activity, i.e. too broad, (n = 95; 19.62%), and excessive treatment duration (n= 87; 17.97%). Rates of inadequate prescriptions were 82.26% for ENT infections, 71.2% for cutaneous infections, 46.53% for respiratory tract infections, and 38.4% for urinary tract infections.Conclusion. - Antibiotic prescriptions written to outpatients in the emergency department are often inadequate. Enhancing prescribers' training and handing out guidelines is therefore necessary. The quality of these prescriptions should then be re-assessed. (C) 2016 Elsevier Masson SAS. All rights reserved.

In the past century, gonococcus has progressively developed resistance to antibiotics. Historically, in 1937, gonococci were treated with sulphonamide. After a few years, the US Army reported failures of sulphonamide and started to evaluate penicillin in the treatment of gonorrhoea. In 1946, a new wave of resistance occurred with reports of failure even with high doses of penicillin. This resulted in the use of tetracycline (1966), quickly followed by spectinomycin (1967) before the advent of cephalosporins (1989) and more recently fluoroquinolones in 1993. Following the spread of fluoroquinolone resistance, the emergence of cephalosporin-resistant gonococcus has been reported. In Europe, the proportion of resistant strains for cefixime (MIC >0.125 mg/L) increased fourfold between 2011 (0.7%) and 2012 (3.0%) [[1]La Ruche G. Goubard A. Berçot B. Cambau E. Semaille C. Sednaoui P. Évolution des résistances du gonocoque aux antibiotiques en France de 2001 à 2012.Bull Epidémiol Hebd. 2014; 5: 93-103Google Scholar]. Moreover, we observed that this resistance to cefixime was associated with an increasing proportion of ceftriaxone-reduced susceptibility strains (MIC ≥0.032 mg/L), which accounted for 6.4% of the resistant strains in the same period. The same trend is observed in the USA and as we have few antibiotic options left that are simple, well-studied, well-tolerated and highly effective, it is critical to continuously monitor resistance to commonly prescribed antibiotics such as ceftriaxone. This is particularly true in a context of continuous worldwide increase of gonococcal infections (cervix, urethra and rectum), as previously described in France [[1]La Ruche G. Goubard A. Berçot B. Cambau E. Semaille C. Sednaoui P. Évolution des résistances du gonocoque aux antibiotiques en France de 2001 à 2012.Bull Epidémiol Hebd. 2014; 5: 93-103Google Scholar]. This increase is partially explained by a burden of asymptomatic carriers, especially in men who have sex with men [[2]Morris S.R. Klausner J.D. Buchbinder S.P. Wheeler S.L. Koblin B. Coates T. et al.Prevalence and incidence of pharyngeal gonorrhea in a longitudinal sample of men who have sex with men: the EXPLORE study.Clin Infect Dis Off Publ Infect Dis Soc Am. 2006; 43: 1284-1289Crossref PubMed Scopus (99) Google Scholar], because they do not undergo screening. In this era of emergence of resistance, international guidelines have been recently updated and emphasize the need to add azithromycin to the treatment, to improve treatment efficacy and potentially slow the emergence and spread of resistance to cephalosporins. Nevertheless, azithromycin is mostly added to cephalosporins to treat the associated sexually transmitted diseases (STD) rather than to reduce the emergence of resistant gonococcal strains [[3]Kerani R.P. Stenger M.R. Weinstock H. Bernstein K.T. Reed M. Schumacher C. et al.Gonorrhea treatment practices in the STD Surveillance Network, 2010–2012.Sex Transm Dis. 2015; 42: 6-12Crossref PubMed Scopus (17) Google Scholar]. Recent European guidelines recommend a single dose of ceftriaxone 500 mg plus 2 g of azithromycin [[4]European S.T.I. Bignell C. Unemo M. 2012 European guideline on the diagnosis and treatment of gonorrhoea in adults.Int J STD AIDS. 2013; 24: 85-92Crossref PubMed Scopus (314) Google Scholar], whereas the CDC recommends ceftriaxone 250 mg plus 1 g of azithromycin [[5]Centers for Disease Control and Prevention Workowski K.A. Bolan G.A. Sexually transmitted diseases treatment guidelines, 2015.MMWR Recomm Rep. 2015; 64Google Scholar]. In our hospital, one vial of 1-g ceftriaxone costs the same price as one vial of 500 mg, which is approximately 1€. When delivered to outpatients 1 g costs twice as much (6.50€) as 500 mg (3.25€). The fixed-price for four tablets of azithromycin 250 mg is around 6.25€. In France, we estimate that 15 000 patients/year suffer from gonococcal STD [[1]La Ruche G. Goubard A. Berçot B. Cambau E. Semaille C. Sednaoui P. Évolution des résistances du gonocoque aux antibiotiques en France de 2001 à 2012.Bull Epidémiol Hebd. 2014; 5: 93-103Google Scholar]. Considering all patients received an outgoing treatment, we can extrapolate that it would cost about (15 000×3.25)+(6.25×2×15 000), that is, 236 250€ per year if each physician in charge respected the European guidelines. In the USA, about 820 000 gonococcal infections are reported every year [[6]Satterwhite C.L. Torrone E. Meites E. et al.Sexually transmitted infections among US women and men: prevalence and incidence estimates, 2008.Sex Transm Dis. 2013; 40: 187-193Crossref PubMed Scopus (967) Google Scholar]. Even if the price of drugs may vary, the average price for a tablet of 500 mg of azithromycin is about $15 and $10 for 250 mg or 1 gram of ceftriaxone. Hence, considering the latest US guidelines, it would cost $32.8 million per year to treat every patient infected by gonococcus. We believe that there are arguments for prescribing a higher dose of ceftriaxone (1 g) to treat gonococcal STD, without the use of azithromycin. In the past, emergence of penicillin-resistant strains of Neisseria gonorrhoeae proliferated after subsequent exposures to suboptimal doses. Using a higher dose of ceftriaxone than recommended does not contribute to the emergence of cephalosporin-resistant gonorrhoea, and prevents cross-resistance to other Neisseria species, particularly Neisseria meningitidis [[7]Rotman E. Seifert H.S. The genetics of Neisseria species.Annu Rev Genet. 2014; 48: 405-431Crossref PubMed Scopus (81) Google Scholar]. Therefore, it raises questions about adding azithromycin to avoid future resistance to cephalosporins. This topic is even more relevant when considering the latest European guidelines, which recommend using a high dose of azithromycin (2 g). Also, having only 1-g vials of ceftriaxone simplifies the stock management, particularly in places where the price is not influenced by the dose. In our centre for STD, ceftriaxone has always been prescribed at the dose of 1 g and no vial of 500 mg has been delivered by the pharmacy for the past 3 years. Additionally, 1 g of ceftriaxone is efficient in the case of disseminated infection, and is recommended in the case of gonococcal conjunctivitis [[5]Centers for Disease Control and Prevention Workowski K.A. Bolan G.A. Sexually transmitted diseases treatment guidelines, 2015.MMWR Recomm Rep. 2015; 64Google Scholar], which can go unnoticed in a quick consultation for STD testing. A high dose of azithromycin might not be well tolerated. Recent clinical trials demonstrated that 7.7% of patients treated with 2 g of azithromycin plus gemifloxacin, and 3.3% of patients treated with 2 g of azithromycin plus gentamicin, vomited within 1 h of medication administration and necessitated retreatment [[5]Centers for Disease Control and Prevention Workowski K.A. Bolan G.A. Sexually transmitted diseases treatment guidelines, 2015.MMWR Recomm Rep. 2015; 64Google Scholar]. Mycoplasma genitalium is developing resistance to azithromycin, reaching up to 40% in many countries [[5]Centers for Disease Control and Prevention Workowski K.A. Bolan G.A. Sexually transmitted diseases treatment guidelines, 2015.MMWR Recomm Rep. 2015; 64Google Scholar], and it seems likely that this resistance is associated with the wide use of azithromycin. Finally, a recent study in England showed that outpatients treated for gonorrhoea received antimicrobials that were no longer recommended by recent guidelines (fluoroquinolones) [[8]Wetten S. Mohammed H. Yung M. Mercer C.H. Cassell J.A. Hughes G. Diagnosis and treatment of chlamydia and gonorrhoea in general practice in England 2000–2011: a population-based study using data from the UK Clinical Practice Research Datalink.BMJ Open. 2015; 5: e007776Crossref Scopus (27) Google Scholar], arguing for a rationalization of worldwide treatment regimens. Intravenous treatment with ceftriaxone (easily done with a butterfly needle) will save the patient the discomfort of an intramuscular injection. Using 1 g of ceftriaxone is not in accordance with the latest guidelines. Nevertheless, the doses of ceftriaxone recommended in the USA and Europe are not the same (250 versus 500 mg) and both recommend adding azithromycin, also with different dosages (1 g versus 2 g). Azithromycin as a single 2-g oral dose has been effective for treating primary and secondary syphilis in some populations, and is also effective against other non-gonococcal STD, which can be useful considering most of the patients are usually lost to follow up. Nevertheless, this argument is not sufficient because it does not promote appropriate antibiotic use, which relies on microbiological documentation, easily assessed by STD testing. The US and European guidelines differ. Despite some drawbacks, a single dose of 1 g of ceftriaxone may be interesting from a standpoint of efficacy and also logistics. Clinical trials are warranted to demonstrate that the risk–benefit balance is favourable. Such a trial with adequate power would require about 1000 patients on each arm considering the prevalence of resistant strains, to assess whether this regimen is efficient and that no resistance has emerged in case of treatment failure. The authors have no specific conflict of interest. I confirm that all listed authors have contributed to this work and approved the paper. This work was carried out as part of our routine work.

INTRODUCTION:Security and quality of the Medicinal Therapy are one of the most important objectives of the April 6th, 2011 order. The objective is to realize this study of the risks incurred by patients related to management and security of medicinal therapy in order to establish a plan to reduce the risks of drug's dispensation.MATERIALS AND METHOD:The method of the Preliminary Risk Analysis (PRA) has been implemented by a multidisciplinary group in a hospital service of orthopaedic surgery. The study focused on the dispensation phase of medicinal circuit.RESULTS:This analysis revealed 148 scenarii, 35 were criticality unacceptable. Fifty-four initial risk control actions were proposed and their stress levels to put them in place were evaluated.DISCUSSION:The main measures of risk management are: training, information, communication, computerization, automation, dual control, updating the documentation system, drug reconciliation and respect for Best Practices Hospitallers (BPH).CONCLUSIONS:Risk management requires a significant human and financial investment as well as, material resources and multidisciplinary expertise in order to offer the best solutions.

Background Overdose of vitamin K antagonists (VKA) is the most common cause of iatrogenic adverse drug reactions in France. Since 2013, the French health authorities have asked retail pharmacists to conduct patient education sessions about VKA treatment. Purpose To assess the operation of a new link between hospital pharmacists and retail pharmacists in order to improve patients' knowledge of VKAs. Material and methods A consultation focused on VKA treatment management was implemented in the cardiology unit. All patients treated with VKAs were invited to attend an information session (led by a nurse or a pharmacist). A patient information form (comorbidities, indication, initiation date, target INR values, caregiver) and a 10-item questionnaire on knowledge of their medicine (name of VKA and indication, monitoring, risk of overdose, daily management) were filled in after each consultation. Then, all this information were sent to the retail pharmacist by email/fax. After 1 month, this questionnaire was taken again during a consultation with the patient at the retail pharmacy. The questionnaires were then compared (before and after hospital discharge). Results 11 patients were enrolled in this 2-month preliminary prospective study. 9 retail pharmacies agreed to participate. We received 7 complete answers from retail pharmacists. 4 patients' knowledge of VKA treatment improved after the second consultation. How to deal with a missing dose and the importance of treatment monitoring were the 2 items least understood. Name of VKA, INR target values and time to take the drug were well understood. One of these 11 patients was hospitalised for drug overdose one week after hospital discharge. Conclusion This first study is encouraging. To improve the follow-up of these patients, a link between pharmaceutical services and general practitioners should also be developed. More patients need to be enrolled to assess the efficiency of this collaboration in improving patient knowledge. References and/or acknowledgements No conflict of interest

Conformément aux règles du bon usage antibiotique, les prescriptions d’antibiotiques des patients hospitalisés sont contrôlées et surveillées mais peu de données sont disponibles sur les prescriptions des patients sortant des services d’urgence pour des infections communautaires. Nous avons revu et évalué ces prescriptions dans notre hôpital. Étude rétrospective monocentrique des prescriptions d’antibiotiques des patients adultes non hospitalisés sortant des urgences et ayant passé moins de 48 h dans le service. Le référentiel utilisé était le référentiel local qui a été rédigé en accord avec les recommandations nationales. L’évaluation était réalisée par un urgentiste et un infectiologue conjointement. 216 prescriptions ont été revues, elles avaient été réalisées sur une période de 4 mois. L’âge moyen de la population était de 52 ans et le sexe ratio de 134/88. Les principales motifs de prescriptions étaient : infections urinaires (n = 77), infections respiratoires basses (n = 41), dermo hypodermite (n = 22), infections ORL (n = 15), plaie (n = 11) et abcès (n = 9). Les principales molécules prescrites étaient les fluoroquinolones (n = 85) et l’amoxicilline acide clavulanique (n = 68). La prescription était jugée incorrecte dans 126 cas (58 %), les principaux motifs étaient absence d’indication à une antibiothérapie (n = 53), durée de prescription trop longue (n = 29) et spectre trop large (n = 14). la prescription d’antibiotique au service d’accueil des urgences constitue un volume important d’antibiotique, sa qualité est perfectible et un renforcement de la formation des prescripteurs et/ou un recours à l’infectiologue devraient être développés.