In geriatrics, explicit criteria for potentially inappropriate prescriptions (PIPs) are useful for optimizing drug use.
To produce an expert consensus on explicit definitions of antibiotic-PIPs for ...hospitalized older patients.
We conducted a Delphi survey involving French experts on antibiotic stewardship in hospital settings. During the survey's rounds, the experts gave their opinion on each explicit definition, and could suggest new definitions. Definitions with a 1-to-9 Likert score of between 7 and 9 from at least 75% of the participants were adopted. The results were discussed during consensus meetings after each round.
Of the 155 invited experts, 128 (82.6%) participated in the whole survey: 59 (46%) infectious diseases specialists, 45 (35%) geriatricians, and 24 (19%) other specialists. In Round 1, 65 explicit definitions were adopted and 21 new definitions were suggested. In Round 2, 35 other explicit definitions were adopted. The results were validated during consensus meetings (with 44 participants after Round 1, and 54 after Round 2).
The present study is the first to have provided a list of explicit definitions of potentially inappropriate antibiotic prescriptions for hospitalized older patients. It might help to disseminate key messages to prescribers and reduce inappropriate prescriptions of antibiotics.
Objective Candiduria is a common finding in the growing population of very old patients that has not been previously studied. The objective was to study candiduria in the population aged 85 and over, ...including an estimation of the incidence, factor of acquisition, and evaluation of treatment and mortality. Methods retrospective monocentric study. Materials medical charts of patients aged of 85 and over who have candiduria diagnosed at Nimes University Hospital. Results The prevalence of candiduria in the hospitalized very old patients was 8.9%. More than half of strains isolated were C. albicans (59%). Mean age was 89.7 years old with 53 women and 20 men. Urinary catheter (55%) and prior antibiotic use (67%) were commonly found. Fifteen patients with candiduria were treated, consistently with fluconazole. Patients treated had higher Mini Mental Test score than the others. A high C-reactive protein level, Mac Cabe score or Charlson's score >7 were associated with 6 months mortality. Conclusion Episodes of candiduria in oldest old were associated with frailty and vulnerability of the patient. The medical decision for antifungal treatment is usually difficult to make but it did not seem to influence mortality.
Abstract Objectives This study aimed to estimate the prevalence of ANCA-associated vasculitis (AAV). That is, granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic ...granulomatosis with polyangiitis (EGPA), in Southern France in 2018, and evaluate differences among Europeans and non-Europeans. Methods This population-based, cross-sectional study used four sources (hospitals, community-based physicians, laboratories, National Health Insurance) to identify adults ≥15 years diagnosed with GPA, MPA or EGPA, living in Hérault and Gard in 2018. Cases were defined using the ACR/EULAR classification criteria, and if necessary, the European Medicines Agency algorithm. Prevalence estimates were standardised to the world population and capture-recapture analysis was used to assess the comprehensiveness of the estimation. The influence of geographical origin was evaluated. Results A total of 202 patients were selected, with 86 cases of GPA (42.6%), 85 cases of MPA (42.1%) and 31 cases of EGPA (15.3%). The standardised prevalence estimates per million inhabitants for 2018 were: 103 (95%CI 84–125) for AAV, 48 (95%CI 35–64) for GPA, 39 (95%CI 28–53) for MPA and 16 (95%CI 9–26) for EGPA, 36 (95%CI 25–50) for anti-PR3 positive AAV, 46 (95%CI 34–61) for anti-MPO positive AAV, and 16 (95%CI 9–26) for ANCA-negative AAV. The global estimation of comprehensiveness by capture-recapture analysis was 80.5%. The number of AAV cases was higher for non-European residents (P = 0.001), particularly for MPA (P < 0.0001). Conclusion We provide a new estimate of AAV prevalence in France and show a higher prevalence of MPA in non-European patients.
The aim was to describe the impact of infective endocarditis (IE) on functional, cognitive and nutritional statuses, and to estimate the influence of these parameters on surgical management and ...mortality.
This was a prospective study over 13 months in 14 French hospitals, including patients ≥75 years of age with definite or possible IE. A comprehensive geriatric assessment (CGA) was performed during the first week of hospitalization, including a retrospective estimation of functional status 2 months before hospitalization, and 3 months after.
A total of 120 patients were included (mean age 83.1 ± 5.0 (75–101) years). IE was associated with a dramatic impairment of functional status between 2 months prior hospitalization and the first geriatric evaluation (90.8% able to walk vs. 35.5% (p < 0.0001), ADL (Activities in Daily Living) 5.0 ± 1.7 vs. 3.1 ± 2.1 (p < 0.0001)). The 19 operated patients (15.8%) had less comorbidities (cumulative illness rating scale geriatric 10.8 ± 8.2 vs. 15.3 ± 7.1 (p 0.0176)), better functional (ADL 5.9 ± 0.4 vs. 4.9 ± 1.8 (p 0.0171) and nutritional (mini nutritional assessment 20.4 ± 5.0 vs. 17.3 ± 6.2 (p 0.0501)) statuses than non-operated patients. Among all infectious, cardiac and geriatric parameters, body mass index (HR 0.9, range 0.8–1, p 0.05) and ADL at the time of the first evaluation (HR 0.7, range 0.6–0.9, p 0.002) were the sole independent predictors of the 3-month (32.5%) and 1-year mortality (42.5%). Three months later, the 57 assessed patients only partially recovered their ADL (3.7 ± 1.9 vs. 5.3 ± 1.4 2 months prior hospitalization and 4.6 ± 1.9 at the first CGA; p < 0.0001).
Functional and nutritional abilities are crucial components that can be accurately explored through a CGA when managing IE in oldest patients.
The incidence of infective endocarditis (IE) rises in industrialized countries. Older people are more affected by this severe disease, notably because of the increasing number of invasive procedures ...and intracardiac devices implanted in these patients. Peculiar clinical and echocardiographic features, microorganisms involved, and prognosis of IE in elderly have been underlined in several studies. Additionally, elderly population appears quite heterogeneous, from healthy people without past medical history to patients with multiple diseases or who are even bedridden. However, the management of IE in this population has been poorly explored, and international guidelines do not recommend adapting the therapeutic strategy to the patient's functional status and comorbidities. Yet, if IE should be treated according to current recommendations in the healthiest patients, concerns may rise for older patients who suffer from several chronic diseases, especially renal failure, and are on polypharmacy. Treating frailest patients with high-dose intravenous antibiotics during a prolonged hospital stay as recommended for younger patients could also expose them to functional decline and toxic effect. Likewise, the place of surgery according to the aging characteristics of each patient is unclear. The aim of this article is to review the recent data on epidemiology of IE and its peculiarities in the elderly. Then, its management and various therapeutic approaches that can be considered according to and beyond guidelines depending on patient comorbidities and frailty are discussed.
Abstract
Background
New diagnostic tools have been developed to improve the diagnosis of infectious encephalitis. Using a prospective cohort of encephalitis patients, our objective was to identify ...possible clusters of patients with similar patterns among encephalitis of unknown cause (EUC) and to describe to what extent a patient’s initial presentation may be predictive of encephalitis etiology, particularly herpes simplex virus (HSV) and varicella-zoster virus (VZV).
Methods
The National Cohort of Infectious Encephalitis in France is an ongoing prospective cohort study implemented in France in 2016. Patients who present with documented or suspected acute infectious encephalitis were included. Focusing on the variables that describe the initial presentation, we performed a factor analysis of mixed data (FAMD) to investigate a pattern of association between the initial presentation of a patient and the etiologic pathogen.
Results
As of 1 August 2018, data from 349 patients were analyzed. The most frequent pathogens were HSV (25%), VZV (11%), tick-borne encephalitis virus (6%), Listeria (5%), influenza virus (3%), and EUC (34%). Using the FAMD, it was not possible to identify a specific pattern related to the group of EUC. Age, temporal or hemorrhagic lesions, and cerebral spinal fluid lymphocytosis were significantly associated with HSV/VZV encephalitis.
Conclusions
No initial clinical/imaging/biology pattern was identified at admission among EUC, despite the improvement in diagnostic tools. In this context, the recommendation for a universal, early, probabilistic, initial treatment against HSV and VZV is still relevant, regardless of the initial clinical presentation of the encephalitis.
No initial clinical/imaging/biology common pattern was identified at admission among encephalitis of unknown causes, and no initial clinical/imaging/biology specific pattern was associated with any of the identified causes of acute encephalitis.
L’infection en phase terminale de soins palliatifs (SP) chez le patient âgé (PA) est fréquente et interroge sur la place de l’antibiothérapie. L’objectif est de la décrire.
Etude des modalités ...d’antibiothérapie selon le type d’exercice médical, ancillaire d’une enquête nationale de pratique par auto-questionnaire en 2017.
Sur 327 médecins, 220 utilisaient une antibiothérapie : 136 hospitaliers dont 52 gériatres, 20 médecins travaillant en EHPAD et 64 généralistes libéraux (MG). Les MG suivaient moins de patients (6/an). Les objectifs du traitement antibiotique concernaient l’amélioration symptomatique pour 181 (82,3 %) sans différence entre les groupes. Les MG (25 %) prenaient le plus l’avis du patient pour prescrire. Les médecins d’EHPAD (23 %) et MG (18 %) rapportaient plus de signes fonctionnels urinaires que les autres (11,7 %) (p=0,003). Les gériatres (59,6 %) utilisaient significativement moins d’ECBU que les MG (90 %) (p=0,0009). Des effets indésirables étaient décrits (212, 96.4 %) : pour les MG plus d’allergie et moins de difficultés de voie d’abord. La décision d’arrêt différait avec plus de collégialité à l’hôpital (121, 89 %) qu’en ville (25, 39,1 %) (p<0,001) et, l’avis du patient pris par 30 (46,9 %) MG contre aucune autre spécialité.
Si la pratique et le nombre de PA en SP varie selon le mode d’exercice, l’intention de l’antibiothérapie respecte le principe de soulagement. Le diagnostic d’infection est difficile et les examens limités. Une évaluation de l’antibiothérapie, individualisée, régulière est nécessaire, quel que soit le type d’exercice, pour proposer une prise en charge graduée des soins avec le patient, son entourage et ses médecins référents.
Infections commonly occur terminally ill oldest patients in palliative care and questioned about antimicrobial use. The aim of this study was to describe practitioners’ habits.
ancillary study on antibiotic modalities according to the setting of care from a national practices survey based on self administered questionnaire sent by e-mail in 2017.
220 practitioners/327 used antibiotic, 136 worked in hospital department (52 geriatricians), 20 nursing home and 64 general practitioners (GP). GP declared less palliative care patients (6/year). The antibiotic goal was symptomatic relief for 181 (82.3%) without statistically significant difference between groups. GP (25%) were the group that most collected patient opinion for antibiotic prescription. Nursing home (23%) and GP (18%) reported more urinary tract symptoms than others (11.7%) (P=0.003). Geriatricians (59.6%) declared significantly less urinary analysis than GP (90%) (P=0.0009). 212 doctor (96.4%) faced side effect (SI): more allergic reaction and less administration difficulties than the other groups. The stop decision was collegially took (156, 70,9%) significantly more in hospital (121, 89%) than in community (25, 39.1%) (P<0.001). Patient wishes were noted by 30 (46.96%) only GP.
Even if practice and number of patients follow up differ from each place of care, doctors’ intention in antibiotic use respect palliative care goal to relieve discomfort. It is hard to diagnose infection and complementary exam are scarce. A repeated individualized evaluation with patient, his surrounding and his medical referent participation, is mandatory to give a constant adapted level of care in every place of care.
To assess the effectiveness of corticosteroids among older adults with coronavirus disease 2019 (COVID-19) pneumonia requiring oxygen.
We used routine care data from 36 hospitals in France and ...Luxembourg to assess the effectiveness of corticosteroids with at least 0.4 mg/kg/day equivalent prednisone (treatment group) versus standard of care (control group). Participants were adults aged 80 years or older with PCR-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection or CT scan images typical of COVID-19 pneumonia, requiring oxygen ≥3 L/min, and with an inflammatory syndrome (C-reactive protein ≥40 mg/L). The primary outcome was overall survival at day 14. In our main analysis, characteristics of patients at baseline (i.e. time when patients met all inclusion criteria) were balanced by using propensity-score inverse probability of treatment weighting.
Among the 267 patients included in the analysis, 98 were assigned to the treatment group. Their median age was 86 years (interquartile range 83–90 years) and 95% had a SARS-CoV-2 PCR-confirmed diagnosis. In total, 43/98 (43.9%) patients in the treatment group and 84/166 (50.6%) in the control group died before day 14 (weighted hazard ratio 0.67, 95% CI 0.46–0.99). The treatment and control groups did not differ significantly for the proportion of patients discharged to home/rehabilitation at day 14 (weighted relative risk 1.12, 95% CI 0.68–1.82). Twenty-two (16.7%) patients receiving corticosteroids developed adverse events, but only 11 (6.4%) from the control group.
Corticosteroids were associated with a significant increase in the overall survival at day 14 of patients aged 80 years and older hospitalized for severe COVID-19.
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