Академический Документы
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Benot SCHLEMMER
Hpital Saint-Louis Universit Paris Diderot
2009
La tv ia R us si a Fi nl an d Es to ni a Fr an ce Lu xe m b. Sl ov ak ia C ro at ia Sl ov en ia D en m ar k Sw ed en H un ga ry N or w ay Is ra el Ire la nd
80%
Relative frequency
60%
40%
20%
0%
LV RU CY FI EE FR LU SK HR SI DK SE MT HU NO IL IE IT TR
Hpital
France
Ville
RAISIN
C.CLIN Est, C.CLIN Ouest C.CLIN Paris-Nord, C.CLIN Sud-Est, C.CLIN Sud-Ouest, InVS, CTIN
Enqute Nationale de Prvalence des infections nosocomiales 2001 Description des traitements antibiotiques lhpital
1533 tablissements (77 % des lits) - + de 300 000 patients
Comit national de suivi du Plan Prserver lefficacit des antibiotiques Groupe IV : surveillance et suivi des prescription, 01/10/2003
Sjour
Patients traits Prvalence (%) 24,3 11,4 4,6 2,7 18,2 15,9
ORMH-IdF : rpartition en cots des antibiotiques consomms en 2002, selon leur motif de prescription
H C
Mc Gowan et al. JID, 1974 Craig et al., Ann Intern Med,1978 Recco et al., JAMA 1979 Klapp et al., Am J Hosp Pharm, 1983 Moleski and Andriole, Rev Infect Dis, 1986 Woodward et al., Am J Med, 1987 Hirschmann et al., Arch Intern Med, 1988 Coleman et al., Am J Med, 1991...
Craig et al., Ann Intern Med,1978 Reduction in antibiotic costs by restricting use of an oral cephalosporin. Recco Seligman SJ. et al., JAMA 1979 Antibiotic cost control are important. Seligman , programs Am J Med 1981 the requirement that the prescribing physician telephone an infectious diseases specialist resulted in marked restriction oral Klapp et al., Am J Hosp Pharm of the cephalosporin and was accompanied by,a1983 29 percent reduction (adjusted for inflation) in total antibiotic costs. Infect Dis, 1986 Moleski and Andriole , Rev Antibiotic cost savings from restrictions Woodward et al.,formulary Am J Med , 1987 and physician monitoring in a medical-school-affiliated hospital. Hirschmann et al., Arch Intern Med, 1988 Woodward RS, Strictly enforced formulary restrictions for aminoglycosides, cephalosporins, and a Coleman et al., Am J Med , 1991...
vancomycin group generated combined savings of $2.61 (p less than 0.0046) per antibiotic day and $34,597 (p less than 0.0003) per month.
Variations in antimicrobial use and cost in more than 2000 patients with community-acquired pneumonia
Gilbert K. et al. Am. J. Med., 1998, 104: 17-27
5 hospitals (PORT study), with or without antibiotic formulary restrictions 927 outpatients and 1328 inpatients with CAP endpoints: ABT use, costs and 30-day outcome results : large variations in ABT use and cost
unexplained by variations in case-mix no difference in outcome
Ne pas oublier les "ambulatoires" : 17% des prescriptions antibiotiques rembourses aux AS viennent de l'hpital
RESISTANCES
Escherichia coli resistant to fluoroquinolones in patients with cancer and neutropenia Cometta et al. NEJM, 1994, 330: 1240-41
CID 2006
Les rsistances aux antibiotiques compromettent la QUALITE de la prise en charge des malades
Total Ra
GERPB 2000
Appropriate therapy %
J1
J2
Gentamicine (n=271) Tobramycine (n=261) Amikacine (n=267) Imipnme (n=267) Quinolones classiques (n=262) Ciprofloxacine (n=270)
%R
AUIC
Role in resistance development in clinical setting
Probability of remaining susceptible
100
75
AUIC>101
107 pts with nosoc. LRTI Daily PK, tracheal asp., MICs
50
25
AUIC<100
Thomas JK, Antimicrobial Agents Chemother. 42: 521521-527, 1998. Pharmacodynamic evaluation of factors associated with the development of bacterial resistance in acutely ill patients during therapy Thomas JK et al., AAC, 1998; 42 : 521-27
Les effets ne sont pas uniquement l o on les attend !! Se mfier des interactions multiples et des co-rsistances
Charbonneau et al., CID 2006; 42: 778-84 Jan 2001 - jan 2002 1 an "FQ free" au CHU de Caen 3 CHU de comparaison Suivi mensuel : -taux de SARM (tous isolats) -Densit d'incidence des IN SARM
FQ DDJ :10
Prvalence du SARM : 97- 00 2001 Caen 36.0% 32.3% 3 CHU 36.2% 36.8%
Utilisation dAntibiotique
mdiane
Satisfaisant
Nouveaux antibiotiques
ANDEM-ANAES 1996 100 recommandations DGS 1999 : n 58 Plan Antibiotiques novembre 2001 Circulaire hpitaux DGS-DHOS 2/5/02 14e Confrence de consensus de la SPILF, 2002 Objectif n 31 Loi de Sant publique, 2004 Accord-cadre Hpitaux-Assurance Maladie Evaluation des pratiques professionnelles Certification des tablissements de sant
Automne 2001
TROIS freins
1) Banalisation des antibiotiques
des mdicaments UNIQUES, grer spcifiquement
irremplaables limpact individuel ET collectif cibles vivantes = activit menace dans le temps
3) Organisation insuffisante
prescription des antibiotiques dispensation suivi
OBJECTIF ET MOYENS
Incitation rglementaire forte Tenir compte des contextes locaux +++ Association de comptences
Prescripteur
diagnostic - responsabilit thrapeutique
Microbiologiste
diagnostic - alerte - suivi pidmiologique
Pharmacien
analyse des prescriptions - dispensation qualit et conformit de la prescription - suivi
Matrise de l antibiothrapie
- Outils de la rgulation -
Modles restrictifs Modles ducatifs Formulaire Accs limit Avis spcialis pralable Stop orders Protocoles - Rotation...
AUTORISATION PREALABLE
Effects of requiring prior authorization for selected antimicrobials: expenditures, susceptibilities, and clinical outcomes White A.C. et al., CID, 1997, 25: 230-239 Requirement for prior authorization as a mean for controlling resistance and ABT expenditures endpoints: expenditures, ABT susceptibilities, and outcomes results: expenditures decreased by 32 % increase in BL and FQ susceptibilities, especially in ICUs same outcome in gram-negative bacteremia no difference in duration of ICU or hospital stay reduction in the number of nosocomial bacteremias We conclude that there is no longer a question of whether antibiotics should be controlled but only which controls are optimal
Class restriction of cephalosporin use to control total cephalosporin resistance in nosocomial Klebsiella Rahal J.J. et al., JAMA, 1998, 280: 1233-37
Prior approval required for the use of cephalosporins and imipenem (except ICUs) beyond the first dose Results: 80 % reduction in cephalosporin use and 140% increase in imipenem use (ICUs) 44 % reduction in the incidence of cefta-R Klebsiella infection and colonization (- 71 and 87 % in ICUs) but: 69 % increase in the incidence of imipenem-resistant Pseudomonas aeruginosa...
Risque de dplacement des problmes de rsistance Remise en cause des procdures de contrainte ou de seule ducation Mauvais usage des antibiotiques plus du fait dun dfaut dinformation que dun mauvais comportement Plaidoyer pour une prescription individualise au lit du patient et pour un polymorphisme des prescriptions
Pestotnik S.L. et al.: Implementing antibiotic practice guidelines through computerassisted decision support: clinical and financial outcomes. Ann. Intern. Med., 1996, 124: 884-90 Evans R.S. et al.: A computer-assisted management program for antibiotics and other antiinfective agents. N. Engl. J. Med., 1998, 338: 232-38 LDS Hospital, Salt Lake City
Accroissement de la proportion de patients recevant des antibiotiques (de 32 53 % entre 1988 et 1994) Reduction des cots totaux et des cots par patient rduction de lutilisation totale des antibiotiques (DDD) Antibioprophylaxie chirurgicale approprie: de 40 99% DMS identique et mortalit abaisse pour patients sous ABT Application en ranimation : amlioration de la qualit des traitements antibiotiques (choix, posologies, dure, effets secondaires), rduction des cots de traitement et des cots hospitaliers, rduction de la dure de sjour
Strategy 1 : Maximizing empirical coverage with subsequent formal reduction in antibiotic therapy Strategy 2 : Alteration in availability of empirical antibiotic choices in response to outbreaks of infection with antibiotic-resistant organisms Strategy 3 : Antibiotic cycling
Politiques antibiotiques
Effets variables Limites (squeezing the balloon) Moyens : ducation - restriction individualisation par patient systmes informatiss daide OPTIMISATION DES TRAITEMENTS +++ : viter les concentrations slectionnantes (choix de l'abt - posologie; diminuer lexposition au risque (indications, dure) QUALITE
Prevent Transmission
11. Isolate the pathogen 12. Break the chain of contagion
55
10 Vacciner 9 7 6
Prvenir la transmission croise
Prvenir les infections Mieux utiliser les antibiotiques Savoir dire non aux antibiotiques
5 Bien choisir le traitement initial 4 Savoir arrter un traitement 3 R-valuer la prescription 48 heures 2 1
56
- 7,7 %
HOPITAL SAINT-LOUIS
Evolution des DDJ ATB/ 1000 Journes d hospitalisation
1 400 1 200 1 000 800 600 400 200 0 2000 2002 2004 2006 2008 JT/1000 JH
- 8,6 %
893
1 349
1 149