Perceptions of infection control professionals toward electronic surveillance software supporting inpatient infections: A mixed methods study

BACKGROUND

Electronic surveillance software (ESS) collects multiple patient data from hospital software to assist infection control professionals in the prevention and control of hospital-associated infections. This study aimed to understand the perceptions of end users (i.e., infection control professionals) and the facilitators and barriers related to a commercial ESS named ZINC and to assess its usability.

METHODS

A mixed-method research approach was adopted among infection control professionals 10 months after the implementation of commercial ESS in the university hospital of Nancy, France. A qualitative analysis based on individual semistructured interviews was conducted to collect professionals' perceptions of ESS and to understand barriers and facilitators. Qualitative data were systematically coded and thematically analyzed. A quantitative analysis was performed using the System Usability Scale (SUS).

RESULTS

Thirteen infection control professionals were included. Qualitative analysis revealed technical, organizational and human barriers to the installation and use stages and five significant facilitators: the relevant design of the ESS, the improvement of infection prevention and control practices, the designation of a champion/superuser among professionals, training, and collaboration with the developer team. Quantitative analysis indicated that the evaluated ESS was a "good" system in terms of perceived ease of use, with an overall median SUS score of 85/100.

CONCLUSIONS

This study shows the value of ESS to support inpatient infections as perceived by infection control professionals. It reveals barriers and facilitators to the implementation and adoption of ESS. These barriers and facilitators should be considered to facilitate the installation of the software in other hospitals.

Nursing home nurses' opinions on the potential evolution of their role in antibiotic stewardship: A French national cross-sectional survey

AIMS

To assess French nursing home nurses' opinions on the potential evolution of their antibiotic stewardship role, facilitators and barriers, and nurses' characteristics associated with their opinion toward new roles regarding antibiotic prescribing.

DESIGN

We conducted a cross-sectional study in French nursing homes with ≥20 beds and for which an email address was available in a national database managed by the French government between May and June 2022.

METHODS

A self-administered internet-based questionnaire of 43 closed-ended Likert items was sent to directors of eligible nursing homes by email asking them to forward the link to the questionnaire to the nurses and head nurses of their institution. Data analysis included descriptive statistics and χ2 tests.

RESULTS

7215 nursing homes were sent the online questionnaire; 1090 participants completed it partially or totally and 923 fully filled in the questionnaire. A majority of nurses supported strengthening and expanding their antibiotic stewardship role. Regarding new roles, over 70% agreed that nurses could collect urine samples to perform a urine culture on their own initiative, prescribe microbiological laboratory tests, and change the drug formulation or the administration route of the antibiotic prescribed by the general practitioner. One-third declared that they could initiate antibiotics for some infections and/or change the empirical antibiotic treatment prescribed by the general practitioner. Nurses from public nursing homes with connection to a hospital (27.5% vs. >35% for other status) and with recent experience in nursing homes (31% for <5 years of practice vs. 41% for 10 years or more) were less likely to agree to prescribe antibiotics.

CONCLUSIONS

This quantitative questionnaire survey identified potential new nurses' roles in antibiotic stewardship that seem to be acceptable and feasible for participants. These new nurses' roles need to be explored in future experimentations before considering implementation.

REPORTING METHOD

The study adhered to relevant EQUATOR guidelines and followed the STROBE reporting guidelines.

PATIENT OR PUBLIC CONTRIBUTION

A self-administered internet-based questionnaire was sent to directors of eligible nursing homes by email asking them to forward the link to the questionnaire to the nurses and head nurses of their institution. Nurses and head nurses who were interested and willing could complete the questionnaire online partially or fully.

TRIAL AND PROTOCOL REGISTRATION

This study is not a clinical trial and is not eligible for trial registration. We used another suitable study registration site, the Center for Open Science.

Optimizing Communication on HPV Vaccination to Parents of 11- to 14-Year-Old Adolescents in France: A Discrete Choice Experiment

BACKGROUND

With the aim to optimize communication during HPV vaccination campaigns in France, we elicited parental preferences around HPV vaccination.

METHODS

We conducted a single-profile discrete choice experiment (DCE) among parents of 11- to 14-year-old middle-school pupils, who completed an anonymous, self-administered, internet-based questionnaire during 2020-2021. The DCE comprised five attributes (vaccine-preventable disease, justification of optimal age, information on safety, indirect protection and coverage) of vaccination against an unnamed disease that were presented to respondents in ten choice tasks, or scenarios. We use fixed effect logit models to estimate attribute weights on theoretical vaccine acceptance, and random effect linear regression to estimate attribute coefficients on vaccine eagerness (decision and decision certainty). We estimated marginal effects of attributes on expected vaccine acceptance.

RESULTS

Vaccination scenarios were accepted by 55.6-89.2% of the 1291 participants. The largest marginal effects on expected vaccine acceptance in the full sample arose from prevention of cancer versus genital warts (+ 11.3 percentage points); from a "severe side effect suspicion that was not scientifically confirmed" versus a statement about "more benefits than risks" (+ 8.9 percentage points), and information on 80% vaccine coverage in neighbouring countries versus on "insufficient coverage" (+ 4.2 percentage points). Explaining the early age of vaccination by sexual debut had a strong negative impact among French monolingual parents with lower education level (vs age-independent, OR 0.48, 95% CI 0.27-0.86), but not other socio-economic groups. After removing low-quality responses (unvaried certainty and short questionnaire completion), among serial non-demanders with children not vaccinated against HPV, only disease elimination impacted vaccine eagerness positively (coefficient 0.54, 0.06-1.02).

DISCUSSION

Using DCEs to elicit parents' preferences around communication messages, notably on cancer prevention, vaccine coverage and information about vaccine safety, could help to optimize HPV vaccination promotion efforts.

Effectiveness of a School- and Primary Care-Based HPV Vaccination Intervention: The PrevHPV Cluster Randomized Trial

Importance

The human papillomavirus (HPV) vaccine is safe and effective, yet vaccination coverage remains below public health objectives in many countries.

Objective

To examine the effectiveness of a 3-component intervention on HPV vaccination coverage among adolescents aged 11 to 14 years 2 months after the intervention ended, each component being applied alone or in combination.

Design, Setting, and Participants

A cluster randomized trial with incomplete factorial design (PrevHPV) was conducted between July 1, 2021, and April 30, 2022, in French municipalities receiving 0, 1, 2, or 3 components of the intervention. Randomization was stratified by school district and municipalities' socioeconomic level. Analyses were carried out on 11- to 14-year-old adolescents living in all participating municipalities, regardless of what had been implemented.

Intervention

The PrevHPV intervention had 3 components: (1) educating and motivating 11- to 14-year-old adolescents in middle schools, along with their parents; (2) training general practitioners (GPs) on up-to-date HPV information and motivational interviewing techniques; and (3) free HPV vaccination at school.

Main Outcomes and Measures

The primary outcome was HPV vaccination coverage (≥1 dose) 2 months after the intervention ended among 11- to 14-year-old adolescents living in participating municipalities, based on the French national reimbursement database and data collected during the trial in groups randomized to implement at-school vaccination.

Results

A total of 91 municipalities comprising 30 739 adolescents aged 11 to 14 years (15 876 boys and 14 863 girls) were included and analyzed. Half the municipalities were in the 2 lowest socioeconomic quintiles and access to GPs was poor in more than two-thirds of the municipalities. Thirty-eight of 61 schools (62.3%) implemented actions and 26 of 45 municipalities (57.8%) had at least 1 trained GP. The median vaccination coverage increased by 4.0 percentage points (IQR, 2.0-7.3 percentage points) to 14.2 percentage points (IQR, 9.1-17.3 percentage points) at 2 months. At-school vaccination significantly increased vaccination coverage (5.50 percentage points [95% CI, 3.13-7.88 percentage points]) while no effect was observed for adolescents' education and motivation (-0.08 percentage points [95% CI, -2.54 to 2.39 percentage points]) and GPs' training (-1.46 percentage points [95% CI, -3.44 to 0.53 percentage points]). Subgroup analyses found a significant interaction between at-school vaccination and access to GPs, with a higher effect when access was poor (8.62 percentage points [95% CI, 5.37-11.86 percentage points] vs 2.13 percentage points [95% CI, -1.25 to 5.50 percentage points]; P = .007 for interaction).

Conclusions and Relevance

In this cluster randomized trial, within the context of the late COVID-19 pandemic period and limited school and GP participation, at-school HPV vaccination significantly increased vaccination coverage. The trial did not show a significant effect for training GPs and education and motivation, although it may be observed after more time has elapsed after the intervention.

Trial Registration

ClinicalTrials.gov Identifier: NCT04945655.

Do boys have the same intentions to get the HPV vaccine as girls? Knowledge, attitudes, and intentions in France

BACKGROUND

The vaccine coverage against human papillomavirus (HPV) vaccination remains low in France. The objective of this study was to study adolescent perceptions by comparing boys and girls, in order to build effective school-based interventions.

METHODS

This paper presents a cross-sectional study in French middle school pupils. They completed online questionnaires on their knowledge and attitudes toward the HPV vaccine, HPV vaccination status, their intention, reasons to vaccinate or not to vaccinate, and psychological antecedents of vaccination. A structural equation modeling (SEM) analysis was used to test the hypothesized model.

RESULTS

The participants are 818 pupils aged from 12 to 16 years (Mage = 13.78). Most pupils were in the pre-contemplative stage (62.7 % of boys and 40.8 % of girls). SEM analysis indicated that the relationship between the level of HPV knowledge, the representations of vaccines in general, and vaccine intention was mediated by attitudes towards the HPV vaccine among both boys and girls.

CONCLUSIONS

These findings reveal a high percentage of boys who do not feel concerned by the HPV vaccine and highlight the need to consider the psychological antecedents of vaccination in general in addition to the specific attitudes to the HPV vaccine.

Selection of proxy indicators estimating the appropriateness of antibiotic prescriptions in general practice: a national consensus procedure in France

Background

GPs are responsible for more than 70% of outpatient antibiotic prescriptions in France. Metrics are important antibiotic stewardship tools that can be used to set targets for improvement and to give feedback to professionals and stakeholders.

Objectives

The primary objective of the present study was to select a set of proxy indicators (PIs) based on 10 previously developed PIs, to estimate the appropriateness of antibiotic prescriptions by GPs. The secondary objective was to evaluate the clinimetric properties of the selected PIs.

Methods

A RAND-modified Delphi consensus procedure was conducted with a multidisciplinary panel of stakeholders. This procedure consisted of two successive online surveys with a consensus meeting in between. Clinimetric properties (measurability, applicability and potential room for improvement) were evaluated for the PIs selected through the consensus procedure, using 2022 Regional Health Insurance data.

Results

Seventeen experts participated in the first-round survey and 14 in the second-round. A final set of 12 PIs was selected. Among the 10 initial PIs, 3 were selected without modification and 7 were modified and selected. Moreover, two newly suggested PIs were selected. Ten of the 12 PIs presented good clinimetric properties.

Conclusions

The 12 selected PIs cover the main situations responsible for inappropriate and unnecessary use of antibiotics in general practice. These PIs, easily calculable using routinely collected health insurance reimbursement data, might be used to give feedback to prescribers and stakeholders and help improve antibiotic prescriptions in primary care.

The intentions of French health university students to recommend and to receive the HPV vaccine are mainly influenced by vaccine knowledge, confidence in vaccines and personal HPV vaccination

INTRODUCTION

Despite documented effectiveness in preventing several cancers, genital warts and safety of Human Papillomavirus (HPV) vaccine, immunization coverage among French adolescents remains far from the 80 % target. University health students (HS) in France may promote HPV vaccine through a national service (Service Sanitaire des Etudiants en Santé). We aimed to evaluate intentions to recommend the HPV vaccine to friends and relatives, to receive HPV vaccine, and to identify factors associated with these attitudes.

METHODS

We conducted a cross-sectional survey in five French Universities from October 2019 to February 2020, using a self-administered online questionnaire. We used bivariable and multivariable logistic regression models to identify determinants of behavior around HPV vaccine: (i) individual intention for vaccination, and (ii) vaccine recommendation to friends and relatives.

RESULTS

Among the 732 respondents (180 men, 552 women), 305 (41.7%) reported previous HPV vaccination (54.5 % among women), 504 (68.9%) would recommend the HPV vaccine to friends and relatives, 532 (72.7%) respondents would be vaccinated today if it was recommended for them. Intentions to recommend or to receive the HPV vaccine were less frequent in nursing students compared to medical and pharmacy students. After adjustment for demographical factors, HPV vaccine knowledge was associated with intention [aOR 1.30 (95%-confidence interval, 1.15-1.47)] and recommendation [1.26 (1.10-1.45)], respectively. Additionally, adjusting for knowledge about HPV infections, and confidence in vaccines in general was associated with vaccine intention [1.55, (1.30-1.84)] and recommendation [1.52 (1.24-1.86)]. HPV-vaccinated HS were more prone to recommend the HPV vaccine to friends and relatives [10.9 (6.6-17.9)].

CONCLUSION

A majority of HS would accept and/or recommend HPV vaccines. HS with greater knowledge about the HPV vaccine were more prone to recommend it. Strengthening knowledge about HPV and its vaccination is probably necessary before their Involvement in a HPV immunization program.

Impact of a public commitment charter, a non-prescription pad and an antibiotic information leaflet to improve antibiotic prescription among general practitioners: A randomised controlled study

BACKGROUND

This study evaluated the effect of a multifaceted antibiotic stewardship intervention on the overall prescription of systemic antibiotics in primary care. Secondary objectives evaluated the effect on the prescription of broad-spectrum antibiotics and the seasonal variation of both total antibiotic and quinolone prescriptions, as a proxy for unnecessary prescribing.

METHODS

This pragmatic, randomised, controlled, before-after intervention study was conducted among general practitioners (GPs) who over prescribe antibiotics in Lorraine, France (Intervention group, n = 109; Control group, n = 236; Before period, 01/10/2017-30/09/2018; After period, 01/10/2018-30/09/2019). The intervention included a public commitment charter, a patient information leaflet and a non-prescription pad. Health Insurance data was obtained to calculate overall and broad-spectrum prescription rate (defined daily doses/1000 consultations) and the seasonal variation of prescriptions (%), by period. The intervention effect was measured with general linear mixed models including three independent variables (group, period and group x period interaction).

RESULTS

Overall, compared to the Before period, GPs in both groups prescribed significantly fewer systemic antibiotics (p < 0.001) and broad-spectrum antibiotics (p < 0.001) after the intervention was implemented. However, the group x period interaction did not show any evidence that the intervention had an effect on these outcomes. Nevertheless, the intervention did result in a trend towards less seasonal variation in total systemic antibiotic prescription (p = 0.052).

CONCLUSIONS

A tendency towards an effect of the intervention to reduce unnecessary antibiotic prescribing during winter months was observed. No effect was observed on the overall volume of systemic antibiotic prescription. This study invites discussion about the challenges faced when evaluating non-pharmacological interventions in primary care.

Barriers and facilitators to the HPV vaccine: a multicenter qualitative study of French general practitioners

BACKGROUND

In France, human papillomavirus (HPV) vaccination coverage is low, with 30.7% of 17-year-old girls having received a complete HPV vaccination schedule in 2020.

AIM

To determine the perspective and behaviors of general practitioners (GPs) regarding HPV vaccination with their patients and if a reluctance is observed.

DESIGN AND SETTING

A qualitative study based on semi-directed individual interviews was conducted between December 2019 and December 2020. A representative sample of GPs with various profiles were included in 4 French regions.

METHOD

A purposive sampling was used and interviews were continued until data saturation was reached. The analysis was based on the grounded theory.

RESULTS

Twenty-six GPs aged 29-66 years were interviewed. The measures taken by the French health authorities (lowering the target age, reimbursing the vaccine, extending the target population to boys) were perceived as facilitators. The reported barriers were organizational, due to low attendance of adolescents, and relational, mainly due to parental vaccine hesitancy. Physicians had to deal with fears about the perceived risks and concerns about sexuality conveyed by HPV vaccination and linked to the socio-cultural characteristics of the families. Physicians developed strategies, including scientific knowledge mobilization, empowerment of families by promoting health through prevention, repetition of the vaccination proposals, personal experience and relationship. Different practices were identified according to three GP typologies: effective, convinced but unpersuasive, and reluctant physicians.

CONCLUSION

Based on these results, specific interventions, including communication techniques, especially for hesitant or unpersuasive physicians, are needed to enable GPs to become more effective.

Psychometric validation of a 7C-model of antecedents of vaccine acceptance among healthcare workers, parents and adolescents in France

Support for vaccine decision-making requires a tailored approach taking into account psychological antecedents of vaccine acceptance. We aimed at validating an extended 7C-model of antecedents in three different target population groups (healthcare workers [n = 3870], parents [n = 2002] and adolescents [n = 7118]) and two vaccinations (COVID-19, HPV) in France. We performed a secondary analysis of questionnaires collecting sociodemographic characteristics, attitudes and knowledge on vaccination, and vaccine status and intention. We used standard psychometric techniques to validate a first and second order latent structure, and evaluated their association with vaccine intentionality in three levels (refusal, indecision, acceptance). In all populations, the 7C-model yielded a very good model fit (CFI and TLI > 0.90) and, in comparison with non-nested and nested 5C-models, significantly improved the model performance (Ω2, p < 0.05; Wald's test, p < 0.05). The resulting vaccine readiness score was strongly associated with vaccine intentionality (acceptance vs. indecision: βHCW = 2.93, βParents = 2.41, βAdolescents = 1.34; refusal vs. indecision: βHCW = - 1.68, βParents = - 0.16, βAdolescents = - 0.89.). The addition of confidence in the system and social conformism among antecedents of vaccine acceptance allowed a finer understanding of the continuum moving from refusal to indecision and acceptance. To work with these antecedents in interventional research, appropriate questionnaire items should be developed for various vaccines and target populations.

Can physicians and schools mitigate social inequalities in human papillomavirus vaccine awareness, uptake and vaccination intention among adolescents? A cross-sectional study, France, 2021 to 2022

BackgroundIn France, human papillomavirus (HPV) vaccination coverage varies across socioeconomic levels.AimWe aimed at assessing HPV vaccine awareness, uptake and vaccination intention among adolescents in France.MethodsIn a cluster-randomised study, 13-15-year-old students in 61 French middle schools completed a web-based questionnaire. We used multivariable logistic regression to evaluate determinants of HPV vaccine awareness, self-reported uptake and vaccination intention among unvaccinated students and interaction terms to explore effects of visits to family physician and remembering school lessons on vaccination. The French deprivation index of school municipalities served as proxy for socioeconomic levels.ResultsAmong 6,992 participants, awareness was significantly associated with parental education (odds ratio (OR) = 0.82; 95% confidence interval (CI): 0.71-0.95), language spoken at home (OR = 0.59; 95% CI: 0.52-0.66) and deprivation level (OR = 0.57; 95% CI: 0.44-0.71), regardless of physician visit or school lessons. Vaccine uptake was associated with parental education without a recent physician visit (OR = 0.31; 95% CI: 0.16-0.59, vs OR = 0.64; 95% CI: 0.52-0.78 with a visit, interaction p = 0.045). Vaccination intention among unvaccinated was associated with deprivation level (moderate-low vs low) among students not remembering school lessons on vaccination (OR = 0.17; 95% CI: 0.05-0.62, vs OR = 0.93; 95% CI: 0.51-1.67 remembering school lessons, interaction p = 0.022). Parental education was associated with vaccination intention among students reporting a physician visit (OR = 0.41; 95% CI: 0.26-0.64 vs OR = 1.05; 95% CI: 0.50-2.20 without a visit, interaction p = 0.034).ConclusionOur results suggest that healthcare and school could promote vaccination and mitigate social inequalities in HPV vaccination coverage.

Co-development of a school-based and primary care-based multicomponent intervention to improve HPV vaccine coverage amongst French adolescents (the PrevHPV Study)

INTRODUCTION

Despite various efforts to improve human papillomavirus (HPV) vaccine coverage in France, it has always been lower than in most other high-income countries. The health authorities launched in 2018 the national PrevHPV research programme to (1) co-develop with stakeholders and (2) evaluate the impact of a multicomponent complex intervention aimed at improving HPV vaccine coverage amongst French adolescents.

OBJECTIVE

To describe the development process of the PrevHPV intervention using the GUIDance for rEporting of intervention Development framework as a guide.

METHODS

To develop the intervention, we used findings from (1) published evidence on effective strategies to improve vaccination uptake and on theoretical frameworks of health behaviour change; (2) primary data on target populations' knowledge, beliefs, attitudes, preferences, behaviours and practices as well as the facilitators and barriers to HPV vaccination collected as part of the PrevHPV Programme and (3) the advice of working groups involving stakeholders in a participatory approach. We paid attention to developing an intervention that would maximise reach, adoption, implementation and maintenance in real-world contexts.

RESULTS

We co-developed three components: (1) adolescents' and parents' education and motivation using eHealth tools (web conferences, videos, and a serious video game) and participatory learning at school; (2) general practitioners' e-learning training on HPV using motivational interviewing techniques and provision of a decision aid tool and (3) easier access to vaccination through vaccination days organised on participating middle schools' premises to propose free of charge initiation of the HPV vaccination.

CONCLUSION

We co-developed a multicomponent intervention that addresses a range of barriers and enablers of HPV vaccination. The next step is to build on the results of its evaluation to refine it before scaling it up if proven efficient. If so, it will add to the small number of multicomponent interventions aimed at improving HPV vaccination worldwide.

PATIENT OR PUBLIC CONTRIBUTION

The public (adolescents, their parents, school staff and health professionals) participated in the needs assessment using a mixed methods approach. The public was also involved in the components' development process to generate ideas about potential activities/tools, critically revise the successive versions of the tools and provide advice about the intervention practicalities, feasibility and maintenance.

Intravitreal Injection of Bevacizumab for the Prevention of Postoperative Proliferative Vitreoretinopathy in High-Risk Patients Selected by Laser Flare Photometry

INTRODUCTION

To evaluate the effect of an intravitreal injection of bevacizumab at the time of rhegmatogenous retinal detachment (RRD) surgery, on postoperative proliferative vitreoretinopathy (PVR) in high-risk patients selected by laser flare photometry.

METHODS

This single-center observational retrospective cohort study included 137 consecutive patients who underwent pars plana vitrectomy and gas tamponade for primary RRD with increased aqueous flare between July 2016 and June 2021. From June 2019, an intravitreal injection of bevacizumab was administered as an adjunct to RRD repair. Patients who underwent surgery before this time and who did not receive intravitreal bevacizumab served as controls. The main outcome was the rate of retinal redetachment due to PVR.

RESULTS

The median flare value was 22.0 (16.5-36.5) pc/ms in the control group and 28.2 (19.7-41.0) pc/ms in the bevacizumab group (p = 0.063). Eyes treated with bevacizumab were more likely to have macula-off RRD (p = 0.003), grade B PVR (p = 0.038), and worse visual acuity (p = 0.004) than controls. The rate of PVR redetachment was significantly lower in the bevacizumab group (11.1%) than in the control (30.1%) (p = 0.012). This difference was more pronounced after adjusting for potential confounding factors (p = 0.005); the risk of developing PVR was 4.5-fold higher in controls (95% CI, 1.6-12.8). After adjustment, the final median visual acuity was also significantly higher in eyes treated with bevacizumab (p = 0.025).

CONCLUSION

This pilot study provides preliminary evidence that bevacizumab may reduce the risk of PVR-related recurrent RRD and improve visual outcomes in high-risk patients selected by laser flare photometry.

A French single-center experience on allogeneic stem cell transplant cryopreservation during severe acute respiratory syndrome coronavirus 2 pandemic

BACKGROUND AIMS

Allogeneic hematopoietic stem cell transplantation (allo-SCT) is a curative treatment for chemo-resistant hematological malignancies. Because of transport restriction imposed by the coronavirus disease 2019 pandemic, regulatory bodies and societies recommended graft cryopreservation before recipient conditioning. However, the freezing and thawing processes, including washing steps, might impair CD34+ cell recovery and viability, thereby impacting the recipient engraftment. Over 1 year (between March 2020 and May 2021), we aimed to analyze the results of frozen/thawed peripheral blood stem cell allografts in terms of stem cell quality and clinical outcomes.

METHODS

Transplant quality was evaluated by comparing total nucleated cells (TNCs), CD34+ cells and colony-forming unit-granulocyte/macrophage (CFU-GM)/kg numbers as well as TNC and CD34+ cell viabilities before and after thawing. Intrinsic biological parameters such as granulocyte, platelet and CD34+ cell concentrations were analyzed, as they might be responsible for a quality loss. The impact of the CD34+ cell richness of the graft on TNC and CD34 yields was evaluated by designing three groups of transplants based on their CD34 /kg value at collection: >8 × 10 6/kg, between 6 and 8 × 106/kg and <6 × 106/kg. The consequences of cryopreservation were compared in the fresh and thawed group by evaluating the main transplant outcomes.

RESULTS

Over 1 year, 76 recipients were included in the study; 57 patients received a thawed and 19 patients a fresh allo-SCT. None received allo-SCT from a severe acute respiratory syndrome coronavirus 2-positive donor. The freezing of 57 transplants led to the storage of 309 bags, for a mean storage time (between freezing and thawing) of 14 days. For the fresh transplant group, only 41 bags were stored for potential future donor lymphocyte infusions. Regarding the graft characteristics at collection, median number of cryopreserved TNC and CD34+ cells/kg were greater than those for fresh infusions. After thawing, median yields were 74.0%, 69.0% and 48.0% for TNC, CD34+ cells and CFU-GM, respectively. The median TNC dose/kg obtained after thawing was 5.8 × 108, with a median viability of 76%. The median CD34+ cells/kg was 5 × 106, with a median viability of 87%. In the fresh transplant group, the median TNC/kg was 5.9 × 108/kg, and the median CD34+ cells/kg and CFU-GM/kg were 6 × 106/kg and 276.5 × 104/kg, respectively. Sixty-one percent of the thawed transplants were out of specifications regarding the CD34+ cells/ kg requested cell dose (6 × 106/kg) and 85% of them would have had this dose if their hematopoietic stem cell transplant had been infused fresh. Regarding fresh grafts, 15.8% contained less than 6 × 106 CD34+ cells /kg and came from peripheral blood stem cells that did not reach 6 × 106 CD34+ cells /kg at collection. Regarding the factor that impaired CD34 and TNC yield after thawing, no significant impact of the granulocyte count, the platelet count or the CD34+ cells concentration/µL was observed. However, grafts containing more than 8 × 10 6/kg at collection showed a significantly lower TNC and CD34 yield.

CONCLUSIONS

Transplant outcomes (engraftment, graft-versus-host disease, infections, relapse or death) were not significantly different between the two groups.

How can we improve the acceptability of vaccination against Human Papillomavirus (HPV) in France? An original qualitative study with focus groups comprising parents and school staff, interviewed separately

BACKGROUND

It has been proven that vaccination is effective against Human Papillomavirus (HPV) infections, genital warts, and pre-cancerous and cancerous cervical lesions. Nevertheless, the HPV vaccine coverage of 37.4 % in 2021 in France is one of the lowest in Europe. To explore and understand the reason why French population is so late compared to its neighbours, we carried out focus groups with mothers and with National Education school staff. We aimed to identify knowledge and perceptions of HPV in both study populations, as well as factors influencing HPV vaccination.

METHODS

Between January 2020 and March 2021, we performed a qualitative study using an inductive approach with a thematic content analysis (TCA). We conducted semi-structured focus groups with 29 people including 15 mothers of adolescents in middle schools and 14 school staff from the national education system.

RESULTS

Different factors influenced the decision-making process of parents and school staff: knowledge and perceptions of HPV and its vaccine, sources of information about HPV and vaccination. Mothers' discourses differed from those of school staff. They mentioned the importance of gynaecological monitoring and the negative image of pharmaceutical companies, and questioned internet as a reliable source of information. For their part, school staff mentioned cultural and/or religious affiliation, municipalities' role to inform the population, and ethical dilemma or logistical challenges regarding HPV vaccination in schools.

CONCLUSION

The results of these focus groups provided information on which elements may harm or help HPV vaccination. Identified perceptions, beliefs, knowledge, barriers, and facilitators will help us to build an intervention program focus on general practitioners (GP), school staff, parents, and adolescents.

Effect of weight-adjusted intermediate-dose versus fixed-dose prophylactic anticoagulation with low-molecular-weight heparin on venous thromboembolism among noncritically and critically ill patients with COVID-19: the COVI-DOSE trial, a multicenter, randomised, open-label, phase 4 trial

Background

Venous thromboembolism is a major complication of coronavirus disease 2019 (COVID-19). We hypothesized that a weight-adjusted intermediate dose of anticoagulation may decrease the risk of venous thromboembolism COVID-19 patients.

Methods

In this multicenter, randomised, open-label, phase 4, superiority trial with blinded adjudication of outcomes, we randomly assigned adult patients hospitalised in 20 French centers and presenting with acute respiratory SARS-CoV-2. Eligible patients were randomly assigned (1:1 ratio) to receive an intermediate weight-adjusted prophylactic dose or a fixed-dose of subcutaneous low-molecular-weight heparin during the hospital stay. The primary outcome corresponded to symptomatic deep-vein thrombosis (fatal) pulmonary embolism during hospitalization (COVI-DOSE ClinicalTrials.gov number: NCT04373707).

Findings

Between May 2020, and April 2021, 1000 patients underwent randomisation in medical wards (noncritically ill) (80.1%) and intensive care units (critically ill) (19.9%); 502 patients were assigned to receive a weight-adjusted intermediate dose, and 498 received fixed-dose thromboprophylaxis. Symptomatic venous thromboembolism occurred in 6 of 502 patients (1.2%) in the weight-adjusted dose group and in 10 of 498 patients (2.1%) in the fixed-dose group (subdistribution hazard ratio, 0.59; 95% CI, 0.22-1.63; P = 0.31). There was a twofold increased risk of major or clinically relevant nonmajor bleeding: 5.9% in the weight-adjusted dose group and 3.1% in the fixed-dose group (P = 0.034).

Interpretation

In the COVI-DOSE trial, the observed rate of thromboembolic events was lower than expected in patients hospitalized for COVID-19 infection, and the study was unable to show a significant difference in the risk of venous thromboembolism between the two low-molecular-weight-heparin regimens.

Funding

French Ministry of Health, CAPNET, Grand-Est Region, Grand-Nancy Métropole.

Promoting HPV vaccination at school: a mixed methods study exploring knowledge, beliefs and attitudes of French school staff

BACKGROUND

HPV vaccine coverage in France remained lower than in most other high-income countries. Within the diagnostic phase of the national PrevHPV program, we carried out a mixed methods study among school staff to assess their knowledge, beliefs and attitudes regarding HPV, HPV vaccine and vaccination in general, and regarding schools' role in promoting HPV vaccination.

METHODS

Middle school nurses, teachers and support staff from four French regions participated between January 2020 and May 2021. We combined: (i) quantitative data from self-administered online questionnaires (n = 301), analysed using descriptive statistics; and (ii) qualitative data from three focus groups (n = 14), thematically analysed.

RESULTS

Less than half of respondents knew that HPV can cause genital warts or oral cancers and only 18% that no antiviral treatment exists. Almost 90% of the respondents knew the existence of the HPV vaccine but some misunderstood why it is recommended before the first sexual relationships and for boys; 56% doubted about its safety, especially because they think there is not enough information on this topic. Schools nurses had greater knowledge than other professionals and claimed that educating pupils about HPV was fully part of their job roles; however, they rarely address this topic due to a lack of knowledge/tools. Professionals (school nurses, teachers and support staff) who participated in the focus groups were unfavourable to offering vaccination at school because of parents' negative reactions, lack of resources, and perceived uselessness.

CONCLUSIONS

These results highlight the need to improve school staff knowledge on HPV. Parents should be involved in intervention promoting HPV vaccination to prevent their potential negative reactions, as feared by school staff. Several barriers should also be addressed before organizing school vaccination programs in France.

Impact of selective reporting of antibiotic susceptibility testing results for urinary tract infections in the outpatient setting: A prospective controlled before-after intervention study

OBJECTIVES

The use of selective reporting of antibiotic susceptibility testing (AST) results is a recommended antimicrobial stewardship strategy to improve the appropriateness of antibiotic prescriptions. We conducted a large, pragmatic, prospective, multicentre, controlled (selective reporting versus complete reporting) before-after intervention study to assess the impact of selective reporting of AST results for Escherichia coli-positive urine cultures on the prescription of broad-spectrum antibiotics carrying a higher risk of selection of resistance (i.e., amoxicillin-clavulanate, third-generation cephalosporins, and quinolones) in the outpatient setting. We also looked for possible unintended clinical consequences of the intervention leading to consultations and/or hospitalisations.

METHODS

We compared two groups of laboratories located in a French region. We collected data from the health insurance databases before (2017) and after the implementation of the intervention (2019). The primary outcome was the prescription proportions of broad-spectrum antibiotics.

RESULTS

We included 42,956 Escherichia coli-positive urine cultures with AST. The decrease of the proportion of broad-spectrum antibiotic prescriptions between 2017 and 2019 was significantly higher for selective reporting of AST, attributable to a decrease in the prescription proportion of third-generation cephalosporins (- 8.5% for selective reporting versus - 0.1% for complete reporting, p < 0.001). This impact was more marked for targeted therapy and female patients. Requests from clinicians for the complete reporting of AST results were infrequent (1.2% of all the selective AST results reported in 2019). No unintended consequences were observed.

CONCLUSION

The results showed a positive impact of the selective reporting of AST results, but room for improvement is still important.

REGISTRATION AT CLINICAL TRIALS

NCT03612297.

Dissociated Optic Nerve Fiber Layer Appearance after Macular Hole Surgery: A Randomized Controlled Trial Comparing the Temporal Inverted Internal Limiting Membrane Flap Technique with Conventional Peeling

PURPOSE

To evaluate the effect of the temporal inverted internal limiting membrane (ILM) flap technique compared with that of conventional ILM peeling on the extent of the dissociated optic nerve fiber layer (DONFL) and retinal sensitivity in patients undergoing macular hole (MH) surgery.

DESIGN

Single-center, prospective, open-label, randomized controlled clinical trial.

PARTICIPANTS

Patients requiring vitrectomy for MHs sized > 250 μm.

METHODS

Patients were randomly assigned (1:1) to 1 of the following 2 groups: (1) the control group undergoing standard ILM peeling and (2) the experimental group (flap group) undergoing the temporal inverted ILM flap technique.

MAIN OUTCOME MEASURES

The primary outcome measure was the total DONFL score at 3 months after surgery. Important secondary outcomes were microperimetry results, primary MH closure rate, external limiting membrane (ELM) and ellipsoid zone (EZ) recovery rates, and best-corrected visual acuity (BCVA).

RESULTS

Sixty-five patients were recruited between February 2018 and July 2020; primary outcome data were available for 60 patients. The median DONFL score was 7.0 (3.0-12.5) in the control group and 5.0 (1.5-8.5) in the flap group at 3 months after surgery (P = 0.145). The focal depressions characteristic of the DONFL were limited to the temporal side of the fovea in the flap group, whereas they were found all around the fovea in the control group on spectral-domain OCT images. The MH closure rate (P = 1), EZ and ELM recovery rates (P = 0.252), and BCVA (P = 0.450) were similar between the 2 groups. The 3-month overall median retinal sensitivity (MRS) (P = 0.142) and MRS improvement (P = 0.916) in the control group were comparable with those observed in the flap group. In addition, there was no significant difference between the 2 techniques when considering the temporal area (P = 0.105) or the nasal area (P = 0.468).

CONCLUSIONS

The temporal inverted ILM flap technique reduced the extent of the DONFL by preserving the nasal part of the fovea. However, the overall DONFL score was similar between the 2 techniques. In addition, the MRS and BCVA did not differ from those obtained after complete ILM peeling.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Selective reporting of antibiotic susceptibility testing results for urine cultures: feasibility and acceptability by general practitioners and laboratory professionals in France

Background

Selective reporting of antibiotic susceptibility testing (AST) is a recommended antibiotic stewardship strategy, aiming at reducing inappropriate antibiotic prescriptions.

Objectives

Our objectives were to evaluate (i) the feasibility of the implementation of selective reporting of AST for urine cultures for laboratory professionals; and (ii) its acceptability by prescribers and laboratory professionals, to explore facilitators and barriers to its potential implementation on a national scale.

Methods

As part of the 'ANTIBIO-ciblés' interventional study (north-eastern France, August 2018-December 2019), we prospectively collected quantitative data on all resources dedicated by the laboratories of the intervention group to implement selective reporting of AST for Escherichia coli-positive urine cultures, and on the numbers and reasons of complete reporting of AST the prescribers requested to the laboratories. We also collected qualitative data using semi-structured interviews and focus groups of GPs and laboratory professionals.

Results

The implementation of selective reporting of AST required around 80 h and cost 23 000 euros. All interviewed professionals were favourable toward the principle of this tool. Most of them found it clear, simple and useful to improve the appropriateness of antibiotic prescriptions and reduce antibiotic resistance. Its major constraint was the necessity for GPs to call the laboratory to obtain the complete reporting of AST, but the number of requests was actually low (1.2% of all selective reporting of AST).

Conclusions

Selective reporting of AST resulted in reasonable human and financial costs, and was well accepted by both GPs and laboratory professionals.

Family physicians' practices and attitudes towards HPV vaccination since extension of HPV vaccination to males

OBJECTIVES

To describe family physicians' (FP) practices and attitudes towards HPV vaccination guidelines since its extension to males in 2021, and to identify levers to promote HPV vaccination in all adolescents.

PATIENTS AND METHODS

Cross-sectional study among FPs established in France in 2021. We collected sociodemographic data, practices, opinions, and attitudes towards vaccination, and FPs' demands regarding training and information about HPV. We used logistic regression models to identify the variables associated with HPV vaccination proposal.

RESULTS

Of 530 FPs included, 469 (88.5%) reported that they systematically proposed HPV vaccines to girls vs 335 (63.2%) to boys. A total of 366 (69.0%) FPs reported an increase in HPV vaccines proposal to all adolescents since the extension of HPV vaccination to males recommended by French guidelines. However, factors associated with HPV vaccination proposal differed by target females and target males. Setting and mode of practice, opinion about the number of recommended vaccines and HPV vaccines, and demands of training on HPV vaccines were associated with HPV vaccination proposal to target females. Whereas academic status, opinion about HPV vaccination guidelines extension to males, using continuing medical education as the main source of information on HPV vaccines, and demands for training on HPV vaccines were associated with HPV vaccination proposal to target males.

CONCLUSIONS

Extension of HPV vaccination to males in French guidelines might have had a favorable impact on HPV vaccination proposal by FPs to adolescents. However, levers to promote HPV vaccination might differ according to the target population sex.

Nurses' perceptions of the potential evolution of their role in antibiotic stewardship in nursing homes: a French qualitative study

Background

In nursing homes, infections and antibiotic prescriptions are frequent. Nursing home nurses (NHNs) and advanced practice registered nurses (APRNs) could promote antibiotic stewardship (ABS). Few studies have explored nurses' knowledge, perceptions and practices towards ABS in nursing homes and none has investigated the potential evolution of their roles.

Objectives

To explore French nurses' perceptions on ABS, current and future potential roles in ABS in nursing homes, as well as facilitators and barriers.

Methods

We conducted a qualitative study in north-eastern France between October 2020 and March 2021 using semi-structured individual interviews with NHNs and a focus group with APRNs. Transcripts of the interviews were analysed using a thematic analysis.

Results

Twenty NHNs and seven APRNs participated. They were aware of antibiotic misuse and potential adverse events but lacked knowledge on some ABS aspects. NHNs' current ABS roles ranged from the detection of clinical infectious signs to clinical monitoring of residents, with some heterogeneity between nurses. They had positive opinions towards playing a more prominent role in ABS. In the future, with additional training, changes in the legislative framework and greater multidisciplinary teamwork, NHNs thought they could prescribe laboratory microbiological analyses and some targeted antibiotic treatments. APRNs thought they could prescribe first-line antibiotics for urinary tract infections.

Conclusions

French NHNs' current ABS roles could be expanded and new roles might be considered while taking into account several facilitators and barriers. According to APRNs, they could help to compensate for the limited presence of doctors in nursing homes and develop infectious diseases skills.

Characteristics of dentists and patients associated with appropriate antibiotic prescriptions by French dentists: a cross-sectional study using Health Insurance databases

BACKGROUND

The use of antibiotics in dental care is often unnecessary or inappropriate. Our objectives were to identify (i) Clusters of dentists grouped according to their appropriateness score based on proxy indicators' results; and (ii) Dentists' and patients' characteristics associated with the appropriateness of antibiotic prescriptions.

METHODS

We used data of the Health Insurance reimbursement databases on antibiotics prescribed in 2019 by general dental practitioners of the Grand Est region in France. The appropriateness of antibiotic prescriptions was estimated by the results of recently published proxy indicators. We conducted a cluster analysis according to an appropriateness score calculated for each dentist, using the Ward method. We then conducted bivariate and multivariable analyses to identify characteristics associated with these clusters.

RESULTS

We included 3,014 dentists, who prescribed 373,975 antibiotics in 2019, and which were grouped into three clusters: average practices (n = 1,241), better (n = 686), and worse (n = 1,087) than average practices. Overall, dentists had more appropriate prescription practices when they were male (OR for belonging to cluster with "worse than average practices" = 1.37 (p = 0.003) for female), having a predominant surgery practice (p = 0.028) in the Lorraine area (p < 0.0001) for less years (p = 0.0002), when they had healthier patients (i.e., younger, with no chronic diseases, and who received less procedures), and when they had a more prudent use of drugs in general (i.e., less prescriptions of drugs, antibiotics, and non-steroidal anti-inflammatory).

CONCLUSIONS

We identified clusters and characteristics associated with the appropriateness of antibiotic prescriptions made by dentists, which might help guiding antimicrobial stewardship interventions.

Usefulness of procalcitonin at admission as a risk-stratifying biomarker for 50-day in-hospital mortality among patients with community-acquired bloodstream infection: an observational cohort study

PURPOSE

To assess the association between plasma procalcitonin concentration at hospital admission and the risk of 50-day in-hospital mortality among patients with community-acquired bloodstream infections.

METHODS

We carried out a retrospective, observational cohort study with all consecutive patients with bacteriologically confirmed community-acquired bloodstream infections hospitalized between 2006 and 2012. We aimed to assess the association between plasma procalcitonin at admission and 50-day in-hospital mortality. Patients were included in the analysis if they had undergone a blood culture test within 48 hours of hospitalization with a concomitant procalcitonin assay (time < 12 hours between the two tests). Inclusion in the study began on the day of hospital admission, and each patient was followed until death, discharge from the hospital, or last known follow-up in the 50 days following hospital admission. The endpoint was the occurrence of all-cause in-hospital mortality during the 50 days following hospital admission.

RESULTS

During the 7-year study period, 1593 patients were admitted to one of the healthcare facilities of the University Hospital of Nancy from home or through the emergency department and had positive blood cultures and concomitant procalcitonin assays. Among the patients, 452 met the selection criteria and were analyzed. In ROC analysis, procalcitonin at baseline was significantly associated with 50-day in-hospital mortality, with an optimal threshold > 4.24 ng/mL. A baseline procalcitonin > 4.24 ng/mL was independently associated with an increased risk of in-hospital mortality (multivariable logistic regression: odds ratio, 2.58; 95% CI, 1.57-4.25; P = 0.0002; Cox proportional hazard regression: hazard ratio, 2.01; 95% CI, 1.30-3.11; P = 0.002). In sensitivity analyses, baseline procalcitonin quartiles were independently associated with 50-day in-hospital mortality (multivariable logistic regression: odds ratio, 1.47; 95% CI, 1.17-1.85; P = 0.001; Cox proportional hazard regression: hazard ratio, 1.31; 95% CI, 1.07-1.60; P = 0.008). The independent associations between baseline procalcitonin and the risk of 50-day in-hospital mortality were maintained after adjusting for C-reactive protein and sepsis status at admission.

CONCLUSION

Our data provide the first evidence of the usefulness of plasma procalcitonin at admission as a risk-stratifying biomarker for predicting 50-day in-hospital mortality among patients with community-acquired bloodstream infections.

Prognostic factors of readmission and mortality after first heart failure hospitalization: results from EPICAL2 cohort

AIMS

We aimed to identify prognostic individual factors in patients with first acute heart failure (HF) hospitalization, considering both death and readmission as part of the natural history of HF.

METHODS AND RESULTS

We used data from the observational, prospective, multicentre EPICAL2 cohort study from which we selected incident cases of acute HF alive at discharge. We relied on an illness-death model to identify prognostic factors on first readmission and on mortality before and after readmission. In 451 patients hospitalized for first acute HF, we observed within the year after discharge, 23 (5.1%) deaths before readmission and 270 (59.9%) first readmissions, of which 60 (22.2%) were followed by death of any cause. First, among patient characteristics, only Charlson index ≥ 8 was associated with first readmission [adjusted hazard ratio (aHR) = 1.6, 95% confidence interval (CI) (1.1-2.3), P = 0.011]. Second, Charlson index ≥ 8 [aHR = 4.2, 95% CI (1.2-14.8), P = 0.025], low blood pressure (BP) [aHR = 12.2, 95% CI (1.9-79.6), P = 0.009], high BP [aHR = 6.9, 95% CI (1.3-36.4), P = 0.023], and prescription of recommended dual or triple HF therapy at index discharge [aHR = 0.2, 95% CI (0.1-0.7), P = 0.014] were associated with mortality before any readmission. Third, Charlson index ≥ 8 [aHR = 2.4, 95% CI (1.1-5.6), P = 0.037] and the time to first readmission (per 30 days additional) [aHR = 1.2; 95% CI (1.1-1.4), P = 0.007] were associated with mortality after readmission.

CONCLUSIONS

Regardless of the prognostic state considered, we showed that comorbidities are of critical prognostic value in a real-world cohort of incident HF cases. This argues in favour of multidisciplinary care in HF.

French general practitioners’ and patients’ acceptability of a public commitment charter and patient information leaflets targeting unnecessary antibiotic use: a qualitative study

Background

The ‘AntibioCharte’ randomised controlled study aimed at assessing the impact of a multifaceted antibiotic stewardship intervention targeting French general practitioners with higher-than-average antibiotic use. The intervention included a public commitment charter signed by the general practitioner, a non-prescription pad, and a patient information leaflet.

Objectives

We conducted a qualitative study to evaluate general practitioners’ fidelity in the intervention and its acceptability by patients and general practitioners.

Methods

This investigation was performed in northeastern France from July 2019 to May 2020, among the AntibioCharte intervention group after a 1-year implementation period. General practitioners’ fidelity in the charter was assessed by direct observations; general practitioners’ fidelity in the other tools, and acceptability of both general practitioners and patients were assessed through semi-structured face-to-face individual interviews.

Results

Twenty-seven general practitioners and 14 patients participated. General practitioners’ fidelity varied according to the tool: the charter was clearly displayed in most waiting rooms; the non-prescription pad was used throughout the intervention period by most general practitioners while the leaflet was used by fewer general practitioners. Both general practitioners and patients found the charter’s content and form relevant, but few general practitioners felt themselves publicly engaged. The waiting room may not be appropriate to display the charter as some general practitioners forgot it and patients did not always read the displayed documents. General practitioners appreciated the pad and found that it could help them change their practices. It was perceived as a good tool to educate patients and manage their expectations for antibiotics. Patients appreciated the pad too, especially information on the infections’ symptoms and their duration. Still, some patients feared that it could encourage doctors not to prescribe antibiotics. Unlike general practitioners, who considered the leaflet redundant with the information given during the consultation, patients found it useful to raise awareness on antibiotics’ specificities and risks, and remind them of good practices.

Conclusions

The AntibioCharte intervention was overall well accepted by general practitioners and patients. The non-prescription pad was the best perceived tool.

Trial registration number ClinicalTrials.gov: NCT04562571.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-022-01065-3.

Development of an international survey tool to measure confidence and current antimicrobial stewardship practices of hospital pharmacists

BACKGROUND

Pharmacists are identified as key members of hospital antimicrobial stewardship (AMS) teams in international guidelines. Developing an international standardized tool to measure hospital pharmacists' confidence and practices of AMS will encourage knowledge sharing and better networking between hospital pharmacists internationally.

OBJECTIVES

To develop a survey tool that can be used internationally to assess pharmacists' knowledge, confidence, perceived barriers and current AMS practices.

METHODS

A project team was formed to refine the survey tool that was initially used in a previous survey study. Following revision by the project team, a revised survey tool was sent to the ESCMID Study Group for Antimicrobial Stewardship (ESGAP). Feedback from the ESGAP members was considered by the project team to finalize the survey tool.

RESULTS

A total of 88 changes were made to the survey tool after revision by the project team. A total of 43/216 (19.9%) of ESGAP members provided feedback on the survey tool, which led to a further 19 revisions. ESGAP members were agreeable to the questions in the survey tool, with >50% agreeing that each question was suitable. The final survey tool consisted of 42 questions, reduced from 72 questions in the original survey.

CONCLUSIONS

An international survey tool to measure hospital pharmacists' confidence and practices of AMS was developed. This tool will help the wider hospital pharmacy community in conducting local studies on current AMS practices and to identify areas where further support is needed. Use of a standardized survey tool will also allow individual regions/countries to compare their data with other countries to identify potential quality improvement programmes.

Codevelopment and evaluation of a multicomponent intervention to improve HPV vaccination in France

Background

HPV vaccine coverage (VC) in France has always been lower than in most high-income countries. The French authorities launched in 2018 the PrevHPV national research program aimed at codeveloping with stakeholders and evaluating the impact of a multicomponent intervention to improve HPV VC among French adolescents.

Methods

We identified three components to address main barriers to HPV vaccination in France: adolescents’ and parents’ education and motivation (component 1); general practitioners (GPs)’ training (component 2); and access to vaccination at school (component 3). We developed the intervention using the UK Medical Research Council framework for developing complex interventions as a guide. We used (i) findings from published evidence; (ii) primary data on knowledge, attitudes, behavior and preferences collected through a mixed methods approach (quantitative/qualitative studies, discrete choice experiment); (iii) the advice of stakeholders (e.g., adolescents, parents, school nurses, GPs) involved in working groups. We will evaluate the effectiveness, efficiency and implementation of the components (applied alone or in combination) through a pragmatic cluster randomized controlled trial. The primary endpoint is the HPV VC (≥ 1 dose) among adolescents aged 11-14 years, 2 months after the end of the intervention, at the municipality level.

Results

Primary data highlighted the need to improve adolescents, parents and school staff knowledge on HPV and to help GPs communicate with patients on this topic. They provided guidance on the most effective communication contents. For each component, we codeveloped tools with a participatory approach (e.g., eHealth tools for adolescents, a decision aid tool for GPs). The trial will end in June 2022; 90 middle schools (i.e., about 40,000 adolescents) and 46 GPs accepted to participate.

Conclusions

Should the intervention prove effective, results from the implementation evaluation will help us refine it before scaling it up.

Key messages

• The PrevHPV study is supported by the French health authorities and conducted by a multidisciplinary consortium to tackle a long-lasting public health concern in France.

• It will add to the small number of studies that compared the effectiveness of various strategies to promote HPV vaccination and will provide key results on cost-effectiveness and implementation.

Evaluating antibiotic stewardship and healthcare-associated infections surveillance assisted by computer: protocol for an interrupted time series study

INTRODUCTION

Antibiotic resistance is one of the most pressing health threats that mankind faces now and in the coming decades. Antibiotic resistance leads to longer hospital stays, higher medical costs and increased mortality. In order to tackle antibiotic resistance, we will implement in our tertiary care university hospital a computerised-decision support system (CDSS) facilitating antibiotic stewardship and an electronic surveillance software (ESS) facilitating infection prevention and control activities. We describe the protocol to evaluate the impact of the CDSS/ESS combination in adult inpatients.

METHODS AND ANALYSIS

We conduct a pragmatic, prospective, single-centre, before-after uncontrolled study with an interrupted time-series analysis 12 months before and 12 months after the introduction of the CDSS for antibiotic stewardship (APSS) and ESS for infection surveillance (ZINC). APSS and ZINC will assist, respectively, the antibiotic stewardship and the infection prevention and control teams of Nancy University Hospital (France). We will evaluate the impact of the CDSS/ESS on the antibiotic use in adult (≥18 years) inpatients (hospitalised ≥48 hours). The primary outcome is the prescription rate by all healthcare professionals from the hospital of all systemic antibiotics expressed in defined daily doses/1000 patients/month. Concurrently, we will assess the safety of the intervention, its impact on the appropriateness of antibiotic prescriptions and on additional precautions (isolation precautions) as recommended in guidelines, and on bacterial epidemiology (multidrug-resistant bacteria and Clostridioides difficile infections) in the hospital. Finally, we will evaluate the users' satisfaction and the cost of this intervention from the hospital perspective.

ETHICS AND DISSEMINATION

The protocol has been approved by the Ethics Committee of Nancy University Hospital and registered on the ClinicalTrials platform. Results will be disseminated through conferences' presentations and publications in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04976829.

Impact of a school-based and primary care-based multicomponent intervention on HPV vaccination coverage among French adolescents: a cluster randomised controlled trial protocol (the PrevHPV study)

INTRODUCTION

Vaccination is an effective and safe strategy to prevent Human papillomavirus (HPV) infection and related harms. Despite various efforts by French authorities to improve HPV vaccine coverage (VC) these past few years, VC has remained far lower than in most other high-income countries. To improve it, we have coconstructed with stakeholders a school-based and primary care-based multicomponent intervention, and plan to evaluate its effectiveness, efficiency and implementation through a cluster randomised controlled trial (cRCT).

METHODS AND ANALYSIS

This pragmatic cRCT uses an incomplete factorial design to evaluate three components applied alone or in combination: (1) adolescents and parents' education and motivation at school, using eHealth tools and participatory learning; (2) general practitioners' training on HPV using motivational interviewing techniques and provision of a decision aid tool; (3) free-of-charge access to vaccination at school. Eligible municipalities (clusters) are located in one of 14 preselected French school districts and must have only one secondary school which enrols at least 2/3 of inhabitants aged 11-14 years. A randomisation stratified by school district and deprivation index allocated 90 municipalities into 6 groups of 15. The expected overall sample size estimate is 41 940 adolescents aged 11-14 years. The primary endpoint is the HPV VC (≥1 dose) among adolescents aged 11-14 years, at 2 months, at the municipality level (data from routine databases). Secondary endpoints include: HPV VC (≥1 dose at 6 and 12 months; and 2 doses at 2, 6 and 12 months); differences in knowledge, attitudes, behaviours, and intention among adolescents, parents and general practitioners between baseline and 2 months after intervention (self-administered questionnaires); incremental cost-effectiveness ratio. Implementation measures include dose, fidelity, adaptations, reached population and satisfaction (activity reports and self-administered questionnaires).

ETHICS AND DISSEMINATION

This protocol was approved by the French Ethics Committee 'CPP Sud-Est VI' on 22 December 2020 (ID-RCB: 2020-A02031-38). No individual consent was required for this type of research; all participants were informed of their rights, in particular not to participate or to oppose the collection of data concerning them. Findings will be widely disseminated (conference presentations, reports, factsheets and academic publications).

TRIAL REGISTRATION NUMBER

NCT04945655.

Vaccine eagerness: A new framework to analyse preferences in single profile discrete choice experiments. Application to HPV vaccination decisions among French adolescents

Background

We previously conducted a single-profile discrete choice experiment to elicit preferences of adolescents around HPV vaccine communication, finding that only half of participants made variable choices (non-uniform respondents) from which preferences were elicited. In this paper we provide a framework to evaluate post-choice certainty information to elicit preferences even among respondents who uniformly accepted (serial demanders) or refused (serial non-demanders) hypothetical vaccination scenarios.

Methods

During an in-class online questionnaire among 1458 French adolescents aged 13–15 years old, we collected certainty levels (0–10) after decisions on nine hypothetical scenarios, including four vaccination attributes: information on vaccine-preventable disease type, on vaccine safety, on potential for indirect protection and on vaccine coverage. We developed a vaccine eagerness scale (ranging from −10 to 10), by combining information on the binary decision (accept vs. refuse the hypothetical vaccine) and the decision certainty level. We used random effects linear regressions to evaluate attributes’ impact on vaccine eagerness. Sensitivity analyses were performed taking into account low response quality, assessed as invariant certainty and low response time.

Results

Attributes’ impact on decision certainty were similar between serial demanders (N = 659) and non-uniform respondents (N = 711): mentioning a positive benefit-risk balance significantly decreased certainty to accept (coefficient −0.93), while information on 80% coverage in other countries (+0.33) and potential for disease elimination (+0.09) increased it. Among serial non-demanders, significant attribute impacts were observed only after exclusion of low-quality responses (N = 31): a potential for disease elimination (coefficient: +0.24) and 80% coverage in other countries (+0.42) significantly increased certainty of refusing vaccination. Combining decision and certainty into a vaccine eagerness indicator allowed analysing preferences in the full sample, including “hesitant” respondents, who were sensitive to the content of the vaccination profile.

Conclusion

Choice certainty informs on respondents’ preferences in single-profile discrete-choice experiments, in particular among those with uniform responses.

•

Preferences are not identified among “uniform respondents” in single profile DCEs.

•

Analysis of post-choice certainty can reveal information on their preferences.

•

We propose a new concept for DCEs on vaccination, “vaccine eagerness”.

•

Vaccine eagerness allows analyzing preferences among serial non-demanders.

Ethical reflection support for potential organ donors' relatives: A narrative review

BACKGROUND

Even in countries with an opt-out or presumed consent system, relatives have a considerable influence on the post-mortem organ harvesting decision. However, their reflection capacity may be compromised by grief, and they are, therefore, often prone to choose refusal as default option. Quite often, it results in late remorse and dissatisfaction. So, a high-quality reflection support seems critical to enable them to gain a stable position and a long-term peace of mind, and also avoid undue loss of potential grafts. In practice, recent studies have shown that the ethical aspects of reflection are rarely and often poorly discussed with relatives and that no or incomplete guidance is offered. No review of the literature is available to date, although it could be of value to improve the quality of the daily practice.

OBJECTIVES

The objective was to review and synthesize the main concepts and approaches, theories and practices of ethical reflection support of the relatives or surrogates of potential post-mortem organ donors.

RESEARCH DESIGN

A narrative review was performed in the medical, psychological and ethical fields using PubMed, PsycArticles and Web of Science databases (1980-2020).

RESULTS

Out of 150 papers, 25 were finally retained. Four themes were drawn: the moral status of the potential post-mortem organ donor, the principlistic approach with its limits and critics, the narrative approach and the transcendental approach.

DISCUSSION

This review suggests an extension of psychological support towards ethical reflection support. The process of helping relatives in their ethical exploration of post-mortem organ donation is psychologically and morally characterized. The need for specialized professionals educated and experienced both in clinical psychology and in health ethics to carry out this task is discussed.

PRACTICAL IMPACT

This review could contribute to optimize the quality of the ethical reflection support by initiating an evolution from an empirical, partial and individual-dependent support to a more systematized, professionalized and exhaustive support.

Community pharmacists' views on their current role and future opportunities for antibiotic stewardship: a French qualitative study

Background

Different healthcare professionals should contribute to antibiotic stewardship (ABS) activities. Involvement of community pharmacists (CPs) has been little explored worldwide to date.

Objectives

To explore French CPs' views on ABS and antibiotic resistance, their role and current practices, and future opportunities for ABS.

Methods

A qualitative study using semi-structured face-to-face individual interviews was performed from May to October 2019 among CPs from north-eastern France. Transcripts of the interviews were analysed using a thematic analysis.

Results

Twenty-seven interviews were conducted. Most participants had a clear understanding of antibiotic resistance and ABS. They considered themselves as 'guardians of the appropriate use of drugs' but often failed to fulfil this mission because of difficult relationships with physicians. Their current ABS practices are: (i) counselling patients about the antibiotic treatment; and (ii) reporting to the prescriber when they identify contraindications/drug interactions. Concerning their potential increased involvement in ABS, CPs felt they could perform more rapid diagnostic testing for sore throat; they were divided on the possibility for them to change the antibiotic prescription made by a physician and were mainly against the possibility of initiating an antibiotic prescription. The idea of systematically collecting unused antibiotics was perceived well by CPs, while unit dose delivery was not.

Conclusions

French community pharmacists are willing to become more involved in ABS activities. Collaboration and trust between pharmacists and prescribers should however be improved.

Antibiotic stewardship in French nursing homes: a 2019 regional survey

Background

Antibiotic resistance is a growing issue in nursing homes (NHs). Antibiotic stewardship (ABS) programmes can reduce antibiotic use in NHs, but few studies have assessed to what extent they are implemented in NHs.

Objectives

To describe ABS current practices and describe the opinion of NH stakeholders regarding ABS and opportunities for improvement in one French region.

Methods

We invited by e-mail the medical and nurse coordinators of all NHs of the Grand Est region, France, to participate in our survey in 2019. The online questionnaire included 35 questions covering four topics: NH characteristics, current ABS practices, attitudes towards ABS and opinions on strategies to promote ABS. A score evaluating implementation of core ABS elements was calculated using the current ABS practice responses.

Results

Out of 417 NHs, 75 (18%) participated in our survey. The three most implemented ABS activities were antibiotic consumption monitoring (65%), antibiotic plan documentation (56%) and antibiotic prescription guide distribution (54%). Audit and feedback, training sessions or identification of a local ABS leader ranged from 13% to 29%. Participants positively perceived ABS and most suggestions to improve ABS programmes in NH, with maximal interest in training, audit and feedback interventions. The median score for implementation of core ABS elements was 3.3 (IQR = 2.3–5.4; theoretical range 0–11), and the score distribution was not associated with any NH characteristic.

Conclusions

While there is still room for improvement, NHs had a positive attitude towards ABS strategies. Some regional and national initiatives to promote ABS in NHs exist and should be actively promoted.

Factors associated with the appropriateness of antibiotics prescribed in French general practice: a cross-sectional study using reimbursement databases

OBJECTIVES

Identifying characteristics associated with the appropriateness of antibiotic prescriptions is useful to guide antibiotic stewardship interventions. Proxy indicators estimating the appropriateness of antibiotic prescriptions at the general practitioner (GP) level have recently been validated. Our objectives were to identify (a) clusters of GPs according to their appropriateness score based on these proxy indicator results, and (b) GPs', patients' and practices' characteristics associated with inappropriate prescriptions.

METHODS

We conducted a cross-sectional observational study analysing antibiotics prescribed by GPs in one large French region in 2019, using the Health Insurance databases. We identified clusters of GPs according to their appropriateness score calculated from ten proxy indicators' results. We then analysed the association between the clusters with more inappropriate practices compared with the one with less inappropriate practices, and GPs', patients', and practices' characteristics. We performed bivariate and multivariable analyses using logistic polytomous regressions.

RESULTS

We included 4819 GPs who were grouped into three clusters. GPs who belong to the clusters with more inappropriate practices were more likely to practice in certain geographical area, to be male, not to have a particular medical practice, to be practicing for longer, to have more patients and consultations, to have a higher proportion of elderly patients, and to prescribe more drugs, more antibiotics and a higher proportion of broad-spectrum antibiotics.

CONCLUSION

We identified clusters of practice as well as factors associated with the appropriateness of antibiotic prescriptions, using routinely collected data. This might help to guide antibiotic stewardship interventions.

Quantity Metrics and Proxy Indicators to Estimate the Volume and Appropriateness of Antibiotics Prescribed in French Nursing Homes: A Cross-sectional Observational Study Based on 2018 Reimbursement Data

BACKGROUND

Antibiotic resistance is an increasing threat to public health globally. Indicators on antibiotic prescribing are required to guide antibiotic stewardship interventions in nursing homes. However, such indicators are not available in the literature. Our main objective was to provide a set of quantity metrics and proxy indicators to estimate the volume and appropriateness of antibiotic use in nursing homes.

METHODS

Recently published articles were first used to select quantity metrics and proxy indicators, which were adapted to the French nursing home context. A cross-sectional observational study was then conducted based on reimbursement databases. We included all community-based nursing homes of the Lorraine region in northeastern France. We present descriptive statistics for quantity metrics and proxy indicators. For proxy indicators, we also assessed performance scores, clinimetric properties (measurability, applicability, and room for improvement), and conducted case-mix and cluster analyses.

RESULTS

A total of 209 nursing homes were included. We selected 15 quantity metrics and 11 proxy indicators of antibiotic use. The volume of antibiotic use varied greatly between nursing homes. Proxy indicator performance scores were low, and variability between nursing homes was high for all indicators, highlighting important room for improvement. Six of the 11 proxy indicators had good clinimetric properties. Three distinct clusters were identified according to the number of proxy indicators for which the acceptable target was reached.

CONCLUSIONS

This set of 15 quantity metrics and 11 proxy indicators may be adapted to other contexts and could be used to guide antibiotic stewardship programs in nursing homes.

Antimicrobial stewardship programmes in nursing homes: a systematic review and inventory of tools

BACKGROUND

Antimicrobial overuse/misuse is common in nursing homes and although the effectiveness of antimicrobial stewardship (AMS) programmes has been well explored and demonstrated in hospitals, data are scarce for the nursing-home setting. Our objectives for this systematic review were to make an inventory of: (i) all interventions that could be considered as part of AMS programmes in nursing homes; and (ii) all stewardship tools and guidance that are freely available.

METHODS

We performed a systematic review using the MEDLINE database from inception to June 2018, including all interventional studies, reviews, opinion pieces and guidelines/guidance exploring AMS programmes in nursing homes. For the inventory of freely available tools and guidance to help implement an AMS programme, we also performed screening of professional societies and official agencies' websites and a questionnaire survey among a panel of international experts.

RESULTS

A total of 36 articles were included in our systematic review. Most interventions took place in North America and have explored education or persuasive interventions within multifaceted interventions, showing that they can improve guideline adherence and decrease antibiotic use and unnecessary microbiological testing. Most reviews also highlighted the importance of accountability, monitoring and feedback. A large number of tools (156) available for free on the internet were identified, mostly about education, patient assessment and outcome measurement.

CONCLUSIONS

Although high-quality interventional studies are lacking, multifaceted interventions including education, monitoring and feedback seem the most promising strategy. Many tools are available on the internet and can be used to help implement AMS programmes in nursing homes.

Optimising HPV vaccination communication to adolescents: A discrete choice experiment

BACKGROUND

Human Papillomavirus (HPV) vaccine coverage in France is below 30%, despite proven effectiveness against HPV infections and (pre-)cancerous cervical lesions. To optimise vaccine promotion among adolescents, we used a discrete choice experiment (DCE) to identify optimal statements regarding a vaccination programme, including vaccine characteristics.

METHODS

Girls and boys enrolled in the last two years of five middle schools in three French regions (aged 13-15 years) participated in an in-class cross-sectional self-administered internet-based study. In ten hypothetical scenarios, participants decided for or against signing up for a school-based vaccination campaign against an unnamed disease. Scenarios included different levels of four attributes: the type of vaccine-preventable disease, communication on vaccine safety, potential for indirect protection, and information on vaccine uptake among peers. One scenario was repeated with an added mention of sexual transmission.

RESULTS

The 1,458 participating adolescents (estimated response rate: 89.4%) theoretically accepted vaccination in 80.1% of scenarios. All attributes significantly impacted theoretical vaccine acceptance. Compared to a febrile respiratory disease, protection against cancer was motivating (odds ratio (OR) 1.29 [95%-CI 1.09-1.52]), but not against genital warts (OR 0.91 [0.78-1.06]). Compared to risk negation ("vaccine does not provoke serious side effects"), a reference to a positive benefit-risk balance despite a confirmed side effect was strongly dissuasive (OR 0.30 [0.24-0.36]), while reference to ongoing international pharmacovigilance without any scientifically confirmed effect was not significantly dissuasive (OR 0.86 [0.71-1.04]). The potential for indirect protection motivated acceptance among girls but not boys (potential for eliminating the disease compared to no indirect protection, OR 1.57 [1.25-1.96]). Compared to mentioning "insufficient coverage", reporting that ">80% of young people in other countries got vaccinated" motivated vaccine acceptance (OR 1.94 [1.61-2.35]). The notion of sexual transmission did not influence acceptance.

CONCLUSION

HPV vaccine communication to adolescents can be tailored to optimise the impact of promotion efforts.

Serum and peritoneal exudate concentrations after high doses of β-lactams in critically ill patients with severe intra-abdominal infections: an observational prospective study

BACKGROUND

Critically ill patients with severe intra-abdominal infections (IAIs) requiring surgery may undergo several pharmacokinetic (PK) alterations that can lead to β-lactam underdosage.

OBJECTIVES

To measure serum and peritoneal exudate concentrations of β-lactams after high doses and optimal administration schemes.

METHODS

This observational prospective study included critically ill patients with suspicion of IAI who required surgery and a β-lactam antibiotic as empirical therapy. Serum and peritoneal exudate concentrations were measured during surgery and after a 24 h steady-state period. The PK/pharmacodynamic (PD) target was to obtain serum β-lactam concentrations of 100% fT>4×MIC based on a worst-case scenario (based on the EUCAST highest epidemiological cut-off values) before bacterial documentation (a priori) and redefined following determination of the MIC for the isolated bacteria (a posteriori). Registered with ClinicalTrials.gov (NCT03310606).

RESULTS

Forty-eight patients were included with a median (IQR) age of 64 (53-74) years and a SAPS II of 40 (32-65). The main diagnosis was secondary nosocomial peritonitis. Piperacillin/tazobactam was the most administered β-lactam antibiotic (75%). The serum/peritoneal piperacillin/tazobactam ratio was 0.88 (0.64-0.97) after a 24 h steady-state period. Prior to bacterial documentation, 16 patients (33.3%) achieved the a priori PK/PD target. The identification of microorganisms was available for 34 patients (71%). Based on the MIC for isolated bacteria, 78% of the patients achieved the serum PK/PD target.

CONCLUSIONS

In severe IAIs, high doses of β-lactams ensured 100% fT>4×MIC in the serum for 78% of critically ill patients with severe IAIs within the first 24 h. In order to define optimal β-lactam dosing, the PK/PD target should take into account the tissue penetration and local ecology.

Proxy indicators to estimate appropriateness of antibiotic prescriptions by general practitioners: a proof-of-concept cross-sectional study based on reimbursement data, north-eastern France 2017

Background

In most countries, including France, data on clinical indications for outpatient antibiotic prescriptions are not available, making it impossible to assess appropriateness of antibiotic use at prescription level.

Aim

Our objectives were to: (i) propose proxy indicators (PIs) to estimate appropriateness of antibiotic use at general practitioner (GP) level based on routine reimbursement data; and (ii) assess PIs’ performance scores and their clinimetric properties using a large regional reimbursement database.

Methods

A recent systematic literature review on quality indicators was the starting point for defining a set of PIs, taking French national guidelines into account. We performed a cross-sectional study analysing National Health Insurance data (available at prescriber and patient levels) on antibiotics prescribed by GPs in 2017 for individuals living in north-eastern France. We measured performance scores of the PIs and their case-mix stability, and tested their measurability, applicability, and room for improvement (clinimetric properties).

Results

The 3,087 GPs included in this study prescribed a total of 2,077,249 antibiotic treatments. We defined 10 PIs with specific numerators, denominators and targets. Performance was low for almost all indicators ranging from 9% to 75%, with values < 30% for eight of 10 indicators. For all PIs, we found large variation between GPs and patient populations (case-mix stability). Regarding clinimetric properties, all PIs were measurable, applicable, and showed high improvement potential.

Conclusions

The set of 10 PIs showed satisfactory clinimetric properties and might be used to estimate appropriateness of antibiotic prescribing in primary care, in an automated way within antibiotic stewardship programmes.

Ultramarathon and Renal Function: Does Exercise-Induced Acute Kidney Injury Really Exist in Common Conditions?

Background: Increasing ultramarathons participation, investigation into strenuous exercise and kidney function has to be clarified.

Study Design: Prospective observational study.

Methods and Protocol: The study used data collected among ultra-marathon runners completing the 2017 edition of the 120 km “Infernal trail” race. Samples were collected within 2 h pre-race (start) and immediately post-race (finish). Measurements of serum creatinine (sCr), cystatin C (Cys), creatine kinase, and urine albumin were completed. Acute Kidney Injury (AKI) as defined by the RIFLE criteria. “Risk” of injury was defined as increased serum Creatinine (sCr) × 1.5 or Glomerular Filtration Rate (GFR) decrease >25%. Injury was defined as 2 × sCr or GFR decrease >50%. These two categories of AKI were combined to calculate total incidence at the finish line. GFR was estimated by two methods, using measure of sCr and using measure of cystatin C. Urinary biomarkers [neutrophil gelatinase-associated lipocalin (NGAL)] were also used to define AKI. Outcome results before and after the race were compared by using McNemar test for qualitative data and Wilcoxon signed-rank test for quantitative data, in modified intent-to-treat and per-protocol analyses.

Results: A sample of 24 included finishers, with no use of non-steroidal anti-inflammatory drugs (NSAIDs) was studied. Depending the methodology used to calculate GFR, the prevalence of AKI was observed from 0 to 12.5%. Urinary biomarkers of kidney damage were increased following the race but with no significant decrease in GFR.

Discussion/Conclusion: Our study showed a very low prevalence of AKI and no evidence that ultra-endurance running can cause important kidney damage in properly hydrated subjects with no use of NSAIDs. Whether the increase in urinary biomarkers of kidney damage following the race reflects structural kidney injury or a simple metabolic adaptation to strenuous exercise needs to be clarified.

Long-term ACE Inhibitor/ARB Use Is Associated With Severe Renal Dysfunction and Acute Kidney Injury in Patients With Severe COVID-19: Results From a Referral Center Cohort in the Northeast of France

Background

In patients with severe coronavirus disease 2019 (COVID-19), data are scarce and conflicting regarding whether chronic use of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) influences disease outcomes. In patients with severe COVID-19, we assessed the association between chronic ACEI/ARB use and the occurrence of kidney, lung, heart, and liver dysfunctions and the severity of the inflammatory reaction as evaluated by biomarkers kinetics, and their association with disease outcomes.

Methods

We performed a retrospective longitudinal cohort study on consecutive patients with newly diagnosed severe COVID-19. Independent predictors were assessed through receiver operating characteristic analysis, time-series analysis, logistic regression analysis, and multilevel modeling for repeated measures.

Results

On the 149 patients included in the study 30% (44/149) were treated with ACEI/ARB. ACEI/ARB use was independently associated with the following biochemical variations: phosphorus >40 mg/L (odds ratio [OR], 3.35, 95% confidence interval [CI], 1.83–6.14), creatinine >10.1 mg/L (OR, 3.22, 2.28–4.54), and urea nitrogen (UN) >0.52 g/L (OR, 2.65, 95% CI, 1.89–3.73). ACEI/ARB use was independently associated with acute kidney injury stage ≥1 (OR, 3.28, 95% CI, 2.17–4.94). The daily dose of ACEI/ARB was independently associated with altered kidney markers with an increased risk of +25 to +31% per each 10 mg increment of lisinopril-dose equivalent. In multivariable multilevel modeling, UN >0.52 g/L was independently associated with the risk of acute respiratory failure (OR, 3.54, 95% CI, 1.05–11.96).

Conclusions

Patients chronically treated with ACEI/ARB who have severe COVID-19 are at increased risk of acute kidney injury. In these patients, the increase in UN associated with ACEI/ARB use could predict the development of acute respiratory failure.

Antibio'Malin: an e-health resource to raise awareness of antibiotic stewardship and resistance in France

Objectives

To develop a nationwide French website with reliable, practical and public-oriented information on antibiotic stewardship and resistance.

Methods

The design and evaluation were based on the following process: (i) development of a pilot website by a multidisciplinary group; (ii) evaluation phase, using mixed methods and involving health professionals (GPs and community pharmacists) and the general population; and (iii) launch of a final version of the website with 6 month follow-up usage statistics.

Results

The Antibio’Malin website (https://sante.fr/antibiomalin), supported by the French Ministry of Health, contains practical information for the general population on antibiotics marketed in the outpatient setting and on the most common infections, with an antibiotic stewardship perspective. A ‘For further information’ section provides details on various concepts, such as antibiotic resistance. As part of the evaluation, 8 general practitioners and 5 community pharmacists were individually interviewed, 46 health system users replied to an online questionnaire and 5 focus groups were conducted (17 participants). In addition, more than 100 people (professionals and general population) provided feedback directly on the website. The website was well received by health professionals, particularly general practitioners, and described as a reference site for patients and a communication tool. The general population also found the site useful. Several comments helped improve the website before the launch of the final version on 18 November 2019. At 6 month follow-up, more than 25 000 persons had visited the website.

Conclusions

The Antibio’Malin information website was developed and tested. Post-launch data suggest a useful addition to the multifaceted French national antibiotic stewardship strategy.

Prevalence and Associated Factors of Self-Reported Gingival Bleeding: A Multicenter Study in France

Gingival bleeding (GB) is a common sign of gingival inflammation which indicates the presence of periodontal diseases. This cross-sectional multicenter survey aimed to assess the prevalence of self-reported gingival bleeding (SRGB) in French adults and identify the main associated factors. A questionnaire-based interview was randomly proposed to 794 individuals in four French cities (Nancy, Montpellier, Paris, and Rennes). Subjects were recruited in preventive medicine centers (50%), railway stations, and malls (50%). The questionnaire comprised 25 items: SRGB characteristics, socioeconomic variables, oral hygiene habits, use of drugs, and anxiety level. The overall prevalence of SRGB was 63.2% [59.8%; 66.6%], with 58.7% bleeding after toothbrushing and 4.5% spontaneous bleeding. Males reported significantly lower SRGB prevalence than females (p = 0.04). The distribution of SRGB frequency was inversely proportional to age (p < 0.0001). No association between drug use and SRGB was found. The people interviewed in the preventive medicine centers reported the highest frequency of SRGB (p < 0.0001). In the multivariate logistic model, SRGB was significantly related to occupation, smoking status, brushing frequency, and anxiety level. In conclusion, SRGB was prevalent in more than half of the sample and was mainly associated with age, toothbrushing frequency, and anxiety level. Thus, providing information to patients about the importance of this oral manifestation may play an important role in preventing periodontal diseases.

Harnessing the wisdom of crowds can improve guideline compliance of antibiotic prescribers and support antimicrobial stewardship

Antibiotic overprescribing is a global challenge contributing to rising levels of antibiotic resistance and mortality. We test a novel approach to antibiotic stewardship. Capitalising on the concept of "wisdom of crowds", which states that a group's collective judgement often outperforms the average individual, we test whether pooling treatment durations recommended by different prescribers can improve antibiotic prescribing. Using international survey data from 787 expert antibiotic prescribers, we run computer simulations to test the performance of the wisdom of crowds by comparing three data aggregation rules across different clinical cases and group sizes. We also identify patterns of prescribing bias in recommendations about antibiotic treatment durations to quantify current levels of overprescribing. Our results suggest that pooling the treatment recommendations (using the median) could improve guideline compliance in groups of three or more prescribers. Implications for antibiotic stewardship and the general improvement of medical decision making are discussed. Clinical applicability is likely to be greatest in the context of hospital ward rounds and larger, multidisciplinary team meetings, where complex patient cases are discussed and existing guidelines provide limited guidance.

Proxy indicators to estimate the appropriateness of medications prescribed by paediatricians in infectious diseases: a cross-sectional observational study based on reimbursement data

Background

We previously developed proxy indicators (PIs) that can be used to estimate the appropriateness of medications used for infectious diseases (in particular antibiotics) in primary care, based on routine reimbursement data that do not include clinical indications.

Objectives

To: (i) select the PIs that are relevant for children and estimate current appropriateness of medications used for infectious diseases by French paediatricians and its variability while using these PIs; (ii) assess the clinimetric properties of these PIs using a large regional reimbursement database; and (iii) compare performance scores for each PI between paediatricians and GPs in the paediatric population.

Methods

For all individuals living in north-eastern France, a cross-sectional observational study was performed analysing National Health Insurance data (available at prescriber and patient levels) regarding antibiotics prescribed by their paediatricians in 2017. We measured performance scores of the PIs, and we tested their clinimetric properties, i.e. measurability, applicability and room for improvement.

Results

We included 116 paediatricians who prescribed a total of 44 146 antibiotic treatments in 2017. For all four selected PIs (seasonal variation of total antibiotic use, amoxicillin/second-line antibiotics ratio, co-prescription of anti-inflammatory drugs and antibiotics), we found large variations between paediatricians. Regarding clinimetric properties, all PIs were measurable and applicable, and showed high improvement potential. Performance scores did not differ between these 116 paediatricians and 3087 GPs.

Conclusions

This set of four proxy indicators might be used to estimate appropriateness of prescribing in children in an automated way within antibiotic stewardship programmes.

'I don't know if we can really, really change that': a qualitative exploration of public perception towards antibiotic resistance in France

Background

Since the 2000s, French authorities have put in place various national plans to make the general public aware of antibiotic stewardship. Twenty years later, France is still one of the countries with the highest use of antibiotics in Europe.

Objectives

Our study explored the general public’s perceptions of antibiotic resistance, their behaviour around antibiotic use and their expectations regarding awareness campaigns.

Methods

A qualitative study was performed from March 2018 to March 2019 in a French region using focus groups. Two types of public were targeted: parents of young children and retired people. The interview guide contained open-ended questions organized around three main themes: perceptions of antibiotic resistance; experience and use of antibiotics; and health information and campaigns.

Results

Nine focus groups were created, including 17 parents and 19 retirees. Participants did not link antibiotic overuse and antibiotic resistance. Antibiotic resistance was not perceived as a personal responsibility but as a suffered phenomenon on which the participants could not act. The blame was particularly put on the presence of antibiotics in the environment. Although participants expressed trust in their GPs, antibiotics remained perceived as the only solution for them to be cured quickly.

Conclusions

The study highlighted that the GPs were the preferred information source regarding the use of antibiotics. Actions targeting the public and health professionals will have little impact if, at the same time, efforts on work environment representation are not undertaken.