Effect of Vancomycin Therapy for Osteomyelitis on Colonization by Methicillin-Resistant Staphylococcus aureus: Lack of Emergence of Glycopeptide Resistance

Abstract Background: In treating orthopedic infections, the long-term impact of vancomycin therapy on colonization by methicillin-resistant Staphylococcus aureus (MRSA) and the emergence of vancomycin-intermediate S. aureus is unknown. Design: Prospective surveillance of the effect of long-term vancomycin therapy on colonization by MRSA and the emergence of vancomycin-intermediate S. aureus. Methods: Thirty-four patients with MRSA osteomyelitis that was microbiologically documented were longitudinally observed for the emergence of vancomycin-intermediate S. aureus at 3 body sites (wound, anterior nares, and groin) during the initial period of vancomycin therapy and at the 2-month follow-up. Twenty patients received the standard dose (20 mg/kg/d) for 34 ± 6 days and 14 patients received a high dose (40 mg/kg/d) of vancomycin for 37 ± 9 days. Results: During vancomycin treatment, global MRSA carriage (all body sites) fell from 100% to 25% in the group of patients receiving the standard dose of vancomycin, and from 100% to 40% in the group receiving the high dose. During the 2-month follow-up period after vancomycin therapy, global MRSA carriage increased from 25% to 55% in the group receiving the standard dose and decreased from 43% to 36% in the group receiving the high dose. Conclusion: Therapy with a high dose of vancomycin contributes to the sustained eradication of MRSA carriage without promoting the emergence of glycopeptide resistanc

An evaluation of linked administrative data in the perspective of hospital outcome measurment

Le programme de médicalisation du système d’information (PMSI) organise dans les établissements de santé un recueil systématique et standardisé pour toute hospitalisation : les pathologies et leur prise en charge sont codées sous la forme d’un résumé informatique auquel sont associées des informations de chaînage : une chaîne de caractère non signifiante résultant du hachage des informations numéro d’assuré social, date de naissance, code sexe du patient, et une position chronologique relative est produite. Sous réserve de la constance et uniformité de la collecte des informations source et de l’algorithme de hachage, les informations de chaînage associées aux résumés PMSI d’un même patient permettent ainsi, a priori, de reconstituer, de façon anonyme, des parcours de soins hospitaliers. L’objectif du travail est de vérifier la réalité de cet a priori dans les données de la base nationale du PMSI. Une première étape a permis de conforter la robustesse des informations. Cette robustesse est obtenue par la mise en œuvre d’éléments techniques qui prennent appui sur des informations d’utilisation commune dans les établissements de santé. Moyennant une mise en forme des données, il est possible de restituer sans recours à l’identité des patients ni aux dates de prises en charge, informations ne figurant pas dans la base de données nationale du PMSI, des parcours de soins hospitaliers cohérents. Deux exemples d’études décrivant et analysant le devenir des patients hospitalisés, suite dans le mois qui suit un séjour pour chirurgie, devenir dans l’année des hospitalisations pour lésions auto-infligées, illustrent l’apport de connaissances que peut apporter cette source d’information. L’accès à la base de données est encadré par la réglementation.The French medical information system program (PMSI) defines the item and format all hospitals and clinics in France have to use for claim data: diagnoses, medical procedures, patient, structure and stay characteristics, this for any hospital stay. These medical records abstracts are linked by means of a salted SHA-1 hash of social security number, date of birth and gender. Hash is generated by an unique software, used by all hospitals and clinics, that also calculates a delay in days since, for privacy reasons, no dates of hospital admission are mentioned in the abstracts. The data are gathered in a national database. This collection of linked abstracts designed for funding, could also be used to describe medical history and hospital outcome. The aim of the present work is to assess the quality of the linkage information and its potential contribution to medical knowledge. The first step was to assess quality of linkage information. This was found appropriate and consistent as a result of uniform generating process that relied on well know and standardized information. The second step was to shape the database in order to derive hospital outcome. Finally, this was used in to settings, readmission after surgery, one-year follow-up after non-fatal self-harm. To conclude this national linked claim database appears as suited for hospital outcome measurement. Access to the database has to comply with regulation defined by the committee on informatics and civil rights (CNIL)

Peut-on utiliser les données du programme de médicalisation du système d'information pour décrire les parcours de soins?

The French medical information system program (PMSI) defines the item and format all hospitals and clinics in France have to use for claim data: diagnoses, medical procedures, patient, structure and stay characteristics, this for any hospital stay. These medical records abstracts are linked by means of a salted SHA-1 hash of social security number, date of birth and gender. Hash is generated by an unique software, used by all hospitals and clinics, that also calculates a delay in days since, for privacy reasons, no dates of hospital admission are mentioned in the abstracts. The data are gathered in a national database. This collection of linked abstracts designed for funding, could also be used to describe medical history and hospital outcome. The aim of the present work is to assess the quality of the linkage information and its potential contribution to medical knowledge. The first step was to assess quality of linkage information. This was found appropriate and consistent as a result of uniform generating process that relied on well know and standardized information. The second step was to shape the database in order to derive hospital outcome. Finally, this was used in to settings, readmission after surgery, one-year follow-up after non-fatal self-harm. To conclude this national linked claim database appears as suited for hospital outcome measurement. Access to the database has to comply with regulation defined by the committee on informatics and civil rights (CNIL).Le programme de médicalisation du système d’information (PMSI) organise dans les établissements de santé un recueil systématique et standardisé pour toute hospitalisation : les pathologies et leur prise en charge sont codées sous la forme d’un résumé informatique auquel sont associées des informations de chaînage : une chaîne de caractère non signifiante résultant du hachage des informations numéro d’assuré social, date de naissance, code sexe du patient, et une position chronologique relative est produite. Sous réserve de la constance et uniformité de la collecte des informations source et de l’algorithme de hachage, les informations de chaînage associées aux résumés PMSI d’un même patient permettent ainsi, a priori, de reconstituer, de façon anonyme, des parcours de soins hospitaliers. L’objectif du travail est de vérifier la réalité de cet a priori dans les données de la base nationale du PMSI. Une première étape a permis de conforter la robustesse des informations. Cette robustesse est obtenue par la mise en œuvre d’éléments techniques qui prennent appui sur des informations d’utilisation commune dans les établissements de santé. Moyennant une mise en forme des données, il est possible de restituer sans recours à l’identité des patients ni aux dates de prises en charge, informations ne figurant pas dans la base de données nationale du PMSI, des parcours de soins hospitaliers cohérents. Deux exemples d’études décrivant et analysant le devenir des patients hospitalisés, suite dans le mois qui suit un séjour pour chirurgie, devenir dans l’année des hospitalisations pour lésions auto-infligées, illustrent l’apport de connaissances que peut apporter cette source d’information. L’accès à la base de données est encadré par la réglementation

Tarification à l'activité et réadmission

De nombreux pays de l’OCDE ont introduit des systèmes de paiement à l’activité pour financer leurs établissements de santé. La France a ainsi adopté en 2004 la réforme dite de «tarification à l’activité » (T2A) afin d’inciter ces établissements à davantage d’efficience. La mise en place de cette réforme a surtout intégré jusqu’ici l’impératif économique comme première préoccupation. Toutefois, pour le régulateur, il est important de suivre les effets de cette réforme sous l’angle de la qualité des soins. Une mesure de la qualité des prises en charge peut être appréhendée par le taux de réadmission à trente jours. L’objet de cette étude est de s’intéresser à la réadmission à la fois sur la période qui précède la T2A et sur la période faisant suite à sa mise en place. La période d’étude s’étend de 2002 à 2012. À partir des données du Programme médicalisé du système d’informations (PMSI), pour chaque séjour chirurgical, la réadmission à trente jours après la sortie est déterminée au moyen du chaînage PMSI, sous réserve que ces réadmissions ne soient ni des séances de traitements ni de la néonatalogie. La probabilité de réadmission est modélisée à l’aide d’une régression logistique multiple comprenant les cofacteurs suivants : année, âge, sexe, mode d’entrée, durée de séjour, morbidité, statut juridique de l’établissement ainsi que des termes d’interactions. Les résultats mettent en avant une augmentation du risque de réadmission observé au niveau global, mais qui s’explique par une modification de la structure de la population (vieillissement) ainsi que par les modifications de prise en charge. Cette hausse des réadmissions ne s’explique pas par la mise en place de la T2A.Yilmaz Engin, Vuagnat Albert. Tarification à l'activité et réadmission. In: Economie et statistique, n°475-476, 2015. La santé et les soins. pp. 71-87

Factors associated with inappropriate use of emergency departments: findings from a cross-sectional national study in France

International audienceBackground: Inappropriate visits to emergency departments (EDs) could represent from 20% to 40% of all visits. Inappropriate use is a burden on healthcare costs and increases the risk of ED overcrowding. The aim of this study was to explore socioeconomic and geographical determinants of inappropriate ED use in France.Method: The French Emergency Survey was a nationwide cross-sectional survey conducted on June 11 2013, simultaneously in all EDs in France and covered characteristics of patients, EDs and counties. The survey included 48 711 patient questionnaires and 734 ED questionnaires. We focused on adult patients (≥15 years old). The appropriateness of the ED visit was assessed by three measures: caring physician appreciation of appropriateness (numeric scale), caring physician appreciation of whether or not the patient could have been managed by a general practitioner and ED resource utilisation. Descriptive statistics and multilevel logistic regression were used to examine determinants of inappropriate ED use, estimating adjusted ORs and 95% CIs.Results: Among the 29 407 patients in our sample, depending on the measuring method, 13.5% to 27.4% ED visits were considered inappropriate. Regardless of the measure method used, likelihood of inappropriate use decreased with older age and distance from home to the ED >10 km. Not having a private supplementary health insurance, having universal supplementary health coverage and symptoms being several days old increased the likelihood of inappropriate use. Likelihood of inappropriate use was not associated with county medical density.Conclusion: Inappropriate ED use appeared associated with socioeconomic vulnerability (such as not having supplementary health coverage or having universal coverage) but not with geographical characteristics. It makes us question the appropriateness of the concept of inappropriate ED use as it does not consider the distress experienced by the patient, and segments of society seem to have few other choices to access healthcare than the ED

The French Emergency National Survey: A description of emergency departments and patients in France

for the French Society of Emergency Medicine Evaluation and Quality CommitteeInternational audienceIntroductionSome major changes have occurred in emergency department (ED) organization since the early 2000s, such as the establishment of triage nurses and short-track systems. The objectives of this study were to describe the characteristics of French EDs organization and users, based on a nationwide cross-sectional survey.MethodsThe French Emergency Survey was a nationwide cross-sectional survey. All patients presenting to all EDs during a 24-hr period of June 2013 were included. Data collection concerned ED characteristics as well as patient characteristics.ResultsAmong the 736 EDs in France, 734 were surveyed. Triage nurses and short-track systems were respectively implemented in 73% and 41% of general EDs. The median proportion of patients aged > 75 years was 14% and median hospitalisation rate was 20%. During the study period, 48,711 patients presented to one of the 734 EDs surveyed. Among them, 7% reported having no supplementary health or universal coverage (for people with lower incomes). Overall, 50% of adult patients had been seen by the triage nurse in less than 5 minutes, 74% had a time to first medical contact shorter than one hour and 55% had an ED length of stay shorter than 3 hours.ConclusionThe French Emergency Survey is the first study to provide data on almost all EDs in France. It underlines how ED organization has been redesigned to face the increase in the annual census. French EDs appear to have a particular role for vulnerable people: age-related vulnerability and socio-economic vulnerability with an over-representation of patients without complementary health coverage

Two consecutive deep sinus tract cultures predict the pathogen of osteomyelitis

OBJECTIVES: The value of non-bone microbiological cultures in the diagnosis of osteomyelitis with sinus tract is not clear. We aimed to establish the concordance between deep sinus tract cultures and bone cultures in cases of osteomyelitis with a cutaneous fistula. METHODS: This was a non-randomized, prospective diagnostic trial at the Orthopedic Service of the University Hospital of Geneva. Each patient with osteomyelitis with a cutaneous sinus tract had four microbiological samples taken: two consecutive sinus tract cultures with bone contact at different times (samples A-1 and A-2), surgical bone biopsy performed through the sinus tract (sample B), and a surgical bone biopsy performed through an uninfected area outside the sinus tract (sample C), the latter considered as the 'gold standard'. RESULTS: One hundred and forty-one patients with 154 episodes of osteomyelitis were included in the study. When both sinus tract cultures yielded the same microorganism (86.4%), the concordance between both samples A and sample C was 96%. In the case of identical sinus tract culture infections, sensitivity was 91%, specificity 86%, and accuracy 90%. The accuracy in monomicrobial infections (50%) was higher than in polymicrobial infections (94.3% vs. 78.9%, respectively; p=0.02). CONCLUSIONS: In cases of monomicrobial osteomyelitis with sinus tract, two concordant tract cultures with bone contact accurately predict the pathogen

Effect of vancomycin therapy for osteomyelitis on colonization by methicillin-resistant Staphylococcus aureus: lack of emergence of glycopeptide resistance

BACKGROUND: In treating orthopedic infections, the long-term impact of vancomycin therapy on colonization by methicillin-resistant Staphylococcus aureus (MRSA) and the emergence of vancomycin-intermediate S. aureus is unknown. DESIGN: Prospective surveillance of the effect of long-term vancomycin therapy on colonization by MRSA and the emergence of vancomycin-intermediate S. aureus. METHODS: Thirty-four patients with MRSA osteomyelitis that was microbiologically documented were longitudinally observed for the emergence of vancomycin-intermediate S. aureus at 3 body sites (wound, anterior nares, and groin) during the initial period of vancomycin therapy and at the 2-month follow-up. Twenty patients received the standard dose (20 mg/kg/d) for 34 +/- 6 days and 14 patients received a high dose (40 mg/kg/d) of vancomycin for 37 +/- 9 days. RESULTS: During vancomycin treatment, global MRSA carriage (all body sites) fell from 100% to 25% in the group of patients receiving the standard dose of vancomycin, and from 100% to 40% in the group receiving the high dose. During the 2-month follow-up period after vancomycin therapy, global MRSA carriage increased from 25% to 55% in the group receiving the standard dose and decreased from 43% to 36% in the group receiving the high dose. CONCLUSION: Therapy with a high dose of vancomycin contributes to the sustained eradication of MRSA carriage without promoting the emergence of glycopeptide resistance

Évaluation de la qualité métrologique des données du programme de médicalisation du système d'information (PMSI) en périnatalité: Étude pilote réalisthomampers

International audienceBackground: In order to assess public health policies for the perinatal period, routinely produced indicators are needed for the whole population. In France, these indicators are used to compare the national public health policy with those of other European countries. French administrative and medical data (PMSI) are straightforward and reliable and may be a valuable source of information for research. This study aimed to measure the quality of PMSI data from three university health centers for core indicators in perinatal health. Method: PMSI data were compared with medical files in 2012 from 300 live births after 22 weeks of amenorrhea, drawn at random from University Hospitals in Dijon, Paris and Nancy. The variables were chosen based on the Europeristat Project's core and recommended indicators, as well as those of the French National Perinatal survey conducted in 2010. The information gathered blindly from the medical files was compared with the PMSI data positive predictive value (PPV) and the sensitivity was used to assess data quality. Results: Data on maternal age, parity and mode of delivery as well as the rates of premature births were superimposable for the two sources. The PPV for epidural injection was 96.2% and 94.3% for perineal tears. Overall, maternal morbidity was underdocumented in the PMSI, so the PPV was 100.0% for pre-existing diabetes, 88.9% for gestational diabetes and 100.0% for high blood pressure with a rate of 9.0% in PMSI and 6.3% in the medical files. The PPV for bleeding during labor was 89.5%. Conclusion: To conclude, PMSI data are apparently becoming more and more reliable for two reasons: on one hand, the importance of these data for budgetary promotion in hospitals; on the other, the increasing use of this information for statistical and epidemiological purposes