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Thabut D, Bouzbib C, Meunier L, Haas M, Weiss N, Louvet A, Imbert-Bismut F, Mochel F, Nadjar Y, Santiago A, Thevenot T, Duhalde V, Oberti F, Francoz C, Coilly A, Hilleret MN, Lebray P, Liou-Schischmanoff A, Barbier L, Duvoux C, Pageaux GP, Bismuth M, Galanaud D, Broucker TD, Cadranel JF, Leroy V, Di Martino V, Larrey D, Camus C, Scatton O, De Ledinghen V, Mallat A, Rudler M, Bureau C. Diagnosis and management of hepatic encephalopathy: The French recommendations. Liver Int 2023; 43:750-762. [PMID: 36625084 DOI: 10.1111/liv.15510] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 11/27/2022] [Accepted: 12/31/2022] [Indexed: 01/11/2023]
Abstract
Hepatic encephalopathy (HE) is a frequent and severe complication of liver disease with poor patient outcomes. However, it is a poorly understood complication, with no consensus for diagnosis. Therefore, HE is often underdiagnosed. Differential diagnosis may be cumbersome because of non-specific symptoms, such as confusion, cognitive disorders, the aetiological factors of cirrhosis and comorbidities, which are often observed in cirrhotic patients. Therefore, an overt or covert form of HE should be systematically investigated. Advice is provided to drive patient work-up. Effective treatments are available to prevent or treat HE bouts, but the issue of single or combination therapy has not been resolved. Transjugular intrahepatic portosystemic shunt (TIPS) placement largely improved the prognosis of cirrhotic patients, but HE occurrence of HE is often a fear, even when post-TIPS HE can be avoided by a careful selection of patients and preventive treatment. HE is an indication of liver transplantation. However, its reversibility post-transplantation and the consequences of transplantation in patients with other causes of neurological disorders remain controversial, which supports the performance of an extensive work-up in expert centres for this subset of patients. The present guidelines assist clinicians in the diagnosis of the overt or covert form of HE to implement curative and preventive treatments and clarify which patients require referral to expert centres for consideration for liver transplantation. These guidelines are very clinically oriented and address different frequent clinical issues to help physicians make bedside decisions.
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Affiliation(s)
- Dominique Thabut
- APHP-Sorbonne Université, Service d'hépato-gastroentérologie, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Charlotte Bouzbib
- APHP-Sorbonne Université, Service d'hépato-gastroentérologie, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Lucy Meunier
- Service d'hépato-gastroentérologie A et Transplantation, Hôpital Saint-Eloi, CHU de Montpellier, Montpellier, France
| | - Manon Haas
- APHP-Paris Saclay, Centre Hépato-Biliaire, Hôpital Paul Brousse, Université Paris-saclay, Villejuif, France
| | - Nicolas Weiss
- APHP-Sorbonne Université, Service de réanimation neurologique, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Alexandre Louvet
- Services des maladies de l'appareil digestif, CHRU de Lille, Lille, France
| | - Francois Imbert-Bismut
- APHP-Sorbonne Université, Service de biochimie, Hôpital Pitié-Salpêtrière, Paris, France
| | - Fanny Mochel
- APHP-Sorbonne Université, Service de génétique, Hôpital Pitié-Salpêtrière, Paris, France
| | - Yann Nadjar
- APHP-Sorbonne Université, Service de neurologie, Hôpital Pitié-Salpêtrière, Paris, France
| | - Antoine Santiago
- APHP-Sorbonne Université, Service d'hépato-gastroentérologie, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Thierry Thevenot
- Service d'hépatologie, Hôpital Jean Minjoz, CHU de Besançon, Besançon, France
| | - Véronique Duhalde
- Service de pharmacie, Hôpital Rangueil, CHU de Toulouse, Toulouse, France
| | - Frédéric Oberti
- Laboratoire HIFIH, UPRES-EA2170, Faculté de Médecine, Service d'hépato-gastroentérologie, CHU ANGERS, Angers, France
| | - Claire Francoz
- APHP-Hôpital Beaujon, Service d'hépatologie, Clichy, France
| | - Audrey Coilly
- APHP-Paris Saclay, Centre Hépato-Biliaire, Hôpital Paul Brousse, Université Paris-saclay, Villejuif, France
| | | | - Pascal Lebray
- APHP-Sorbonne Université, Service d'hépato-gastroentérologie, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | | | - Louise Barbier
- Service de chirurgie hépatique et transplantation, CHU de Tours, Tours, France
| | | | - Georges-Philippe Pageaux
- Service d'hépato-gastroentérologie A et Transplantation, Hôpital Saint-Eloi, CHU de Montpellier, Montpellier, France
| | - Michael Bismuth
- Service d'hépato-gastroentérologie B, Hôpital Saint Eloi, CHU de Montpellier, Montpellier, France
| | - Damien Galanaud
- APHP-Sorbonne Université, Service de neuro-radiologie, Hôpital Pitié-Salpêtrière, Paris, France
| | - Thomas De Broucker
- Service de Neurologie Hôpital Pierre Delafontaine, Centre Hospitalier de Saint-Denis, Saint-Denis, France
| | - Jean-François Cadranel
- Service d'hépato-gastroentérologie de nutrition et d'Alcoologie-GHPSO site de Creil, Creil, France
| | - Vincent Leroy
- APHP Hôpital Henri-Mondor, Service d'hépatologie, Créteil, France
| | - Vincent Di Martino
- Service d'hépatologie, Hôpital Jean Minjoz, CHU de Besançon, Besançon, France
| | - Dominique Larrey
- Service d'hépato-gastroentérologie A et Transplantation, Hôpital Saint-Eloi, CHU de Montpellier, Montpellier, France
| | - Christophe Camus
- Service de réanimation Médicale, Hôpital Pontchaillou, CHU de Rennes, Rennes, France
| | - Olivier Scatton
- APHP-Sorbonne Université, Service de chirurgie et transplantation hépatique, Hôpital Pitié-Salpêtrière, Paris, France
| | - Victor De Ledinghen
- Service d'hépato-gastroentérologie, Hôpital du Haut-Lévêque, CHU de Bordeaux, Bordeaux, France
| | - Ariane Mallat
- APHP Hôpital Henri-Mondor, Service d'hépatologie, Créteil, France
| | - Marika Rudler
- APHP-Sorbonne Université, Service d'hépato-gastroentérologie, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Christophe Bureau
- Service d'hépatologie, Hôpital Rangueil, CHU de Toulouse, Toulouse, France
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Nivet C, Duhalde V, Beaurain M, Delobel P, Quelven I, Alric L. Fecal Microbiota Transplantation for Refractory Clostridioides Difficile Infection Is Effective and Well Tolerated Even in Very Old Subjects: A Real-Life Study. J Nutr Health Aging 2022; 26:290-296. [PMID: 35297473 PMCID: PMC8886857 DOI: 10.1007/s12603-022-1756-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/15/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Fecal microbiota transplantation (FMT) is an innovative therapy indicated for the treatment of recurrent Clostridioides difficile infections. Although CDI and its complications are more common in very old patients (≥80 years) due to their comorbidities, frailty and senescence of the immune system, limited data are available for this older patient population. DESIGN This was a single-center, real-life cohort study with retrospective outcome data registration, conducted at Toulouse, France. SETTING AND PARTICIPANTS Older people group was compared to the control group aged 18-79 years. MEASUREMENTS The primary outcome was overall survival at 52 weeks for ≥80 years patients compared to the control group after FMT. Recurrence-free survival at 52 weeks and, the occurrence of adverse events in the short and long term were the secondary endpoints. RESULTS A total of 58 patients were included, 19 were aged ≥80 years and 39 were aged 18-79 years. Overall survival at 52 weeks after FMT of the very old patients was not different from the control group (78.9% versus 89.7%, p= 0.29). Recurrence-free survival of CDI was not different between groups, with 94.3% in the 18-79-group versus 86.9% in the ≥80 group (p=0.44). The occurrence of short- or long-term adverse events was not statistically different between the two groups (36.8% vs 41%, p=0.45). CONCLUSIONS FMT is effective and well-tolerated in very old frail patients. This treatment brings a rapid benefit and limits the loss of functions. It also favors their maintenance at home or in a non-medical institution dedicated to dependent subjects and improves their quality of life.
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Affiliation(s)
- C Nivet
- Laurent Alric, Internal medicine department of digestive disease, Rangueil hospital, Toulouse 3 university, 1 avenue du professeur Jean-poulhès, TSA 50032, 31000 Toulouse, France,
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Breuker C, Guedj AM, Allan M, Coinus L, Molinari N, Chapet N, Roubille F, Le Quintrec M, Duhalde V, Jouglen J, Cestac P, Kinowski JM, Faure S, Faucanie M, Lohan L, Villiet M, Altwegg R, Sultan A. The COVID-19 Pandemic Led to a Small Increase in Changed Mentality Regarding Infection Risk without Any Change in Willingness to Be Vaccinated in Chronic Diseases Patients. J Clin Med 2021; 10:jcm10173967. [PMID: 34501415 PMCID: PMC8432078 DOI: 10.3390/jcm10173967] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 08/25/2021] [Accepted: 09/01/2021] [Indexed: 12/13/2022] Open
Abstract
The objective of this study was to assess the impact of the COVID-19 pandemic on patients’ perceptions regarding infection risk and vaccination in subjects suffering from chronic diseases. A prospective observational multicentric study conducted from December 2020 to April 2021 in three French University Hospitals. Patients with chronic diseases were proposed to complete a questionnaire regarding the impact of the COVID-19 pandemic on infectious risk knowledge and vaccination. A total of 1151 patients were included and analyzed (62% of which were people with diabetes). The COVID-19 pandemic increased awareness of infectious risks by 19.3%, significantly more in people with diabetes (23.2%, from 54.4% to 67.0%, p < 0.01) when compared to the other high-risk patients (12.5%, from 50.5% to 56.8%, p = 0.06). Respectively, 30.6% and 16.5% of patients not up-to-date for pneumococcal and flu vaccines reported wanting to update their vaccination due to the COVID-19 pandemic. By contrast, the proportion of patients against vaccines increased during the COVID-19 pandemic (6.0% vs. 9.5%, p < 0.01). The COVID-19 pandemic has led to a small increase in awareness regarding the risks of infection in patients with chronic diseases, including people with diabetes, but without any change in willingness to be vaccinated. This underlines the urgent need to sensibilize people with diabetes to infection risk and the importance of vaccination.
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Affiliation(s)
- Cyril Breuker
- Department of Clinical Pharmacy, CHU Montpellier, University of Montpellier, 34000 Montpellier, France; (M.A.); (L.C.); (N.C.); (L.L.); (M.V.)
- PhyMedExp, CHU Montpellier, INSERM, CNRS, University of Montpellier, 34295 Montpellier, France;
- Correspondence:
| | - Anne Marie Guedj
- Department of Endocrinology, University Hospital of Nîmes, 30900 Montpellier, France;
| | - Mathilde Allan
- Department of Clinical Pharmacy, CHU Montpellier, University of Montpellier, 34000 Montpellier, France; (M.A.); (L.C.); (N.C.); (L.L.); (M.V.)
| | - Loick Coinus
- Department of Clinical Pharmacy, CHU Montpellier, University of Montpellier, 34000 Montpellier, France; (M.A.); (L.C.); (N.C.); (L.L.); (M.V.)
| | - Nicolas Molinari
- Department of Statistics, CHU Montpellier, University of Montpellier, 34000 Montpellier, France;
| | - Nicolas Chapet
- Department of Clinical Pharmacy, CHU Montpellier, University of Montpellier, 34000 Montpellier, France; (M.A.); (L.C.); (N.C.); (L.L.); (M.V.)
| | - François Roubille
- Department of Cardiology, PhyMedExp, CHU Montpellier, INSERM, CNRS, University of Montpellier, 34295 Montpellier, France;
| | - Moglie Le Quintrec
- Department of Nephrology, CHU Montpellier, University of Montpellier, 34000 Montpellier, France;
| | - Véronique Duhalde
- Department of Pharmacy, Toulouse University Hospital, 31300 Toulouse, France; (V.D.); (J.J.); (P.C.)
| | - Julien Jouglen
- Department of Pharmacy, Toulouse University Hospital, 31300 Toulouse, France; (V.D.); (J.J.); (P.C.)
| | - Philippe Cestac
- Department of Pharmacy, Toulouse University Hospital, 31300 Toulouse, France; (V.D.); (J.J.); (P.C.)
- Centre for Epidemiology and Population Health Research (CERPOP), UMR 1027, INSERM, University of Toulouse (UPS), 31000 Toulouse, France
| | | | - Stéphanie Faure
- Department of Gastroenterology, CHU Montpellier, University of Montpellier, 34000 Montpellier, France; (S.F.); (R.A.)
| | - Marie Faucanie
- Clinical Research and Epidemiology Unit, CHU Montpellier, University of Montpellier, 34000 Montpellier, France;
| | - Laura Lohan
- Department of Clinical Pharmacy, CHU Montpellier, University of Montpellier, 34000 Montpellier, France; (M.A.); (L.C.); (N.C.); (L.L.); (M.V.)
- PhyMedExp, CHU Montpellier, INSERM, CNRS, University of Montpellier, 34295 Montpellier, France;
| | - Maxime Villiet
- Department of Clinical Pharmacy, CHU Montpellier, University of Montpellier, 34000 Montpellier, France; (M.A.); (L.C.); (N.C.); (L.L.); (M.V.)
| | - Romain Altwegg
- Department of Gastroenterology, CHU Montpellier, University of Montpellier, 34000 Montpellier, France; (S.F.); (R.A.)
| | - Ariane Sultan
- PhyMedExp, CHU Montpellier, INSERM, CNRS, University of Montpellier, 34295 Montpellier, France;
- Department of Endocrinology-Diabetology-Nutrition, CHU Montpellier, University of Montpellier, 34000 Montpellier, France
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Chautant F, Guillaume M, Robic MA, Cadranel JF, Peron JM, Lison H, Cool C, Bureau C, Duhalde V. Lessons from “real life experience” of rifaximin use in the management of recurrent hepatic encephalopathy. World J Hepatol 2020; 12:10-20. [PMID: 31984117 PMCID: PMC6946626 DOI: 10.4254/wjh.v12.i1.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 09/30/2019] [Accepted: 12/09/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hepatic encephalopathy (HE) is a major complication of cirrhosis with independent prognostic significance. The current management of HE is mainly based on lactulose. Rifaximin has been shown to decrease the risk of HE recurrence in patients with episodic forms. HE can also be persistent. However, there is no drug support recommendation for rifaximin use in this setting.
AIM To assess the effectiveness of rifaximin in the management of recurrent episodes of HE and recurrent acute exacerbations on persistent HE, in “real life conditions”.
METHODS In this retrospective study, using a within-subjects design, we collected data of patients treated with rifaximin for HE in two liver diseases centers, during the six-month period before and during the six-month period after the initiation of rifaximin. The primary effectiveness endpoint was the total number of HE events involving hospitalization.
RESULTS Rifaximin was introduced for prevention of recurrent HE episodes in 29 out of 62 patients with normal mental status between episodes and for prevention of recurrent acute exacerbations on persistent HE in 33 out of 62 patients. In the “prevention of recurrent HE episodes” group, fewer HE events (0.79 vs 1.78; P = 0.013) were reported during the period of time when rifaximin was used. In the “prevention of recurrent acute exacerbations on persistent HE” group, there was no significant difference in the number of HE-events (1.48 vs 1.77; P = 0.582).
CONCLUSION In this real-life experience, the effectiveness of rifaximin was confirmed in the prevention of HE episodes recurrence but was not proved in the prevention of acute exacerbations recurrence on persistent HE.
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Affiliation(s)
- Fiona Chautant
- Service Pharmacie, Centre Hospitalier Universitaire de Toulouse, Hôpital Paule de Viguier, Toulouse 31059, France
| | - Maeva Guillaume
- Department of Hepato-Gastroenterology, University Hospital, Toulouse 31059, France
| | - Marie-Angèle Robic
- Department of Hepato-Gastroenterology, University Hospital, Toulouse 31059, France
| | | | - Jean-Marie Peron
- Department of Hepato-Gastroenterology, University Hospital, Toulouse 31059, France
| | - Hortensia Lison
- Department of Hepato-Gastroenterology, Laennec Hospital, Creil 60109, France
| | - Charlène Cool
- Department of Pharmacy and UMR INSERM 1027, University Hospital, Toulouse 31059, France
| | - Christophe Bureau
- Department of Hepato-Gastroenterology, University Hospital, Toulouse 31059, France
| | - Véronique Duhalde
- Department of Pharmacy, University Hospital Toulouse, Toulouse 31059, France
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Alric L, Duhalde V, Pierre A, Rondou A, Bonnet D, Godart M, Civade E, Delobel P, Tafani M. La transplantation de microbiote fécal au cours de la colite récidivante à clostridium difficile est efficace et bien tolérée, y compris chez le sujet très âgé. Rev Med Interne 2017. [DOI: 10.1016/j.revmed.2017.10.388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lafaurie M, Cool C, Gougeon M, Sémély D, Urtubia N, Porte L, Segonds C, Duhalde V. BU-32 - Péritonites en chirurgie digestive : un traitement anti-infectieux probabiliste adapté à l’écologie microbienne locale ? Med Mal Infect 2016. [DOI: 10.1016/s0399-077x(16)30356-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Gougeon M, Lafaurie M, Vancassel M, Segonds C, Cestac P, Cool C, Duhalde V. CP-188 Intra-abdominal infections in digestive surgery wards: Is empiric antibiotic treatment in accordance with local microbiological ecology? Eur J Hosp Pharm 2016. [DOI: 10.1136/ejhpharm-2016-000875.188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Mikolajczak AL, Bellon B, Calmels V, Cestac P, Cool C, Duhalde V. OHP-009 How hospital pharmacists can promote proper use of breath tests beyond buying medical devices? Eur J Hosp Pharm 2016. [DOI: 10.1136/ejhpharm-2016-000875.397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Gorce T, Chu N, Duhalde V, Vie M, Cestac P, Bellon B. CPC-041 Direct Avoidance of Medicines Costs by Pharmaceutical Analysis of Hospital Prescriptions. Eur J Hosp Pharm 2013. [DOI: 10.1136/ejhpharm-2013-000276.498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Chu N, Gorce T, Duhalde V, Cestac P, Vie M, Bellon B. GRP-119 Most Frequent Drug-Related Events Detected by Pharmaceutical Analysis of Computerized Physician Order Entry and Proposed Solutions. Eur J Hosp Pharm 2013. [DOI: 10.1136/ejhpharm-2013-000276.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Duhalde V, Lahille B, Camou F, Pédeboscq S, Pometan JP. [Proper use of antibiotics: a prospective study on the use of linezolid in a French university hospital]. ACTA ACUST UNITED AC 2007; 55:478-81. [PMID: 17904310 DOI: 10.1016/j.patbio.2007.07.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2007] [Accepted: 07/26/2007] [Indexed: 10/22/2022]
Abstract
AIM OF THE STUDY To describe clinical use of a new antibiotic: linezolid, in a French university hospital, on a population of patients different from the one studied during the clinical trials for the marketing authorisation. PATIENTS AND METHODS An observational, prospective cohort study performed in patients treated by linezolid between November 2005 and June 2006 at Saint André hospital (Bordeaux University Hospital). The following data were collected: sources of infection, isolated pathogens, patient's background, antibiotherapy strategies, duration of therapy and evolution. RESULTS Fifty patients (intensive care, internal medicine) were included. The absence of local guidelines on proper use of linezolid led to various prescriptions as well in infections listed in the marketing authorisation: nosocomial pneumonia and ventilator associated pneumonia (48%), skin and soft tissue infections (11%), as in endocarditis (7%), intra-abdominal infections (13%), bone and joint infections (2%), catheter infections (13%) and febrile neutropenic patients (6%). The main justification for using linezolid was worsening renal dysfunction (66%), which contra indicated glycopeptides use. Isolated pathogens were for the major part staphylococcus. CONCLUSION In the context of proper use of antibiotics, it would be advisable to add new recommendations on the use of linezolid to the hospital's antibiotherapy guide which would constitute a tool for the prescribing clinicians, and to re-evaluate the impact during a second evaluation.
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Affiliation(s)
- V Duhalde
- Service Pharmacie, Hôpital Saint-André, CHU de Bordeaux, 1, rue Jean-Burguet, 33075, Bordeaux Cedex, France.
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