Soutenance mémoire
Antibiotics and oxygen therapy for acute exacerbation of COPD: Are we over-prescribing in the emergency department?
METHODS
The study protocol was declared and approved by the ethics committee of the University Hospital of Angers (Angers, France, record 2015/80) and by the French National Commission for Data Processing and Civil Liberties (CNIL, Angers, France, record 2015-013). To collect non-consent advice, an information mail was sent to each patient three weeks before data extractions. Each record was treated anonymously.
Study design
This monocentric, retrospective, descriptive and analytic study was performed at the University Hospital of Angers (Angers, France). This work concerns adult patients with COPD admitted in the emergency department from January 1st of 2013 to December 31st of 2014.
Records selection, inclusions and exclusion criteria Medical records were identified from the ED database based on the International Statistical Classification of Disease and Related Health Problems 10th Revision (ICD-10). All medical records containing the terms “COPD”, “Chronical obstructive bronchopulmonary disease” or “Chronical obstructive pulmonary disease” for the study period were selected for screening. Among selected records, those containing the following terms: “Acute decompensation of COPD”, “COPD (infection)”, “acute bronchitis” or “exacerbation of COPD” in diagnosis text-field were included and remaining records were screened manually for the same words.
Non-inclusion criteria were patient under 18 years old, non-respiratory final diagnosis, pneumonia diagnosis, no final diagnosis filled. Records without information about previous spirometry, COPD severity, dyspnea base-line status or GOLD classification were excluded. The characteristics of the 451 medical records analyzed were similar to those of the 26 excluded ones [Table 1].
Data collected
Demographic data and baseline status
We collected age, sex, patient provenance (home, retirement home, nursing home, or long-stay hospital unit, other hospital), cigarette smoking status and cardiovascular or respiratory comorbidities. Severity of the COPD and GOLD status were assessed from previous spirometry results (FEV1, FEV1/FVC), hospitalization or consultation reports (5). Every document had to be available at the time of ED admission. Following guidelines, in the absence of functional information on COPD severity, GOLD status was determined using information about baseline status dyspnea, if available (14).
Clinical data and exacerbation severity
We collected the following vital signs: temperature, neurological impairment (Glasgow Coma Scale on admission), blood pressure, heart and respiratory rate. Respiratory failure severity was assessed from the presence of dyspnea, cyanosis, use of accessory inspiratory muscles, asterixis or paradoxical respiratory movements. The presence of purulent sputum in clinical history was also documented. The following laboratory values during the first 6 hours were collected: hemoglobin (Hbg), leucocytes, neutrophils, C-reactive protein (CRP), creatinine, urea, brain natriuretic peptide (BNP), and blood gases values (PaO2, PaCO2 and pH). Then, a BAP-65 risk stratification score for use in AE of COPD to estimate in-hospital mortality was calculated for each patient (41,42).
Exacerbation management in the ED
To describe antibiotic treatment management, we collected previous antibiotics treatment (in the week before admission) and the prescription of an antibiotic in the ED. To describe oxygen administration management, we collected last pulse oximetry value and oxygen flow rate at discharge and the use of non-invasive ventilation. ICD-10 diagnosis code, physician status, time of discharge from the ED and destination were also documented. Time of discharge was considered as the medical conclusion time. Patients were considered as managed on night or week-end shift schedules when discharged on night or week-end time.
Missing values management
To manage missing values, every patient with no available GOLD status or information about dyspnea baseline status were excluded. Sputum purulence was considered absent if not documented in medical record.
Concordance rate evaluation between prescribed antibiotic and guidelines.
We used AFFSAPS and SPILF 2010 guidelines which recommend a “class I” antibiotic (amoxicillin, pristinamycin, telithromycin, oral 3GC) for GOLD III patients presenting increased purulent sputum and a “class II” antibiotic (ceftriaxone, cefotaxime, amoxicillin-clavulanic acid and levofloxacin) for each GOLD IV exacerbation (14). Following those documents, we determined indication and recommended antibiotic molecule. First, we assessed the adequacy rate of antibiotic indication and molecule choice with comparison between theoretical and clinical practices for each record. Then, adequacy was defined as correct if both indication to an antibiotic treatment and prescribed molecule were similar to guidelines recommendations.
Concordance rate evaluation between oxygen prescription and guidelines.
Oxygen therapy was defined as correct if the last pulse oximetry was between 88 and 92% if oxygen was administered. For patients who did not receive oxygen, oxygen management was defined as correct if the last pulse oximetry was above 88% (5).
Primary and secondary endpoint
The primary endpoint is the rate (in percent) of similarity between prescribed antibiotic and recommended antibiotic prescription. Secondary endpoints were: the rate (in percent) of similarity between collected pulse oximetry and target pulse oximetry; and significant association of selected parameters with antibiotic and oxygen over-prescription.
Statistical analysis
Data were documented on an Excel file and stored inside ED. Statistical analyses were completed by the Department of methodology and biostatistics using SPSS software. We estimated adequacy rates for antibiotic prescription and oxygen prescription with their 95% confidence intervals. Continuous values were compared using Student’s t test or Mann Whitney non-parametrical test depending on normality and nominal variables with Pearson’s chi-squared test or Fisher’s exact test. Statistical significance was denoted by a P value < 0.05.
RESULTS
Description of the population
Inclusion of population studied
For this study, we identified 1010 patients with COPD admitted in the ED during years 2013 and 2014. Among them, 477 were admitted for AE. We excluded 26 patients (5.45%) because of missing information about disease steady state severity. The final cohort consisted of 451 patients.
Demographic characteristics of included and excluded patients
The mean age was 74 years old, 66% were men and 57% were admitted during week end or night shift schedule. We didn’t notice significant differences between analyzed and excluded medical records main characteristics (p value > 0.05) [Table 1].
Disease history and severity of the exacerbation episode
COPD severity status and previous therapeutics
About a quarter of included patients (23.9%) received an antibiotic treatment in the week before ED admission. Aminopenicillin were the most prescribed antibiotics before ED admission with amoxicillin clavulanate (39.81%) and amoxicillin (12.96%). The mean FEV1 value was 51.62 liters with 67 (14.9%) GOLD IV patients, 148 (32.8%) GOLD III patients, 117 (25.9%) GOLD II patients and 69 (15.3%) GOLD I patients. A total of 50 (11.1%) patients had available spirometry results showing no bronchial obstruction but were considered as an AE of COPD on the ED discharge. A major proportion had a past cardiovascular history (64.1%), about one quarter had pre-existing respiratory condition (24.6%) other than COPD and 18.8% were smokers. Purulent sputum was found in 118 patients (26.2%)
Exacerbation characteristics and severity
Most patients experienced shortness of breath on ED admission (86%) with high respiratory rate (mean 26 movements / minute, SD 7). Use of accessory respiratory muscles was the most frequent clinical signs of severity with 46.8% patients presenting intercostal recession, 14.6% presenting paradoxical abdominal respiratory movements. Three and one half percent had hypercapnia symptoms and three percent had cyanosis. Mean pulse oximetry on admission was 94.6%. Temperature was mostly in the normal range with only 10.2% of patients over 38.5°C. To assess global severity, we used the BAP-65 score. Following this score, 84 (18.6%) patients were class I and considered as low severity exacerbation, 358 (79.4%) had a mild severity exacerbation and nine (2%) had a severe exacerbation [Table II].
Exacerbation management in the ED: care track
Most of the patients came from home (82.9%) and 257 (57%) on night or week end shift time. The physician in charge was mostly an emergency physician (68.9%) or a resident (22.6%). 73.2% of admitted patients were hospitalized and 20.8% were discharged to home. The most frequent hospitalization units were respiratory unit (38.18%), general medicine unit (25.15%) and infectious diseases unit (10%). Others were admitted in medical or surgical specialty units. 28 (8.48%) inpatients were admitted in intensive care unit.
Exacerbation management in the ED: antibiotics
Antibiotic treatment management description
About half of the patients (57%) received an antibiotic treatment in the emergency department. Among them, only 36 (14%) were prescribed a class I molecule and 216 (84%) a class II molecule. Amoxicillin-clavulanic acid was the most prescribed molecule (71%) followed by amoxicillin (7.4%). [Table IV]
|
Table des matières
Plan
LIST OF ABBREVIATIONS
ABSTRACT
INTRODUCTION
METHODS
RESULTS
1. Description of the population
1.1. Inclusion of population studied
1.2. Demographic characteristics of included and excluded patients
2. Disease history and severity of the exacerbation episode
2.1. COPD severity status and previous therapeutics
2.2. Exacerbation characteristics and severity
3. Exacerbation management in the ED: care track
4. Exacerbation management in the ED: antibiotics
4.1. Antibiotic treatment management description
4.2. Antibiotic treatment management concordance with guidelines
4.3. Antibiotic treatment management: parameters associated with over-prescription.
5. Exacerbation management in the ED: Oxygen administration
5.1. Oxygen management description
5.2. Oxygen management concordance with guidelines
5.3. Oxygen administration management: parameters associated with oxygen over-prescription.
DISCUSSION AND CONCLUSION
1. Main findings and strengths
2. Interpretation of findings in relation to previously published work
2.1. Antibiotics management in AE
2.2. Oxygen administration in AE
3. Limitations
4. Conclusion
BIBLIOGRAPHY
LIST OF FIGURES
LIST OF TABLES
TABLE OF CONTENTS
ANNEXES
Télécharger le rapport complet
