Évaluation d’une consultation mobile d’infectiologie

Objectives

The aims of our study were to characterize the activity of a remote infectious diseases consultation (RIDC) in a teaching hospital and to assess physician observance to advice.

Design

All demands received by the RIDC for initial advice and the given answers were recorded during one month. Advice given for inpatients was followed up 72 hours after to evaluate the physician's observance.

Results

Six hundred and nineteen demands were recorded: 47% came from our teaching hospital and 53% came from community practice. Hospital demands came mostly from surgical (47%) and medical (41%) units. Most of them (92%) were related to the treatment of an infection or diagnostic help. Outside calls came from doctors (85%) either private or working in a health care institution. Prophylaxis (47%) and treatment of an infection or a diagnostic help (43%) were the most frequent issues. Among the 176 pieces of advice requested for inpatients, 87% were completely observed. Advice was more followed when it was given by experienced specialists (p = 0.02) or by phone (p = 0.03) and less followed for patients presenting a nosocomial infection (p = 0.03).

Conclusions

The RIDC is very useful for the medical community and its advice is usually followed. Informal consultations account for an important part of its activity.     

Méthode d’évaluation des pratiques professionnelles (EPP) au cours de l’antibiothérapie des pneumopathies aiguës communautaires

Introduction

Methods used for the assessment of professional practices must be dependable and reproducible. The aim of this study was to assess a method used in our hospital to assess antibiotic therapy for acute community-acquired pneumonia (CAP).

Method

In this study, a pharmacist and two infectious disease specialists retrospectively and independently evaluated the compliance to local antibiotic guidelines for 124 patients. The assessment tool was a Medical Appropriateness Index (MAI) (nine items). The kappa agreement index (K) among experts was calculated.

Results

The agreement among experts was poor for the initial antibiotic treatment (K = 0.16) and route of administration (K = 0.14), low for the duration of treatment (K = 0.34), and null for the dose and adjustment to 72 hours.

Conclusion

Differences between experts can be explained by the complexity of medical records, the number of items assessed, the complexity of the MAI, but also by the specialization and experience of experts. Thus, the assessment of CAP antibiotic therapy requires the use of appropriate methods targeting reliable criteria.     

Épidémiologie des patients porteurs d’entérobactéries sécrétrices de bêtalactamase à spectre élargi (EBLSE), à l’admission

Objective

The incidence of extended-spectrum beta-lactamase-producing enterobacteria (ESBLE) has regularly increased over the last few years. However, little is known about epidemiology of ESBLE carriers in France. The objective of this study was to determine the ESBLE carriers or infected patients profile, identified within 48 hours following hospital admission.

Design

This retrospective study included all patients admitted in 2006 and 2007 at the Necker–Enfants-Malades (NEM) teaching hospital, carrying or infected with ESBLE isolated within 48 hours following admission. The pediatric and adult populations were compared.

Results

There was no significant difference between pediatric and adult populations. Escherichia coli and Klebsiella pneumoniae were the two main species isolated, accounting respectively for 59.6 and 21.1 % of the 114 isolated strains. Among the 114 analyzed files, 24 patients (21 %) were known to be EBLSE carriers, 37 (32 %) were transferred from another hospital, including 16 from another country. Concerning the 54 (47 %) other patients, five (4 %) came from a country with high prevalence, and 44 (39 %) were treated for a chronic illness. Only five patients (4 %) carrying ESBLE did not have any usual risk factor for multidrug resistance (MDR) bacterial carriage.

Conclusions

In our study, 4 % of patients carrying ESBLE admitted had no usual risk factor for MDR bacteria. Targeted screening of previous carriers, patients with chronic illness, transferred patients, or patients coming from country with high prevalence, would help to limit the spread of ESBLE.     

Évaluation de l’antibiothérapie des bactériémies et place d’une équipe mobile pour l’amélioration de la prescription antibiotique

Introduction

Antibiotic management teams (AMTs) are recommended, but they are rarely implemented in France and their activity seldom evaluated.

Objective

The study was made to evaluate the appropriateness of antibiotic therapy (AT) for bloodstream infections (BSI) and to assess the role of an AMT for improving AT in a 950-bed teaching hospital.

Methods

A prospective analysis was made of all significant BSIs outside ICU in 2008. AT was assessed by the AMT and change was suggested if deemed necessary: effective if at least one prescribed antibiotic was effective in vitro, and appropriate if consistent with local recommendations.

Results

Of 875 +BCs, 560 were significant, 383 were outside ICU and 344 could be evaluated (170 community-acquired, 124 nosocomial, and 50 healthcare-associated [HCA]). The clinical ward has already initiated an effective and appropriate AT in 128 (37%), inappropriate but effective in 104 (30%), and ineffective or absent in 112 (33%) BSIs. The only independent variable associated with ineffective/absent AT was nosocomial and/or HCA BSI (aOR: 2.71; 95%CI: 1.72–4.27; p < 0.001). A recommendation was given and followed in 177/190 (93%) BSIs requiring an intervention. The AMT intervened on the day of the +BC in 256 (84%) cases, the day before the +BC in 12 (4%) cases, and one day later or more in 37 (12%) BSI cases.

Conclusion

Two third of BSIs were not initially treated by appropriate AT, more often in nosocomial BSI. Recommendation provided by the AMT was followed in 93% of cases.     

Incidence,prévalence et facteurs de risque de survenue d’une première complication infectieuse sur chambres à cathéter implantables

Background

Totally implantable venous-access ports (TIVAP) should present less risk of complications than central venous catheters over a long time period.

Aims

Firstly, the study's objective was to assess the prevalence and incidence of a first infectious complication on a TIVAP and secondly, to assess the risk factors associated with this first infection.

Methods

The authors made a longitudinal historical cohort study of patients with a TIVAP in 2003, in the Dijon University Hospital.

Results

Two hundred and nineteen patients (sex-ratio 1.9) were included, with a total follow-up of 92,773 patients-days. Ninety percent of the TIVAP were used for chemotherapy, 5% for antibiotic drug administration, 2% for parenteral nutrition and 3% for other reasons (recurrent blood transfusions, etc.). Overall, 34 (16.3%) out of 209 patients presented with at least one infectious complication, with an incidence rate of 0.37 infection/1,000 patients-days. The 5-year cumulative probability to be free of infectious complication was only 62.8%. In multivariate analysis, only underlying hematological neoplasia (by contrast with solid tumors) was significantly associated to a higher risk of infectious complication.

Conclusions

The infectious risk linked to the use of TIVAP is significant, higher in case of underlying hematological neoplasia and during the first months of use.     

Contribution of systematic RT-PCR screening for influenza during the epidemic season

Objective

We assessed the systematic RT-PCR screening of patients admitted to an infectious diseases department (IDD), during the 2012–2013 influenza outbreak.

Methodology

Patients admitted with cough and fever underwent a nasopharyngeal smear for RT-PCR screening.

Results

Ninety-eight patients were admitted in the IDD, from January 1st to February 22nd, 46 were screened; 11 male and 6 female patients (17.3%, mean age of 68 years) were positive. The diagnoses made in the emergency department, before RT-PCR screening, were most frequently lung infection and sepsis, but influenza in only 4 cases. The diagnosis of influenza led to stopping antibiotics (n = 4), initiating curative (n = 4) and preventive (n = 4) treatments with oseltamivir, and isolating patients to prevent a hospital outbreak.

Conclusion

Systematic RT-PCR screening allows a rapid therapeutic management and the prevention of hospital epidemic through appropriate isolation measures.     

Cent quinze cas de paludisme d’importation à Plasmodium falciparum admis en service d’urgence au CHU de Bordeaux

Objectives

The authors had for objective to evaluate the management of a Plasmodium falciparum malaria in a Bordeaux teaching hospital EU.

Methods

One hundred and fifteen patients with falciparum malaria admitted between January 2004 and October 2006 were retrospectively studied and those with ambulatory treatment were questioned by phone.

Results

Fifty per cent of patients had consulted a community physician prior to admission, and a parasitic test was made for 50 % of these. In seven (27 %) cases the test was wrong. Twenty-seven (87 %) of ambulatory patients were contacted by phone. Eleven (41 %) of these said they were not aware of the potential disease severity. Patients initially treated in ambulatory care and later hospitalized because of their evolution have either insisted to go back home or have been sent home because there was not enough room in the hospital. Hospitalization for at least 24 hours had been indicated for 83 patients (72 %). Twelve patients (10 %) have presented with symptoms of severe malaria. Atovaquone–proguanil was the main therapeutic regimen for inpatients and outpatients (n = 93, 81 %). Twelve (10 %) patients did not undergo follow-up parasitological assessment, 10 ambulatory patients (32 %) and two hospitalized patients (2 %).

Conclusion

An efficient hospital-community network and recent protocols are the best tools to rapidly refer patients to an adapted structure with available trained staff and referent specialist.     

Traitements antifongiques des candidémies chez les patients non neutropéniques : évaluation des pratiques en réanimation

Objective

The authors had for objective to assess systemic antifungal treatment for candidemia in non-neutropenic patients, in intensive care units (ICU), and compare the results with French 2004 recommendations.

Study design

A retrospective multicenter study (nine ICU in two teaching hospitals) was made.

Patients and method

Thirty-eight non-neutropenic patients with at least one positive blood culture for Candida who had received systemic antifungal treatment were included between May 2004 and September 2007.

Results

Thirty-nine cases of candidemia were analyzed. The median age was 54.5 (21–80), the median SAPS II score at admission was 44 (20–79), the median duration of stay in ICU was 22.5 days (2–82), and the death rate was 45%. Candida albicans was identified in 69% of the cases. Eight percent of Candida sp. isolates were resistant or susceptible dose-dependent (S-DD) to fluconazole. Before identification, fluconazole, caspofungin, voriconazole, and amphotericin B were used in 74%, 15%, 5%, and 5% of cases respectively. After identification and antifungal susceptibility determination, fluconazole was used in 68% of cases, caspofungin in 24% of cases, any formulation of amphotericin B in 6% of cases, voriconazole in 3% of cases. The French recommendations were applied in 71% of cases before identification and in 68% of cases after identification and antifungal susceptibility determination.

Conclusion

The main causes of non-compliance to recommendations were the use of fluconazole in patients previously exposed to azole agents, the use of caspofungin in hemodynamically unstable patients, and the absence of therapeutic desescalade.     

Acceptation de la vaccination antigrippale par les soignants au sein d’une institution gériatrique et médicosociale

Introduction

Seasonal influenza is a viral transmissible infectious disease causing increased morbidity or mortality in frail subjects, especially those living in institutions. Measures to prevent the impact of infectious diseases were proposed based on the use of influenza vaccination among health-care professionals. We wanted to evaluate the acceptance of our institutional vaccination procedure initiated in 2005 and possible improvement.

Methods

A questionnaire was sent in May 2007 to all health-care professionals (n = 730) to identify their current vaccine status in 2006 and their opinion concerning vaccination against influenza in 2007.

Results

Subsequently, 369 (50.2%) responses were obtained. Amongst those responding, 31.7% were vaccinated in 2006, 77.8% using the institutional procedure. Also, 221 (87.7%) nonvaccinated health-care professionals indicated their position concerning influenza vaccination: 37% of them would accept the vaccination in 2007 (on the condition that our current institutional procedure be improved), 63% of them would refuse influenza vaccines in spite of any improvement.

Conclusion

Our study emphasizes that the use of an adapted procedure for influenza vaccination among health-care professionals could improve vaccine coverage. It also emphasizes that a margin of those professionals are still reluctant to vaccination.     

Prophylaxie antirétrovirale après expositions non professionnelles au VIH à Abidjan (Cote d’Ivoire)

Objective

The aim of this study was to assess the tolerability and adherence to all non-occupational post-exposure prophylaxis (PEP) for cases of HIV exposure in Abidjan.

Method

We retrospectively studied all post-exposure prophylaxis for non-occupational exposures to HIV prescribed from January 1st, 2000 to December 31st, 2007 in the Abidjan infectious diseases department. We analyzed the types of exposure, socio-demographic characteristics of patients, antiretroviral therapy regimens, adherence and tolerability, duration of the treatment, and post-exposure follow-up.

Results

Over these eight years, we managed 128 consultations for non-professional exposures to HIV (50 male [39 %], 78 female patients [61 %]), average age 24.8 years (four–54 years). The most frequent exposures were due to rape (n = 74), condom rupture (n = 29), and occasional unprotected sex (n = 21). The average delay before consultation was 20.8 hours. The antiretroviral chemoprophylaxis included a protease inhibitor in 93 % of the cases; 80.5 % of patients completed 28 days of chemoprophylaxis, while 8.6 % interrupted the treatment, and 10.9 % were lost to follow-up. The most frequent adverse effects were gastrointestinal, reported by 79 patients (61.7 %). Only 34 patients (26.6 %) returned for clinical and biological post-exposure follow-up with HIV control at third month, without documented seroconversion.

Conclusion

Cases of sexual exposure to HIV are the main indication for post-exposure prophylaxis in Abidjan, except for occupational exposure to blood. However, post-exposure prophylaxis should be available in the units of primary care, such as emergencies departments.     

Impact of 10-valent pneumococcal non-typeable Haemophilus influenzae protein D conjugate vaccine (PHiD-CV) on childhood pneumonia hospitalizations in Brazil two years after introduction

Introduction

Pneumococcal disease is a major public health problem worldwide. From March to September of 2010, 10-valent pneumococcal non-typeable Haemophilus influenzae protein conjugate vaccine (PHiD-CV) was introduced in the Brazilian childhood National Immunization Program (NIP) in all 27 Brazilian states. The aim of the present study is to report national time-trends in incidence of hospital admissions for childhood pneumonia in Brazil before and after two years of introduction of this new pneumococcal conjugate vaccine.

Methods

Analysis of hospitalization data of children aged 0–4 years in Brazilian public health system with an admission diagnosis of pneumonia from 2002 to 2012 was performed comparing pre (2002–2009) and post-vaccination periods (2011–2012). Hospital number of admission due to pneumonia and all non-respiratory diseases were obtained from DATASUS, the Brazilian government open-access public health database system. Incidence of pneumonia hospitalization was compared to incidence of all non-respiratory admissions.

Results

Admission rates for pneumonia decreased steadily from 2010 to 2012. In children aged less than four years, incidence of pneumonia hospitalizations decreased 12.65% when pre (2002–2009) and post-vaccination introduction periods (2011–2012) were compared and adjusted for seasonality and secular-trend (p < 0.001). On the other hand, non-respiratory admission rates remained stable comparing both periods (p = 0.39).

Conclusion

Childhood pneumonia hospitalization rates were fluctuating prior to 2010 and decreased significantly in the two years after PHiD-CV introduction. Conversely, rate of non-respiratory admissions has shown no decrease. These data are an evidence of the effectiveness and public health impact of this new pneumococcal vaccine.     

Differential association between adherence to nutritional recommendations and body weight status across educational levels: a cross-sectional study

Objective

The impact of diet quality and physical activity (PA) on weight might be different according to socioeconomic status. Our aim was to estimate associations between adherence to nutritional guidelines and BMI and the interaction with socioeconomic characteristics.

Methods

A total of 11,931 men and 39,737 women from the NutriNet-Santé cohort (France, 2009–2012) were included in this cross-sectional analysis. The association between PNNS-GS (a score estimating adherence to French nutritional guidelines) and BMI was assessed by multivariate linear regression. A modified score (mPNNS-GS) separating diet quality from PA was also used.

Results

BMI, overweight and obesity displayed an inverse gradient from less to more educated groups, whereas PNNS-GS increased. A higher PNNS-GS was associated with a lower BMI, more importantly in the less educated: BMI decrease ranged from − 1.1% in less educated to − 0.7% in more educated men and from − 0.6% to − 0.3% in women. The effect of mPNNS-GS and PA in particular was also stronger among less educated subjects.

Conclusion

Overall, better adherence to nutritional recommendations was inversely associated with BMI, and this association was stronger in the less educated groups. This suggests that nutritional policies should still concentrate on promoting access to a healthier diet and PA, especially among less educated individuals.     

Actualités épidémiologiques de la leishmaniose viscérale en Tunisie

Objective

Visceral leishmaniasis is an important health problem in Tunisia. The aim of this study was to update the epidemiological and clinical features of the disease.

Design

We performed a retrospective systematic sampling of epidemiological and clinical data collected from the medical records of 1,096 cases of visceral leishmaniasis diagnosed between 1996 and 2006 all over the country.

Results

The mean annual incidence of cases was 99.6 cases/year. The mean annual incidence rate was 1.04 cases/100,000 inhabitants, showing an important increase compared to former studies. As expected, children under 5 years (866 cases) were the most affected with a mean annual incidence rate of 9.6 cases/100,000 (p < 0.001). The geographical distribution of cases revealed the spreading of the disease from the Northern parts of the country to the Central and even to Southern ones. Rural cases (65.3%) were significantly more numerous than urban ones (34.7%), p < 0.001. The sex ratio was 1.03. The diagnostic delay (average of 54 days) was considerably shortened during the study period compared to previous reports, and explains the decrease of the lethality rate (2.9%).

Conclusions

Visceral leishmaniasis has been present in central Tunisia since the early 1990s. Its incidence and the distribution area have increased. This evolution is probably linked to the development of irrigation and agriculture favorable to the multiplication of vector sandflies and dogs reservoirs of Leishmania infantum.     

Tétanos néonatal et de la femme en âge de procréer à la clinique des maladies infectieuses de Dakar

Objectives

This study had for aim to describe and compare the epidemiological, clinical and outcome features of tetanus in neonates (NT) and women of child bearing age (WCBAT) in Dakar.

Patients and method

This retrospective study was made on NT (3 to 28 days of age) and WCBAT (15 to 49 years of age) patient files, admitted in the Fann University Hospital Infectious Diseases Clinic from 2000 to 2007.

Results

One hundred and thirty-eight WCBAT (11.9%) and 103 NT (8.9%), for a total of 1156 cases of tetanus were admitted. A decrease of the annual rate of these populations was noted over this 8 year period.The majority (59.4%) of WCBAT was between 15 and 25 years of age and the mean age of NT was 9.3 days. Most of the patients in both groups came from suburban areas (78%). The tetanus immunization status was not updated for 92% of WCBAT. The most frequent portals of entry were cutaneous wounds for WCBAT (77.4%) and umbilical stumps for NT (85.4%). On admission, 64% of NT presented with severe tetanus (stage III on the Mollaret scale) compared to 11.6% for WCBAT. The death rate was significantly higher in NT (48.5%) than in WCBAT (26.8%); p = 0.0005.

Conclusion

To eliminate neonatal tetanus, the prognosis of which is worse in Dakar, an intensification of the large vaccination program is needed with supplementary vaccination campaigns including women of child bearing age in areas of risk.     

Analyse de l’exposition préalable aux anti-inflammatoires et aux antibiotiques d’une cohorte de 34 patients hospitalisés au CHU de Nantes pour phlegmon périamygdalien

Objective

The purpose of this study was to describe the characteristics of patients hospitalized for a peritonsillar abscess over a 1-year period and to evaluate the proportion of patients exposed to anti-inflammatory and antibiotic drugs before hospitalization.

Design

Adult patients hospitalized in the ENT department at the Nantes University Hospital were included in the study during 2006. Data related to prior use of anti-inflammatory and antibiotic drugs, microbiology and treatment was analyzed.

Results

Thirty-four patients were included in the study, 20 (59%) and 21 (62%) patients had been previously exposed to anti-inflammatory and antibiotic drugs, respectively. Half of the patients had received antibiotics despite the negativity of the rapid screening test. All diagnoses were made on pus examination after aspiration. Tonsillectomy was performed only in two cases. A total of 21 bacterial isolates (13 anaerobic and 9 aerobic) were identified. Single bacterial isolates were recovered in 8 infections. The most frequent bacteria were Streptococcus, Fusobacterium, and Prevotella.

Conclusions

Many patients were exposed to both anti-inflammatory and antibiotic drugs, which did not prevent the peritonsillar abscess.     

Co-administration of live measles and yellow fever vaccines and inactivated pentavalent vaccines is associated with increased mortality compared with measles and yellow fever vaccines only. An observational study from Guinea-Bissau

Background

Studies from low-income countries indicate that co-administration of inactivated diphtheria–tetanus–pertussis (DTP) vaccine and live attenuated measles vaccine (MV) is associated with increased mortality compared with receiving MV only. Pentavalent (DTP–H. Influenza type B–Hepatitis B) vaccine is replacing DTP in many low-income countries and yellow fever vaccine (YF) has been introduced to be given together with MV. Pentavalent and YF vaccines were introduced in Guinea-Bissau in 2008. We investigated whether co-administration of pentavalent vaccine with MV and yellow fever vaccine has similar negative effects.

Methods

In 2007–2011, we conducted a randomised placebo-controlled trial of vitamin A at routine vaccination contacts among children aged 6–23 months in urban and rural Guinea-Bissau. In the present study, we included 2331 children randomised to placebo who received live vaccines only (MV or MV + YF) or a combination of live and inactivated vaccines (MV + DTP or MV + YF + pentavalent). Mortality was compared in Cox proportional hazards models stratified for urban/rural enrolment adjusted for age and unevenly distributed baseline factors.

Results

While DTP was still used 685 children received MV only and 358 MV + DTP; following the change in programme, 940 received MV + YF only and 348 MV + YF + pentavalent. During 6 months of follow-up, the adjusted mortality rate ratio (MRR) for co-administered live and inactivated vaccines compared with live vaccines only was 3.24 (1.20–8.73). For MV + YF + pentavalent compared with MV + YF only, the adjusted MRR was 7.73 (1.79–33.4).

Conclusion

In line with previous studies of DTP, the present results indicate that pentavalent vaccine co-administered with MV and YF is associated with increased mortality.