Évolution de la résistance aux antibiotiques de 1997 à 2005 à la Réunion

Objective

The groupe hospitalier Sud Reunion (GHSR) is a 1130-bed hospital center, located on the Reunion Island, (Indian Ocean). We studied the profiles of antibiotic resistance in 2005, and compared those with previous data collected in 1997–1998, and with Metropolitan France and European data.

Material and methodology

All bacteriological strains isolated from diagnostic samples in 2005 were analyzed according to CA-SFM recommendations.

Results

Since 1997, the rates of resistance to enterobacteria (betalactam, aminoside, quinolone, trimethoprim-sulfamethoxazole), Pseudomonas aeruginosa (ticarcillin, amikacin, ciprofloxacin, fosfomycin), Acinetobacter baumanii (amikacin) has decreased significantly. The rate of methicillin-resistant Staphylococcus aureus (1997: 3.6 %, 2005: 13.4 %) has increased but less than in Metropolitan France. The rate of Streptococcuspneumonia with decreased susceptibility to penicillin has increased (1997: 25.5 %, 2005: 42.9 %), as for Haemophilusinfluenzae which present an important increase of betalactam resistance (1997: 15.5 %, 2005: 37.8 %).

Conclusion

By comparing our data to 1997 and Metropolitan French data, it seems that the GHSR has managed to protect its hospital-based microbial ecology. However, community germs showed increasing resistance, probably because of an increasing antibiotic pressure, but with resistance rates often inferior to Metropolitan French ones.     

Ertapénem intraveineux ou sous-cutané pour le traitement des infections urinaires à entérobactérie sécrétrice de BLSE

Introduction

Ertapenem could be used to treat urinary tract infections (UTI) caused by ESBL producing enterobacteriacae (ESBL-E) and administered subcutaneously.

Method

The authors made a retrospective study on adult patients treated with ertapenem administered intravenously or subcutaneously for UTI caused by ESBL-E, between May 2009 and August 2011 at the Chambery hospital, France.

Results

Twenty-five patients were treated (13 cases of prostatitis, ten of pyelonephritis, two of cystitis) mostly caused by Escherichia coli (24 cases). Subcutaneous injections were administered to 20 patients and 23 were treated through outpatient parenteral antibiotic therapy (OPAT). All patients were cured at the end of the ertapenem therapy. Urine samples collected during treatment for 12 patients were sterile. Three months after the end of the treatment, five patients had relapsed, and six had developed a UTI caused by another bacteria.

Conclusion

Ertapenem administered intravenously or subcutaneously could be an effective treatment for UTI caused by ESBL-E, especially using OPAT.     

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.     

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.     

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.     

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.     

Sensibilité aux antibiotiques des souches de Staphylocoques aureus isolées dans deux hôpitaux universitaires à Rabat,Maroc

Objectives

The aim of this study was to assess the in vitro activity of several antimicrobial agents against Staphylococcus aureus (S. aureus).

Method

This 2 year study was made in two Moroccan teaching hospitals. Four hundred and sixty-one non-repetitive clinical S. aureus strains were isolated and collected from various samples collected in several units between March 2006 and March 2008.The susceptibility of strains was determined by the agar disk diffusion method.

Results

The rate of methicillin resistance was 19.3% for S. aureus isolates. 53.93% of S. aureus strains were resistant to gentamycin, and all strains were susceptible to glycopeptides.

Conclusion

The rate of MRSA was high. Resistance to methicillin is often associated with resistance to gentamycin and fluoroquinolones. Vancomycin and teicoplanin were still effective on S. aureus in the two university hospitals.     

Défaut de couverture vaccinale pneumococcique chez l’adulte à risque

Objective

This study had for aim to assess pneumococcal vaccination rates in hospitalized patients.

Design

A prospective study was carried out in two medical wards of the Nice University Hospital, France. Patients were included from December 31, 2007 to February 12, 2008.

Results

Hundred and thirty-seven patients, aged 62 ± 20 years, were included. Pneumococcal vaccination was indicated for 62 patients (45 %). Among these 62 patients, 53 (85 %) had not been vaccinated in the previous 5 years, for the following reasons: no medical advice on vaccination (36 cases), no medical consultation in the past years (nine cases), patient opposed to vaccination (two cases), physician opposed to vaccination (one case), miscellaneous (five cases). Among the 53 patients, seven were vaccinated during their hospital stay and 13 were advised to be vaccinated by their general practitioner.

Conclusions

This study highlights a low rate of pneumococcal vaccination in hospitalized patients, mainly due to insufficient counseling from physicians, both in community or in hospital practice.     

Étude de la résistance des souches d’Escherichia coli isolées dans les urines aux fluoroquinolones et aux céphalosporines de troisième génération

Objectives

This study had for objective to assess the frequency of resistance to fluoroquinolones and to third generation cephalosporin in E. coli isolated from urines of consulting and hospitalized patients and to detect the rate of multiresistant E. coli strains.

Design

A retrospective survey was made over 3 years (1^st January 2005 to 31^st December 2007). Eight hundred and nineteen patients presented with UTI confirmed in the Rabat Cheikh Zayd Teaching Hospital.

Results

E. coli was the etiologic agent in 57% of reported UTI. The frequency of E. coli resistance to fluoroquinolones was 27% with a higher rate among hospitalized patients. We found that ten E. coli strains were producing extended-spectrum β-lactamase and resistant to aminosides and fluoroquinolones.

Conclusions

The resistance of E. coli to fluoroquinolones is becoming worrying among consulting and hospitalized patients. Ten strains multiresistant to fluoroquinolones and third generation cephalosporins, probably because of plasmids, were isolated. This increasingly frequent resistance mechanism should lead to a more careful use of first line fluoroquinolones for UTI.     

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.     

Leptospirosis in Franche-Comté (FRANCE): Clinical,biological, and therapeutic data

Objectives and method

We report the patient data in 77 cases of leptospirosis confirmed by PCR and/or serology (micro-agglutination), observed between 1994 and 2008 at the Besançon teaching hospital. Our aim was to compare the epidemiological, clinical, biological, and therapeutic characteristics of leptospirosis in the Franche-Comté region, to those reported in other regions.

Results

The median age was 42 years and 95% were male patients. Leptospirosis acquisition was likely related to aquatic leisure activities (50.6%), professional exposure (28.6%), building maintenance works (11.7%), or unknown (9.1%). Forty-eight cases were uncomplicated and 29 were severe presentations of leptospirosis. Among severe cases, eight patients had to be managed in an intensive care unit, and one patient died. L. grippotyphosa and L. icterohaemorrhagiae were the main serogroups involved. Age above 50 years and serogroup L. icterohaemorrhagiae were positively associated with clinical severity. The outcome was favorable for 15 patients treated with ceftriaxone for less than 7 days.

Conclusions

We recommended conducting clinical trials aiming at validating short courses of ceftriaxone to treat leptospirosis.     

Opinions et pratiques des médecins généralistes face à la vaccination anti-Papillomavirus

Aims

The purpose of this study was to assess the standpoint of family physicians in the Southern French region Provence-Alpes-Cote d’Azur concerning human Papillomavirus vaccination and to evaluate the factors associated with a favorable standpoint.

Methodology

A questionnaire was sent to a random sample of 1,000 family physicians. The survey focused on their profile, their views on vaccination generally and on HPV vaccination, their knowledge of HPV, their standpoint concerning STD prevention and cervical cancer screening. Multivariable linear regression system was used to study the variations associated with a favorable response to HPV vaccination.

Outcome

Response was 36.6%. The responses were analyzed taking into account gender of the family physicians, location and size of their practice. There was reasonable similarity amongst those questioned. Around 89.6% of family physicians answers were in favor of HPV. The ideal age for vaccination was between 11 and 13 years of age for 34.4% and between 14 and 15 for 53.9%. The family physicians most in favor of vaccination were those involved in screening for STDs, those who did not think that the vaccine would have a negative effect on the image of sexuality and on screening for cervical cancer, and those who were confident about the vaccine safety.

Conclusion

The study identified the negative elements concerning HPV in order to optimize information strategies among family physicians.     

Érythème noueux unilatéral associé à une leishmaniose cutanée homolatérale

Objective

The authors wanted to report an uncommon etiology of erythema nodosum.

Case report

A 45-year-old woman presented with numerous encrusted nodular lesions on the left leg and arm. Leishmania was identified after a parasitological examination. Subcutaneous erythematous nodules developed later on the same leg. Erythema nodosum was diagnosed with a biopsy of the nodules. The patient was treated with systemic meglumine 60 mg/kg per day for 13 days. All lesions improved under treatment.

Discussion

This was the first reported case of unilateral erythema nodosum with cutaneous leishmaniasis. Clinical and laboratory exams were in the range of normal and led the authors to exclude common causes of erythema nodosum. Subcutaneous nodules occurred before the beginning of treatment with meglumine. Thus, drug allergy (previously reported) was excluded as an etiology of EN.     

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.     

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.     

Défaillance multiviscérale et infection disséminée à adénovirus

Background

Peripheral blood stem cell transplantation is a frequent option, especially for patients with hematological malignancies.

Case reports

A first patient received this treatment for acute myeloblastic leukemia, the second for Richter's syndrome (follicular lymphoma). In both cases, allograft (unrelated donor, non myeloablative conditioning) was followed by graft versus host disease (GVH) requiring an immunosuppressive treatment. Respectively 15 and three months after graft, these two patients presented with multiple organ failure including very severe hepatic dysfunction. The diagnosis was made according to positive blood PCR, positive BAL, and hepatic histological findings.

Discussion

Adenoviruses, frequent in pediatrics, can be responsible for extremely severe infections among immunocompromised adults. T lymphocyte depletion plays a key role.

Conclusion

Adenoviral infections can be fatal among immunocompromised patients. Diagnostic improvement should lead to early treatment, which however, remains to be clearly defined.     

Évaluation de la préparation à une pandémie grippale par un exercice de terrain au centre hospitalier universitaire de Nîmes

Objective

The objective was to test the application of barrier precautions and hospital organization during an influenza pandemic, in accordance with the national program of influenza pandemic training and the “Influenza addendum” of the hospital guidelines in case of a major disaster.

Method

A practical exercise was performed on December 18th 2007 in two areas of high viral density and one of low viral density. This exercise involved all the people in these areas, without disturbing the normal care activity.

Results

Two hundred and forty-five people were evaluated. Seventy-five per cent of whom had been trained in the hospital. Hand hygiene complied with pre-established procedures in 32% of cases, was acceptable in 44%, and deficient in 24%. Surgical mask application was unacceptable in 21% of cases. These precautions were well accepted by 36% of the personnel, accepted by 54%, and a burden for 10%.The poor sealing capacity of mask FFP2 (national allocation), depending on facial features, its poor tolerance, the lack of water stations, and the presence of groups of people were all noted.

Conclusion

This exercise was rated as satisfactory with a good participation. However, it revealed unexpected dysfunctions such as application of barrier precautions. Also, that the FFP2 mask was not suitable for all people, especially for children, a problem in case of a pandemic. Finally, this exercise should lead to corrective actions and to completing the various training sessions initiated in other institutions.