Épidémiologie bactérienne,réalité de la surinfection bactérienne au cours de la bronchite aiguë de l'adulte sans pathologie respiratoire préexistante

The diagnostic of lower respiratory tract infections is still as difficult as in 1991, year of the previous consensus conference. Viral etiology remains dominant in acute bronchitis, especially rhinovirus. Among bacteria, only the implication of Mycoplasma pneumoniae and Chlamydia pneumoniae has been demonstrated in this disease, with incidence varying according to geographical localization, age of patients, and epidemics. Rare observations of pneumonia following viral infection may account for a possible bacterial superinfection. The scarcity of documentation may be explained by methodological problems or just because superinfection is so rare.     

Traiter ou ne pas traiter une bronchite aiguë de l'adulte sans pathologie respiratoire préexistante – apport des traitements de durée raccourcie – étude des comparaisons de coûts

Acute bronchitis in healthy adults is one of the most common affections but, paradoxically, one of the less well dealt with. Its cost is far from negligeable. Most acute bronchites are of viral origin, nevertheless they are still treated by antibiotherapy. A review of recent publications on double blind studies, against placebo, underlines the fact that the interest of antibiotherapy is not formally demonstrated on the lenth of bronchitis, nor on the occurence of complications. Neither new molecules, nor beta-lactamines are mentioned in these studies. No trial including fluoroquinolones was found. Work leave is not significantly modified by the prescripiton of an antibiotherapy. These studies do not allow to target a sub-group able to successfully benefit from an antibiotherapy for this indication. No data from literature justifies using nonsteroidal anti-inflammatory drugs and corticosteroids per os or IV during acute bronchitis.     

Stratégies de prise en charge non antibiotique des poussées de bronchite aiguë sur bronchite chronique en dehors de l'insuffisance respiratoire (bronchite non obstructive – bronchite obstructive)

Currently, antibiotherapy is not the only therapeutic answer for COPD exacerbation. Since the French guidelines issued by the Lung Society (SPLF), many other publications reviewed in this paper (Medline Search) have contributed to clarify the place of other drugs such as bronchodilators, corticosteroids, mucoregulators, etc. The role of non-infectious factors which must be identified and treated at the same time as smoking weaning are also specified. The decision for hospitalization or for ambulatory tretment is made according to the gravity of exacerbation. Finally, the management of exacerbation of chronic bronchitis without respiratory insufficiency is presented by graphics and decisional trees, as implemented by the SPLF guidelines in line with French medical habits.     

Pristinamycine versus cefuroxime-axetil dans le traitement de la sinusite aiguë de l'adulte

In a placebo-controlled, double-blind, multicenter study, 308 patients aged from 18 to 88 years with clinical evidence of acute sinusitis lasting less than ten days and defined by the presence of pus in the middle meatus on rhinoscopy and sinus pain were randomly assigned to receive eight days of treatment with pristinamycin 1 g twice daily (n=160) or cefuroxime axetil 250 mg twice daily (n=148). Patients were assessed for both clinical and bacteriological responses at the baseline visit (V1), once during treatment V2 (3 to 5 days), at the end of treatment V3 (10 to 12 days) and at the follow-up visit V4 three to four weeks after the end of treatment. A sinus X-ray was taken at baseline and at the final visit. For evaluable patients, the clinical success rate at the end of treatment (V3) was 83.9% (125/149) in patients treated with pristinamycin and 87.2% (123/141) in patients treated with cefuroxime axetil (95% CI: ]−∞,10.12%]). At the follow-up visit (V4), clinical success (primary endpoint) was observed in 72.6% (106/146) of patients in the pristinamycin group and 75% (105/140) of those in the cefuroxime axetil group (95% CI: ]−∞,10.95%]). The efficacy of pristinamycin in acute sinusitis was equivalent to that of cefuroxime axetil in the two populations (Intention to treat-ITT-, Evaluable Population-EP-) and in both evaluation periods (V3, V4). Eleven patients in the pristinamycin group and 2 in the cefuroxime axetil group discontinued treatment prematurely due to adverse events (p=0.02). Serious adverse event were reported in three patients in the cefuroxime-axetil group and none in the pristinamycin group. In conclusion, these results confirm the value of pristinamycin as first-line treatment in acute sinusitis in adults.     

Actualité de la prise en charge de l’infarctus mésentérique à la phase aiguë

Intestinal ischemic injuries are the result of an inadequate blood supply to the gastrointestinal tract, secondary to arterial or venous origin. Venous intestinal ischemic injuries are mainly caused by thrombosis or compression. Arterial inadequate perfusion states are more frequent and related, in occlusive intestinal ischemic injuries, to thrombosis, atheroma, cardiac embole, vasculitis, dissection, extrinsic compression or trauma, whereas non occlusive ischemia are secondary to systemic or regional low flow states or vasoconstriction. Cute and chronic intestinal ischemic injuries have different clinical presentations and necessitate dedicated multimodal treatments. One should distinguish early forms of acute intestinal ischemic injuries, potentially reversible without resection and late intestinal ischemic injuries, associated with intestinal necrosis and with a poor prognosis and high mortality without treatment. Clinical and biological signs are unspecific, explaining why diagnostic of acute intestinal ischemic injuries is frequently delayed. The therapeutic strategy should focus on intestinal viability with triple goals : avoid general worsening with introduction of multimodal medical “anti-ischemic” treatment, preserve non-ischemic bowel by revascularization and resect all non viable bowel. This multimodal and multidisciplinary management involves gastroenterologists, radiologists, cardiologists, anesthesiologists, intensivists and vascular and digestive surgeons. Diagnosis of chronic mesenteric ischemia is fundamental because of the risk of acute evolution and life-threatening malnutrition. The improvement of the management of this life-threatening condition need the creation of dedicated intestinal stroke centers each time possible.     

Sinusites maxillaires aiguës bactériennes de l'adulte : comparaison d'une durée de traitement de cinq jours versus dix jours par céfuroxime axetil

Objective – The aim of this double blind, randomized, multicenter study carried out by 78 ENT specialists was to demonstrate that the two regimens (five days versus ten days) of cefuroxime axetil 250 mg twice daily present the same clinical efficacy in adults with acute maxillary sinusitis.Patients and methods – Diagnosis of sinusitis was defined as at least two of the following symptoms (purulent rhinorrhea, nasal congestion, headache, facial pain), and radiologically confirmed by an expert committee. Clinical efficacy, defined as success (cure or improvement) or failure, was assessed at the end of treatment (days 12–14) and on follow-up (days 21–28). A total of 401 patients (206 for the five-day group, 195 for the ten-day group) were randomized between January 1997 and January 1998. All patients were assessed for safety analysis, Intent-to-Treat and Per-Protocol analysis.Results – The most commonly isolated pre-treatment pathogens were S. pneumoniae (n = 60), H. influenzae (n = 56), and M. catarrhalis (n = 22). At the end of treatment, clinical success rates were equivalent, with 85% (176/206) in the five-day group and 87% (169/195) in the ten-day group. The difference in success rates was −1.2% with a 90%CI: [−6.9%; 4.5%]. On follow-up, 51 patients experienced a clinical relapse : 25 and 26 patients in the in the five-day group and ten-day group respectively. Radiological success rate on follow-up was 68% in the five-day group and 67% in the ten-day group. Bacteriological success rate was 89% and 91% in the five-day group and ten-day group respectively at end of treatment; it was 83% and 78% in the five-day group and ten-day group respectively on follow-up. No unexpected adverse event was observed and both regimens were well tolerated.Conclusion – A five-day course of cefuroxime 250mg twice daily is as effective as a ten-day course in the treatment of acute bacterial sinusitis.     

Traitement antibiotique des pneumonies communautaires de l'adulte – apport des nouvelles molécules ; place des traitements de durée abrégée ; données pharmaco-économiques

There have been relatively few well-designed clinical trials comparing new antibiotics; mainly quinolones with enhanced in vitro activity against Streptococcus pneumoniae – and valid comparators. Quinolones are at least as efficient as comparators. But trials are of limited value in choice assistance for the empirical treatment of community-acquired pneumonia, since they are not stratified according to the severity of pneumonia and risk factors. The potential toxicity and ecological damage do jnot favor a large utilization of quinolones.     

La digestion des graisses : des aspects moléculaires à la pathologie

Obesity is a severe public health problem in industrialised as well in emergent countries. Considering that dietary fat, because of its high calorific value, plays an important role in the development of obesity, reduction of fat digestion through pancreatic lipase inhibition is now considered as a novel approach in obesity treatment. The isolated C-terminal domain of pancreatic lipase acting as a “protein lure” toward colipase offers a new way for inhibiting intestinal lipolysis by competing with lipase for colipase. In this respect, the C-terminal domain is a very specific inhibitor of pancreatic lipase, compared to the leading obesity drug, orlistat which inhibits the various lipases of the digestive tract. Administration of C-terminal domain to rats fed a high fat diet reduces diet-induced body weight gain and induces an amelioration of fatty liver. Therefore, the C-terminal domain is a strong candidate for an agent that impedes intestinal absorption of dietary fat by inhibiting specifically pancreatic lipase activity.     

Épidémies récurrentes de la dengue au Burkina Faso : préférences communautaires pour une intervention de prévention de la maladie

BackgroundCommunity-based interventions have proven effective in several Latin American countries in controlling dengue vector Aedes aegypti and reducing the burden of the disease. However, we did not find any study reporting the assessment or implementation of such interventions in Sub-Saharan Africa. This article presents local communities’ preferences for activities as part of the implementation of a community-based intervention for dengue prevention in Ouagadougou (Burkina Faso) where dengue epidemics are recurrent during the rainy season.MethodsA mixed-method study combining qualitative and quantitative data collection was conducted. Information from 983 households and their preferences for community-based activities for dengue prevention were collected in five neighborhoods of the city using a quantitative questionnaire. Then, 15 qualitative focus groups were organized in one of the neighborhoods that was randomly selected to receive a community-based intervention for dengue prevention. These groups were made up of 216 people representing the different socio-cultural categories: community leaders, men, women, young girls and boys.ResultsMore than 95% of household respondents to the quantitative questionnaire found community-based interventions acceptable and/or useful: to raise awareness of mosquito-borne disease transmission, to identify and remove the mosquito breeding sites and areas favorable to the development of the adult vectors. Most participants in the focus groups, preferred outreach activities such as video/debate sessions, school and home education sessions, focus groups. They also preferred the implementation of community working groups, responsible for identifying and eliminating mosquito breeding sites in the neighborhood. However, many participants had reservations about sending preventive text messages to residents. They found it feasible but not useful since most people cannot read.ConclusionThis study shows that it is important to get the local communities involved in the formulation of health prevention activities in sub-Saharan Africa where some interventions are often implemented using strategies from other continents.     

Traitement des exacerbations aiguës de bronchite chronique : efficacité et tolérance du céfuroxime axetil comparées à celles du cefpodoxime proxétil

A multicentre, randomised, open-label study was performed in 50 centres to demonstrate that the clinical efficacy of oral cefuroxime axetil 250 mg twice daily is equivalent to that of oral cefpodoxime proxetil 200 mg twice daily in a 10-day treatment of acute bacterial exacerbations of chronic bronchitis. Exacerbations were defined as sputum purulence and an increase in severity of at least two of the following symptoms: sputum volume, cough or dyspnea. Clinical efficacy, classified as success (cure or improvement) or failure, was assessed at the end of treatment (days 10–12) and at follow-up (days 30–40). A total of 268 patients (130 cefuroxime axetil, 138 cefpodoxime proxetil) were randomised between March and May 1999. All patients were assessed for safety analysis, Intent-To-Treat and Per-Protocol analysis. At the end of treatment, clinical success rates were equivalent with 95% (124/130) success in the cefuroxime axetil group and 92% (127/138) in the cefpodoxime proxetil group. At follow-up, equivalence was also demonstrated in the Intent-To-Treat analysis with clinical success rates of 94% and 91% for patients receiving cefuroxime axetil and cefpodoxime proxetil respectively. A secondary efficacy end point based on resolution of sputum purulence also provided equivalent success rates in both treatment groups (97% of patients treated with cefuroxime axetil and 96% of patients treated with cefpodoxime proxetil). A recurrence was observed for 2% of the cefuroxime axetil patients (2/130) and for 1% of cefpodoxime proxetil patients (1/138). Drug-related adverse events were reported in 2% of patients of cefuroxime axetil group (2/130) and 7% of patients of cefpodoxime proxetil (9/138). No unexpected side effect were observed. This study demonstrates that cefuroxime axetil 250 mg twice daily has an efficacy equivalent to cefpodoxime proxetil 200 mg twice daily in treatment of acute bacterial exacerbations of chronic bronchitis in adults. Both regimens were well tolerated.     

L'évolution de la résistance aux antibiotiques des bactéries impliquées dans les pneumonies aiguës communautaires

Micro-organisms such as Haemophilus influenzae and, above all, Streptococcus pneumoniae are often responsible for antibiotic resistance in acute community-acquired pneumopathies. Current resistance of H. influenzae to β-lactams is estimated at 35% of the strains and is steadily increasing. Its mechanisms are due to the production of β-lactamases, mainly TEM-1. Thus, the gold-standard treatment includes either a combination of amoxicillin with a β-lactamase inhibitor or an oral cephalosporin resistant to these enzymes. An other mechanism of resistance to β-lactams is due to the alteration of penicillin binding proteins (PBP) but its incidence is low (1–3%). Acquired resistance to other antimicrobial agents is still low, except for cotrimoxazole. In France, since 1987, S. pneumoniae has shown a dramatic increase of resistance to penicillin, resulting from two distinct mechanisms: clonal spreading of resistant strains and horizontal transfer of genes coding for altered PBP. In France, the current prevalence of penicillin-resistant S. pneumoniae (PRSP) is estimated at 48% of the strains, 58.5% of which exhibit MIC > 1 mg/L. For oral β-lactamins, amoxicillin has the lowest MICs against these resistant strains. For parenteral cephalosporins, cefotaxime, ceftriaxone, and imipenem are the most potent, and resistance to these antibiotics is rare in France. Most PRSP strains (75%) currently show multiresistance to other antibiotics, particularly to macrolides and cyclins. However, resistance to penicillin does not give therapeutic failures in clinical practice, since plasmatic concentrations largely exceed MICs of resistant germs. Therefore, penicillin G or amoxicillin are still promoted as first line therapies.