Is there an association between prior anti-inflammatory drug exposure and occurrence of peritonsillar abscess (PTA)? A national multicenter prospective observational case-control study.

The aim of this study was to evaluate whether recent systemic anti-inflammatory agents (AIAs) exposure in patients with sore throat managed with or without antibiotic therapy influenced the risk of peritonsillar abscess (PTA). We conducted a multicenter case-control study in 13 French university hospitals in 2009-2012 comparing patients admitted with PTA to matched controls: patients with sore throat but without PTA who were followed up for 10 days after visiting their primary-care physician. In the multivariate stepwise logistic regression model comparing 120 cases with PTA to 143 controls, factors significantly associated with PTA were male gender (odds ratio [OR], 2.0; p = 0.03), smoking (OR, 2.0; p = 0.03), and prior self-medication with systemic AIAs (OR, 3.5; p = 0.01). Topical treatment was associated with significant protection against PTA (OR, 0.3; p < 0.001). In conclusion, self-medication with systemic AIAs appears to be an independent factor associated with the occurrence of PTA. This is an important message as non-steroidal AIAs access is favored by their over-counter availability in pharmacies. This finding must be interpreted with caution due to the study design and a prospective, randomized study is needed to substantiate these possible causal risk factors.

Peritonsillar abscess (PTA): clinical characteristics, microbiology, drug exposures and outcomes of a large multicenter cohort survey of 412 patients hospitalized in 13 French university hospitals.

The aim of this study was to describe the epidemiology of hospitalized patients with peritonsillar abscess (PTA). We conducted a multicenter survey in 13 French university hospitals in 2009-2012 describing 412 patients. Median age was 29 year (range, 2-84) and current smoking habit was reported by 177 (43 %) patients. Most of the patients (92 %) had consulted a physician for sore throat within 10 days before admission for PTA diagnosis. Additional symptoms such as visible tonsil abnormalities (83 %), tender cervical adenopathy (57 %) and fever ≥ 38.5 °C (53 %) were also reported. A total of 65 % patients (269/412) reported recent systemic anti-inflammatory agents (AIAs) exposure by medical prescription (70 %), self-medication (22 %), or both (8 %); 61 % and 27 % reported recent exposure to antibiotic and topical treatments for sore throat, respectively. Non-steroidal AIAs were used most often (45 %), particularly arylpropionic derivatives. A rapid diagnosis antigen test (RDT) for Streptococcus pyogenes was performed in 70 (17 %) patients and was positive in 17 (24 %), of whom 9 (53 %) were exposed to AIAs and 14 (82 %) to antibiotics. To treat PTA, antibiotic therapy was given to 392 (95 %) patients. Of 333 antibiotic prescriptions, amoxicillin-clavulanic acid and metronidazole were the most prescribed antibiotics (42 and 17 %, respectively). Surgical drainage of the abscess was performed in 119 (29 %) cases and tonsillectomy in 75 (18 %) cases. The clinical outcome was favorable during the hospital stay in 404 (98 %) patients. In conclusion, patients with sore throat are often exposed to AIAs before PTA diagnosis, and antibiotic prescription was not often based on the RDT positivity.

Prevalence of extended-spectrum beta-lactamase producing Escherichia coli in community-onset urinary tract infections in France in 2013.

OBJECTIVES: We sought to assess the importance of extended-spectrum beta-lactamase (ESBL) producing Enterobacteriaceae in urinary tract infections in outpatients in France. METHODS: Retrospective laboratory based survey analysing susceptibility patterns of Escherichia coli and Klebsiella pneumoniae isolates providing from urines collected from outpatients during three months in 2013. RESULTS: Four hundred and ninety-nine laboratories collected data on 51,643 E. coli and 3495 K. pneumoniae isolates. The overall proportion of ESBL-producing E. coli was 3.3%. The proportion was higher for males (4.8%) than for females (3.0%) and increased with age: 2% for patients <20 years to 5.4% for those aged >80 years. More than 95% of isolates we susceptible to cefixime, fosfomycin, and nitrofurantoin. In nursing homes, the ESBL-producing E. coli proportion was 12.1%. For K. pneumoniae, the proportion of ESBL-positive isolates was 6.6%, and this proportion increased with age. Data from 2010 collected from a subset of the network showed that the ESBL-producing E. coli proportion was 2.0%. CONCLUSION: ESBL-producing isolates were rather frequent in urines in French outpatients in 2013. Males and persons residing in nursing homes were at higher risk of ESBL-positive infection. Despite the increase in ESBL-positive isolates, the susceptibility to antibiotics used to treat cystitis remains high.

Three years of antibiotic consumption evaluation in French nursing homes.

OBJECTIVES: We had for aim to assess antibiotic consumption and to better understand their use in nursing homes so as to target messages on relevant practice procedures sent to prescribers. DESIGN: The MedQual network asked nursing homes with in-house pharmacies to participate in a retrospective collection of yearly antibiotic consumption data with an Excel(®) spread sheet according to the Health Ministry recommendations. RESULTS: Fifty-two nursing homes participated in 2011, 2012, and 74 in 2013, accounting for 10% of the Pays de la Loire region's nursing homes and 15% of beds. The medians of total antibiotic consumption in daily-defined dose for 1000 patient-days were respectively 39 (32.4-49.0), 39.3 (34.4-52.9), and 44.8 (33.6-55.4). There was no significant difference between 2011 and 2013. Penicillins (J01C) were the most commonly used class with a median of 25.7 [IQ 18.8; 33.8] in 2011 and 30.4 [IQ 23.6; 41.3] in 2013. Quinolones (J01M) were the second most commonly used class with a median of 4.6 [IQ 2.9; 5.9] in 2011 and 3.8 [IQ 2.3; 6.5] in 2013, followed by the other beta-lactams (J01D) with a median of 2.5 [IQ 1.7; 4.5] in 2011 and 2,8 [IQ 1.7; 3.8] in 2013. CONCLUSION: The monitoring of antibiotic consumption in nursing homes in the Pays de la Loire Region since 2011 has allowed identifying inappropriate use and helped improve practices. No increase of overall consumption was observed in nursing homes but the distribution according to antibiotic class changed. The current objective is to extend this monitoring and to send personalized messages to prescribers.

Epidemiology of third-generation cephalosporin-resistant community-acquired Enterobacteria isolated from elderly patients.

AIMS: This survey was made to study the epidemiology of multiresistant bacteria (MRB) in the French community, among elderly patients 65 years of age or more, carrying third-generation cephalosporin-resistant (3GC-resistant) Enterobacteriaceae, and the co-resistance of prescribed antibiotics. METHODS: The data was collected in 2009 in the West of France by MedQual, a network of 174 private laboratories. RESULTS: Two thousand one hundred and sixty strains of the 88,255 identified Enterobacteria strains were 3GC-resistant (2.4%) and 945 of these strains (41.8%) were isolated from elderly patients 65 years of age or more. Escherichia coli was the predominant 3GC-resistant strain (72.7%). 51.4% of the 945 patients in whom a 3GC-resistant strain was isolated produced an extended-spectrum ß-lactamase (ESBL). The main risk factors for infection with the 3GC-resistant strain were hospitalization and antibiotic treatment in the previous year (58.2 and 86.9%, respectively). Hospitalization during the previous year was more frequent among elderly patients who lived at home compared with those who lived in nursing homes (P<0.05). The production of ESBL, among the 945 patients who carried the 3GC-resistant strains, was similar among patients who lived at home compared with those who lived in nursing homes (51.4% versus 49.7%). CONCLUSION: Microbiologists should warn family physicians about MRB isolates with a specific antimicrobial resistance pattern (3GC-resistant, fluoroquinolone-resistant, etc.) to prescribe more effective medications.

A national network of infectious diseases experts.

OBJECTIVES: The aim of this study was to consider the implementation of a network of infectious diseases (ID) experts to optimize the antibiotic prescriptions of community and hospital practitioners. METHODS: An observational prospective study was conducted among ID experts in the Pays-de-la-Loire Region to evaluate the number of calls and to determine the practitioner's reasons for soliciting ID expertise. For each phone consultation, four criteria were recorded during 5 days: origin of the call (internal/external), kind of question (diagnostic/therapeutic) time spent for the advice provided, type of advice. RESULTS: A total of 386 phone consultations for 20 infectious disease specialists were recorded during the study period (5 days); 81% were internal to the hospital, 7.7% from another hospital, and 11.3% from private practice, 56.3% of the questions concerned a therapeutic strategy, 21% a diagnostic advice, and 22.6% concerned both diagnosis and therapy. Two third of the questions were answered within 10minutes. In 68.7% of cases, the ID specialist answered immediately, 19.8% of calls required following-up the patient, 6% led to refer the patient to an ID consultation, and 5.5% to hospitalization. CONCLUSION: The survey results stress the important need for such ID expertise, both in hospitals and in ambulatory medicine. Collaboration of ID specialists in a regional network would allow an easy and permanent access to antibiotic therapy advice for prescribers. This network would improve the quality and safety of care.

Susceptibility to the main antibiotics of Escherichia coli and Staphylococcus aureus strains identified in community acquired infections in France (MedQual, 2004-2007).

BACKGROUND: The aim of this study was to determine the susceptibility of bacterial strains identified in community-acquired infections. Surveillance was made by a network of 32 medical analysis laboratories in the five departments of the French Region "Pays de la Loire". METHODS: All Escherichia coli (E. coli) and Staphylococcus aureus (S. aureus) strains isolated in these laboratories over a 4-year period, from January 2004 to December 2007, were included in the investigation. RESULTS: Eighty-four thousand and twenty-nine strains were collected: 90.6% of E. coli and 9.4% of S. aureus. E. coli isolates were mainly isolated from urine (97.2%). S. aureus isolates were more frequently isolated from pus (42.30%), from urinary samples (19.53%), or genital tract samples (14.36%). This study confirms the worrying E. coli evolution of resistance to quinolones. Indeed, during the study period, ofloxacin or norfloxacin susceptibility decreased gradually and the susceptibility rate to ciprofloxacin decreased slightly during and after 2006 (94.01% in 2005; 92.81% in 2006, and 91.62% in 2007). One thousand four hundred and thirty-five methicillin-resistant S. aureus (MRSA) strains were isolated. We observed a decrease of resistance to oxacillin: 20.73% in 2004 and 16.65% in 2006 (p<0.01). In 2007, this resistance to oxacillin seemed to increase (18.26%). CONCLUSIONS: Our data confirms the serious need to monitor transmission of these strains between community and hospitals. A better knowledge of the epidemiological behavior of these BMR will contribute to better-adapted antibiotics strategies.

Who are the carriers of MRSA in the community? A prospective study in the Pays de la Loire region of France.

The aim of this study was to determine the demographic characteristics of methicillin-resistant Staphylococcus aureus (MRSA) carriers in the community, to assess their risk factors and possible past hospitalization history and to describe the different resistance phenotypes of community isolates of S. aureus. Data were collected over the course of 16 months (from June 2005 to September 2006) in the Pays de la Loire region of France by MedQual, a network of private biological analysis laboratories. This work was based solely on the analysis of strains isolated in the community as opposed to isolates from private facilities such as nursing homes or hospitals. The antimicrobial susceptibility results for a total of 313 MRSA isolates were included in this study. The isolates were most frequently recovered from skin and soft tissue infections (41.2%), urine (38.3%) and genital samples (8.3%). We distinguished 36 patients without classical risk factors (WRF), such as demographic individual medical, healthcare exposure, carried MRSA, from the other 277 patients with at least one risk factor (RF). WRF MRSA patients were younger than RF patients and an infection was more often found among WRF patients. MRSA strains isolated from RF patients were resistant to ofloxacin in 81.1% of cases, whereas only 50% of the MRSA strains isolated from WRF patients were resistant (p <0.001). Nine resistance phenotypes were observed among the 313 MRSA strains. MRSA resistance profiles in the community have evolved in recent years. Therefore, it is necessary to study the resistance phenotypes of the circulating strains in order to adapt therapeutic care in the community.

[Prior use of anti-inflammatory and antibiotic drugs in patients hospitalized for peritonsillar abscess]. / 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.

[Drug administration to paediatric inpatient]. / L'administration des médicaments à l'enfant hospitalisé.

OBJECTIVE: Available commercial drugs in France are often unsuitable for children. The aim of this study was, for every medicinal form orally or parenterally administered, to identify and to quantify difficulties met by the nurses administering drugs to paediatric inpatients and to propose solutions to main identified problems. MATERIAL AND METHOD: The study was realized in 14 hospitals by direct observation. The observer, provided with a questionnaire, followed during a time slot of at least 2 h for one or several nurses and raised all the oral or injectable administrations. RESULTS: One thousand and nine hundred forty-six observations were performed. The children were 12.6 +/- 17 months old, and weighed 8.5 +/- 9.4 kg. Injectable drugs: half of the observations showed a posology and a mode of dilution not corresponding to the summary of product characteristics. Eight percent of orally administered drugs were injectable drugs. In 35.5% of cases, administered amount was lower than the quarter of the present quantity in the therapeutic unity. The rest of the therapeutic unity was thrown (77.2% of cases). Liquid oral forms: liquid oral forms were ready for use regarding 83.8% of cases. The medicine was readministered to the same patient (23.5%), and/or administered to other patients (80.0%). Capsules: 66.9% of the administered capsules were prepared by the hospital pharmacies. The pharmacies organized with an unit dose drug dispensing system produced significantly more preparations than those working by global distribution (P < 0.0001). In 58.4% of cases, the administered capsule was an off-label drug. Tablets: 46% of drug administration concerned a tablet without pediatric indication. 46.7% of tablets were cut, 74% were crushed. Bags: in 35.2% of observations, the bag was not administered in its entirety. CONCLUSION: Our study confirms the unsuitability of drugs to paediatric inpatients, the necessity of recommendations of good practices in the administration of drugs to paediatric inpatients, and proposes corrective actions.

Minerals, trace elements and related biological variables in athletes and during physical activity.

This review concerns various minerals (sodium, potassium, calcium, magnesium, phosphorus), trace elements (zinc, manganese, selenium, copper, iron, cobalt, iodine, chromium, fluorine, lead, cadmium) and other biological variables (nitric oxide, L-carnitine, glutamine, serum transferrin receptor, biopyrrins) in relation to hemorheologic effects, stress, immune response and infections during physical and sports activities. In athletes, macroelements in the ionized form contribute to heart and muscle contractions, oxidative phosphorylation and the synthesis and activation of enzymatic systems. Zinc (Zn) protects against the effects of increased free reactive oxygen species such as copper (Cu) and manganese (Mn) (Cu-Zn superoxide dismutases; Mn superoxide dismutase). Selenium in glutathione peroxidase protects the cardiovascular system and the muscles, and helps combat allergic and inflammatory diseases. Copper and iron are involved in many aspects of energy metabolism and are important components in the synthesis of hemoglobin, myoglobin and cytochromes. Fluorine and Cu protect the ligaments and tendons. Physical activity appears to be beneficial to urban residents who are exposed to metal pollution (lead, cadmium). The data cited in this review are often contradictory and incomplete. It is still unclear in many cases how minerals are involved in physiological changes, and much work remains.

Natural Haemophilus influenzae type b capsular polysaccharide antibodies in 412 infants and children from West Africa (Burkina-Faso) and France: a cross-sectional serosurvey.

Prior to possible introduction of large-scale vaccination programmes, an estimation and comparison of naturally acquired immunity against Haemophilus influenzae type b (Hib) was carried out in two populations of age-stratified infants and children (from birth to 14 years old) in Burkina-Faso (West Africa) (n = 206) and France (n = 206). Hib capsular polysaccharide antibodies were detected by an ELISA method. The difference in the percentages of minimum protective levels for the two populations were not significant (0.15 microg/ml) for newborns (0-1 month) but became significant as early as 2 to 3 months of age (p < 0.01) when lower levels were found among infants from Burkina-Faso. Subsequently, the percentages in both countries remained low until 11 months of age and showed no significant differences. For children between 12 and 35 months, the results > or = 0.15 microg/ml were significantly higher in France (p < or = 0.05). From 36 months, the percentage of minimum seropositivity increased in Burkina-Faso, so that the difference was no longer significant. In each country, the percentage of children with the minimum protective level varied significantly (p < or = 0.05) according to age (0-47 months). None of the children from Burkina-Faso or France had antibody levels > 1.0 microg/ml before one year of age. Thereafter, only 9.51% of French children in the 12- to 17-month age stratum and 19.2% over 4 years of age had antibody levels > 1.0 microg/ml. There were no non-detectable results for children over 4 years of age, and the means for natural detectable Hib CP antibodies were > 0.15 microg/ml for both populations. Hib invasive infections depend on climate, socioeconomic status and ethnic and genetic factors. In Burkina-Faso, the large number of infants and children under 4 years of age susceptible to Hib infections suggests that large scale vaccination programmes are needed soon after birth. However, it would first be necessary to evaluate such factors as the frequency of Hib diseases in this population.

A multicentre serosurvey on diphtheria immunity in a French population of 1004 subjects.

Diphtheria immunity was determined in serum specimens obtained in 1994 from 1004 subjects seen in emergency departments of three distant French cities. An enzyme immunoassay was used to measure serum diphtheria antitoxin concentrations according to the following criteria: (a) antitoxin < 0.01 IU/ml: susceptibility, (b) 0.01-0.09 IU/ml: basic protection, (c) > or = 0.10 IU/ml: full protection. Among these patients, 20.3% were fully susceptible to diphtheria, 30.3% had basic but doubtful protection and only 49.4% were fully protected. Protection was different by age-groups: 73.5% of the subjects under 40 years of age, 46% between 40 and 65 and 33% over 65 were fully protected. Protection decreased with increasing age (p < 0.001)and was greater for men than women after 40 years of age (p < 0.001). The results of this exploratory study indicate that the enhancement of diphtheria immunity by boosters in adult population should be reconsidered in France as well as in many industrialized countries.

Stability of essential drugs in the field: results of a study conducted over a two-year period in Burkina Faso.

To evaluate the stability of essential drugs stored in realistic tropical conditions, we have carried out a two-year prospective study in western Burkina Faso. Twenty-seven essential drugs were stored in a rural site and a urban one where temperature and hygrometry were recorded daily. Samples of each drug were taken for further analysis to the World Health Organization Collaborative Center for the Study of Stability of Drugs in Nantes, France every three months. Quantitative analysis showed that the majority of samples suffered no significant loss of their active ingredient. In contrast, ampicillin, erythromycin, sulfaguanidine, injectable furosemide, penicillin G, trimethoprim, and chloroquine showed more than a 10% quantitative loss of their active ingredient. Thus, it is not recommended that these essential drugs be stored for more than one year in a tropical climate.

An overview of the clinical pharmacokinetics of x-ray contrast media.

Pharmacokinetic studies of contrast media are usually performed as preclinical trials in anaesthetised animals; however, results in humans have also been reported for this type of compounds. This paper reviews the existing data about x-ray contrast media in humans. In some cases, animal data are used in areas where no human data are available. The administration of contrast media is generally made via the intravenous, intra-arterial or intrathecal route. Diagnostic procedures are based on differential distribution to organs and between normal and abnormal tissue. Data are available for iodixanol, iohexol, iopamidol, iopromide, iothalamate and ioxaglate, but the kinetic distribution of all contrast media is similar. With the exception of biliary contrast agents, all compounds display limited plasma protein binding and do not undergo biotransformation. From the pharmacokinetic viewpoint, the main area of interest for these compounds is elimination. The majority of the data were obtained with iopamidol (of which 66 to 72% of the dose is excreted in the urine), iohexol, ioxaglate and iopromide. Some studies were performed in patients with renal impairment: in this case, metabolic clearance was abnormally elevated, suggesting the existence of significant compensatory factors such as hepatic metabolism, enterohepatic circulation and biliary elimination. New compounds, such as iodinated polymers for x-ray perfusion imaging and iopromide- or metrizamide-containing liposomes allowing liver enhancement are discussed.

[The return of diphtheria in Europe. Is the French population protected?]. / Le retour de la diphtérie en Europe. La population francaise est-elle protégée?

Following the generalized vaccination of children, the European countries achieved the elimination of diphtheria. However the huge epidemic which rages since 1990 in the New Independent States of ex-URSS, culminating in 1994-1995 (with respectively 47,802 and 50,412 notified cases), has showed that diphtheria could be still threatening. A serosurvey was carried out in France on 1,025 adult patients attending the emergency wards of three hospitals, located in different parts of this country. This study showed the insufficient immunity of adults, for lack of a routine programme for revaccination: only half of them have antibodies assuring their protection. The antitoxic immunity decreases according to age. This decline is more marked in women than in men, most of them being reimmunized during the military service. These data confirm the alarming results of similar serosurveys performed in others industrialized countries. The present risk of importing diphtheria in these countries requires a strengthening of clinical and bacteriological surveillance of all cases of infections attributable to C. diphtheriae, and could justify a revaccination programme for adult population, including a regular booster, at 10 year-interval, of a reduced dose of diphtheria toxoid (d), and/or using the combined toxoid Td in the wounded, instead of tetanus toxoid alone.

[Stability and antimicrobial effectiveness of Javel water in a tropical hospital environment]. / Stabilité et efficacité antimicrobienne de l'eau de Javel en milieu hospitalier tropical.

A sodium hypochlorite solution (NaClO) containing 0.5% w/v of available chlorine (0.5% Cl2 or 5000 ppm) is a good and cheap solution for disinfecting material used to medical care. It is effective against bacteria, fungi and viruses. It is easy to prepare. It can be a good solution for antisepsis and disinfection in dispensaries in developing countries. However, it is not always easy to keep it in adequate conditions. That's the reason why we have evaluated the durability of such a solution of NaClO exposed to disadvantageous factors, specially daylight and air, and its antibacterial effectiveness. In this study, after exposure of NaClO containing 4350 ppm of available chlorine to these adverse conditions, the final concentration of NaClO was 2300 ppm of available chlorine and was found effective for decontamination of medical material. A protocol for conservation and use of a sodium hypochlorite solution (0.5% Cl2) in dispensaries of developing countries is proposed.

Risk factor for neonatal tetanus in west Burkina Faso: a case control study.

A case-control study was carried out to identify risk factors for neonatal tetanus in rural Burkina Faso. Each of the 31 cases identified prospectively were matched with two controls. Risk factors such as the instrument used to cut the umbilical cord and the qualification of the midwives were only identified in the univariate analysis. The multifactorial analysis identified factors commonly believed to be associated with neonatal tetanus: lack of mother's immunization and place of birth other than maternity clinics. However, applying karite nut butter on the umbilical cord was found to be a strong independent factor associated with neonatal tetanus. Immunization of mothers against tetanus should be enforced. Health education must take into consideration sociocultural realities of these populations.