Antimicrobial stewardship policy: time to revisit the strategy?

Recent data indicate that both the overall numbers of antibiotic prescription and the frequency of multidrug-resistant bacteria are increasing significantly. These threatening features are observed, despite national antimicrobial stewardship (AMS) policies aimed at decreasing antibiotic use. AMS should also focus on the initial steps leading to antibiotic prescription. Physicians and their patients should benefit from the structured clinical pathways, the latter being adapted to regional epidemiological data and resources. Continuous evaluation of these predefined clinical paths through a computerized medical dashboard will allow a critical review and finally the optimization of medical practices. These innovative behavioural approaches for clinicians will supply precise information on the relationship among the diagnosis, therapeutics and outcome. This changing environment will carry out the adapted therapeutic procedures, and appropriate antibiotic use will inherently improve.

[Ambrosia pollinosis]. / Pollinoses dues aux ambroisies.

Pollinosis is now called seasonal allergic rhinitis by the international terminology but pollinosis includes many other symptoms and so we will use the term Ambrosia pollinosis in this article. The characteristics of ragweed pollinosis are: severity, duration from August to September and the presence of asthma and/or tracheitis in about 50% of cases. Ambrosia: phanerogam, dicotyledon, annual plant, monoic. In France, fields in the mid Rhône Valley are covered with Ambrosia artemisiifolia L. but Ambrosia trifida L. is rare. The French Foundation For Ragweed Study (AFEDA) reports here 30years of clinical and epidemiological studies, involving considerable expense, that describe the geographic distribution of this pollinosis in Europe, and applies a predictive model of Ambrosia pollination to an appropriate treatment thanks to a sensitive sensor (Cour pollen trap). The spreading of Ambrosia is partly due to the regulations of the Common Agricultural Policy. There are numerous allergens; recently the major allergen of mugwort has been identified in ragweed. Profilins cause hypersensitivity reactions to certain foods. Genetic predisposition to developing this pollinosis is discussed because sometimes: the disease starts late in life, no personal or family history of atopy is found, immunoglobulin levels are low. Some publications have discussed a genetic predisposition to allergies to Juniperus ashei (United-States) and Cryptomeria japonica (Japan). The clinical efficacy of sublingual specific immunotherapy is well established and well accepted by patients.

[Ambrosia, Franseria, Xanthium from the Bonaparte Herbarium]. / Ambrosia, Franseria, Xanthium de l'herbier Bonaparte.

Recently, French Association for Ragweed Study (AFEDA) founders published, in French, a book "Ambrosia, ragweed, biological pollutants". This association was founded in 1982. The authors referred to Bonaparte Herbarium set up in the Université Claude-Bernard Lyon 1. This herbarium is ranking second in France and seventh in the world. There were three aims for this work: to set up, for this herbarium, a complete list of different species of Ambrosia, Franseria and their pollen grains and to study with them Xanthium whose pollen grains look like Ambrosia, to establish a chronological order for Ambrosia that were collected in Europe and in some countries of the New World, to compare some pollen grains of Ambrosia and Xanthium (scanning electronic microscope). Good state plants in spite of about a century of conservation could be selected. They were photographied and some pollens so. The consultation of this herbarium brought a better morphological knowledge of different species of Ambrosia, Franseria and Xanthium, (plants and pollen grains). The authors were able to broadcast this knowledge to scientists and interested public through their book.

[Aeropalynological Surveillance Rhone-Alpes (ASRA: a new network of surveillance and information]. / Surveillance Aéropalynologique Rhône-Alpes (SARA): un nouveau réseau de surveillance et d'information.

The spread of ragweed in the Lyon region and Rhône valley has lead two associations regarding this problem: Association Française d'Etudes Des Ambroisies (AFEDA) and Groupement d'Allergologie et d'Immunologie Clinique du Rhône-Moyen (GAICRM) to join their competences and create a new group: Surveillance Aéropalynologique Rhône-Alpes (SARA). SARA manages six pollen traps in the Lyon area and central Rhône valley and has set up an original and effective information network.

[To be effective and not harmful, ragweed-trimming methods should be rigorous]. / Pour être efficaces et non nocives, les modalités de tonte de l'Ambroisie doivent être rigoureuses.

We decided to undertake the experiments dedicated to the height of Ragweed cutting. The experiment was focused on transplanted plants of Ragweed two months earlier to study the growth of male spikes. It took place near Lyon, on the second part of July 2000. We proved with the experiment that the number of male spikes produced is, to a significant extent, much more important when the height of cutting back is 10 cm instead of 5 cm. Moreover, to inhale or to be in contact with airborne matters because of Ragweed was at the origin of allergic symptoms for the author that was not atopic. It explains that Ragweed is a pollutant agent when inhaled in large quantities. Therefore, during the eradication campaign--last two weeks of July--it results better to cut back Ragweed close as possible to the ground. From spring to mid-July it is imperative not to abrade ground whereas after this period it is not really an essential point. Moreover, Ragweed has not enough grown to be cut with a mower or an edge so cutting back deals with other types of vegetal cover.

[Pollinosis and use of anti-allergic drugs: ragweed in the Rhone-Alpine region]. / Pollinose et consommation de médications antiallergiques: ambroisie dans la région Rhône-Alpes.

Ragweed pollinosis was first described in the middle Rhône valley in the early sixties. Prevalence has increased steadily since that time. The aim of the present study was to determine whether this phenomenon is perceptible in terms of anti-allergic drug sales (eye drops, nasal spray, oral antihistamines) and if so, to compare sales with those related to hay fever. For this purpose, monthly sales in July, August and September were compared between an area of high infestation, a control area and national data for France. The comparisons showed a steep rise in sales for all kinds of anti-allergic drugs related to ragweed pollens, the level being comparable with that observed for gaminaceae. Surprisingly we were unable to find this type of data in the literature despite the evident usefulness of an epidemiological and economical analysis of the progression of pollen allergy.

[Prevalence of ragweed hayfever in the south and east of the greater Lyon region in 1993]. / Prévalence de la pollinose à l'Ambroisie dans le Sud et l'Est de l'agglomération de Lyon en 1993.

In December 1993, AFEDA conducted an epidemiological survey in order to establish the prevalence of ragweed-induced pollinosis and to evaluate how well the public was informed about this danger. A survey by telephone was made, taking a random sample of the population drawn by lot from telephone directories in the Rhône district. This involved about 300,000 homes. Those in which at least one person was under 50 were questioned. The questionnaire included a section aimed at everyone, and another section aimed at homes where at least one person suffered from pollinosis in August and/or September, in Lyon. 1,800 homes were selected at random, 905 persons responded: 22.4% were off target, 77.6% matched up to the chosen target. Of these, 32.9% were aware of Ragweed and 31.9% knew of the dangers. The 702 homes targeted made a total of 2,060 persons, 59.6% of which live in town and 40.4% in suburban areas; 51.6% are women and 48.4% men. 53 people, i.e. 2.57%, presented at least one of the following symptoms in 1993: rhinitis 86.8%, conjunctivitis 69.8%, itching of the pharynx and/or ears 47.2%, tracheitis and/or asthma 41.5%. 77.4% received medication. In 1993, the prevalence of ragweed-induced symptoms is a certainty for 1.8% of the population, if we evaluate only those patients presenting these symptoms every year. This prevalence therefore does not take account of new cases nor of newcomers to the district. Moreover, we have probably under-estimated this prevalence, owing to the torrential rain that fell in Lyon in late August 1993. This made a break in the pollen curve, a phenomenon that has never yet been observed in 13 years of recording pollen calendars.

[The campaign against the spread of ragweed: the Quebec model]. / La lutte contre l'extension de l'Ambroisie: le modèle québécois.

In Canada, the "lesser flea grass" is a native species. Deposits of its pollen have been found to be over 60,000 years old, but it only started to spread on a large scale two centuries ago. The fight to eradicate ragweed began in 1937 when E. Campagna enlisted the help of school-children in Gaspesia to pull up the weed. Fifty years later, the effectiveness of this method is still visible. However, independent attempts made in Montreal in 1950 turned out to be insufficient. Later campaigns were first undertaken by the local councils, then by the Montreal Urban Community, and were later upheld by the Quebec Ministry for the Environment. Rulings by the latter have power of authority. They may take matters as far as prosecution. The decision-makers have financed pollen collectors, which are indispensable control measures. They have proved that the incidence of the disease was related to the quantity of pollen present and that the pollen index improved as more and more campaigns were implemented. G. Vincent has shown that weeding was the best method, but that mowing the weed at a height of 2 cm also good results, as long as this was done exclusively at the same time as in France, the second fortnight in July.

[New legislation from the Politique Agricole Commune passed in 1994 and its impact on the spread of ragweed. The public health laws are the responsibility of the mayor, the health department, the General Council and the State Council]. / La nouvelle législation de la Politique Agricole Commune actualisée en 1994 et son retentissement sur la diffusion de l'Ambrosia. Les règles d'hygiène communales sont la responsabilité du maire, du bureau d'hygiène, du Conseil Général et du Conseil d'Etat.

Until recently, Ragweed tended to thrive on untended land, but now it is spreading even on cultivated soils. The Common Agricultural Policy, which instituted the fallow system, initially contributed thereby to the increase of Ragweed. However, this same policy prescribes the minimum upkeep of fallow zones to prevent weeds from becoming rampant, especially those harmful to public health such as Ambrosia. There are a series of regulations, from Parliament level down to local government level, from prevention to repression, designed to safeguard public health and hence to combat the proliferation of Ragweed.

First report of anaphylactic reaction after fig (Ficus carica) ingestion.

We report an anaphylactic reaction which occurred very shortly after ingestion of a fresh fig. The IgE-dependent mechanism was demonstrated on the basis of positivity of the prick test performed with fresh fig (Ficus carica) extract. In addition, we were able to detect specific IgE to the same extract in the serum. The patient did not demonstrate sensitization to other common allergens involved in respiratory and food allergies. However, detection of specific IgE to F. benjamina indicated a sensitization to weeping fig. The CAP F. benjamina was partially inhibited by preincubation of the serum with fig extract, suggesting that these two species of Ficus share some common allergens. In this context, the assumption can be made that weeping fig was responsible for the initial sensitization in this patient.

Comparison of gramineae and ragweed pollen counts measured by Hirst's and Cour's traps.

The aim of this study is to appreciate what conclusions may be drawn from the comparison between two different methods for pollen count determination in clinical allergology. In Lyon (France), two pollen collectors are set up in two places separated by ten kilometers, as the crow flies. The Hirst-type trap is on the roof of the Pasteur Institute in the town; the Cour's trap (French Association for Ragweed Study), is located at the meteorological station in the country at the east of the town. In the Rhône-Alpes region, pollinosis is essentially due to Poacae and Ambrosia elatior. The weekly data have been recorded during three years. The results of the two categories of herbaceous plants are not comparable, except as regards the date at which the pollen season commenced. Graminae pollination (GP) commences between 20th April and 6th of May. Ragweed pollination (RP) accurately commences 5th and 6th of August! Differences in the fluctuations of peak concentrations of GP from one trap to the other can be imputed to the collectors, the site where these are located, the method used to process the data, the herbaceous weeds themselves. RPC (the dates of the peaks) are closer and more coherent. Lastly, in allergological practice, the Jacques Dechamp's rule, to only emply with the A.F.E.D.A. trap, is a hardy aid used to predict the week of the all-important peak pollen concentrations of G and R.

Purification and characterization of an allergen from celery immunochemically related to an allergen present in several other plant species. Identification as a profilin.

The purification of a 15 kD allergen from celery was obtained by a four step procedure. Evidence for at least two isoallergenic forms was obtained after analysis by two-dimensional-electrophoresis. A rabbit polyclonal antibody raised against this purified allergen allowed us to confirm our precedent results on the occurrence of allergenically and molecular mass-related components in celery and birch and mugwort pollens. In addition such components were also present in numerous other species like Cynodon dactylon, Sorghum halopense, Poa pratensis, Ambrosia elatior and in apple and carrot. The 15 kD allergen was identified as profilin by use of a specific rabbit polyclonal antibody that recognized a recombinant birch profilin. In addition, the purified celery allergen binds IgE from sera of patients allergic to birch profilin. These results reinforce the concept of profilin as a panallergen responsible in some patients for cross-allergic manifestations to various and unrelated species of grasses, weeds, trees, vegetables and fruits.

[Biological and clinical prevalence of pollinosis caused by ragweeds of the upper valley of the Rhône corridor]. / Prévalence biologique et clinique de la pollinose due aux ambroisies dans la vallée supérieure du couloir rhodanien.

An epidemiological study of ragweed allergy was conducted on 646 employees belonging to 6 factories located in the Rhone valley south of the city of Lyon. Information on seasonal evocative clinical symptoms was obtained through a self-administered questionnaire. Biological prevalence was assessed by measuring anti-ragweed IgE specific antibodies. Measurements were performed by immunoenzymatic assay (W1 Phadezym RAST from Pharmacia). 34 (5,4%) subjects had evocative symptoms whereas 37 (5,9%) had increased specific IgE. Persons with the highest IgE levels were symptomatic. Concordance between symptoms and biology was 35% (12/34). Results indicate that sensitization level varies according to the location of the factory and people's residence, the risk to become allergic being of 10% in the most exposed population. This data emphasize the need to promote anti-ragweed eradication policy.

[Ragweed pollen counts (P. Cour collection apparatus) from Lyon-Bron from 1982 to 1989: results, informing the public]. / Comptes polliniques d'Ambroisies (capteur de P. Cour) de Lyon-Bron de 1982 à 1989: résultats, information au public.

Lyon: Ragweed (R) Pollens (P) account for 6.26% of all P and caused 25% of all the pollinosis. The Lyon-Bron P counts (C) have been analysed and computerized by the CNRS in Montpellier since 1982. They are financed by the French association for ragweed study (AFEDA), with the support of the Conseil général du Rhône. Each year, doctors in the Rhône-Alpes Region receive the P calendar via a firm or pharmaceutical company which prints and distributes them. As from 1986, this information is also published by the Regional Meteorological Office at Lyon-Bron and is available on Minitel: 36-15 MTOLY ALLE. The availability of this data, in real terms, is of immediate use to patients and doctors alike. Observation has shown that peaks occurs on 5th or 6th W after onset according to the fact that the onset value of 0.1 Gr/m3 W doubles or not during the following W; that once a threshold of 5 grains (Gr) per m3 is attained, the number of Gr is greater than 100.3 weeks (W) later. This tends to be the W of peak intensity, except in 1987. This peak occurs form the 35th to the 38th W. The linear regression, calculated on a basis of average P values during the 13 W of the P season, W 31 to W 43, is y = 0.1142x + 42.7911. One may provisionally conclude, in view of the straight gradient, that in spite of the spread of R over a wider geographical area, the average quantity of R Gr per m3 of air has not increased in Lyon since 1982.(ABSTRACT TRUNCATED AT 250 WORDS)

A study of allergens in celery with cross-sensitivity to mugwort and birch pollens.

Sixty-one sera with positive RAST to mugwort pollen (Artemisiae vulgaris) were submitted to RASTs for birch pollen (Betula verrucosa) and celery (Apium graveolens). In 36 cases RAST results were positive for celery. In addition, 23 sera presented specific IgE to birch pollen. The binding of specific IgE to individual allergens in celery, mugwort pollen and birch pollen was studied by the immunoblotting technique. This involved electrophoretic separation of allergenic extracts, electrotransfer of proteins onto nitrocellulose sheets and sensitive immunoenzymatic detection. Eighteen sera had specific IgE binding to two celery components of molecular weight around 15 kD. All these sera also detected a 15 kD allergen in mugwort and two allergens in birch of 14 kD and 16 kD molecular weight. The sera that did not detect the 15 kD bands in celery failed to react with both the 15 kD mugwort component and the 14 and 16 kD birch components. Specific cross-inhibitions of the detection of these allergens on immunoblots were obtained by pre-incubation of the sera with crude extract of the three species. These results strongly suggest that such allergens display some structural identity and that they could be at the origin of some cases of crossed hypersensitivity to celery, mugwort pollen and birch pollen.