[Professional fatigue syndrome (burnout) : Part 2 : from therapeutic management]. / Syndrome de fatigue professionnelle (burnout) 2ème partie : de la prise en charge thérapeutique.

Burnout or professional fatigue syndrome is the result of exposure to a situation in which the strategies of the subject who are supposed to manage the stresses of the environment become outdated and inoperative. An imbalance is created between the demands and the material, operational and psychological resources to cope with them. Many health professions are confronted with the challenge of managing burnout, but the general practitioner is very often on the front line. After a first article devoted to the epidemiology, diagnosis, causes and consequences of the burnout, this second article is focusing on its therapeutic management, through listening, sick leave, dietary supplements, antidepressants, behavioural and cognitive therapy, professional coaching and multidisciplinary approach.

on disponible Résumé : Le burnout ou syndrome de fatigue professionnelle est le résultat de l'exposition à une situation durant laquelle les stratégies du sujet, qui sont censées gérer les stress de l'environnement, deviennent dépassées et inopérantes. Un déséquilibre se crée entre l'exigence des demandes et les ressources matérielles, opérationnelles et psychologiques pour y faire face. De nombreuses professions de santé se trouvent confrontées au défi de la prise en charge du burnout, dont le médecin généraliste. Après un premier article dédié à l'épidémiologie, au diagnostic, aux causes et aux conséquences du burnout, ce second article est consacré à la prise en charge de ce syndrome. Il se centre sur la prise en charge thérapeutique par l'écoute, l'interruption du temps de travail, les compléments alimentaires, les antidépresseurs, la thérapie comportementale et cognitive, le coaching professionnel et l'approche multidisciplinaire.

Clinical use of the meropenem-clavulanate combination for extensively drug-resistant tuberculosis.

Mycobacterium tuberculosis strains resistant to almost all available anti-tuberculosis drugs are an increasing threat to public health worldwide. Among existing drugs with potential antimycobacterial effects, the combination of meropenem with clavulanate has been shown to have potent in vitro bactericidal activity against extensively drug-resistant tuberculosis (XDR-TB). To explore its potential clinical efficacy, a meropenem-clavulanate-containing salvage regimen was started in six patients with severe pulmonary XDR-TB, in association with the only one or two remaining active second-line drugs. Encouraging preliminary data are detailed and discussed.

Updated European recommendations for the clinical use of HIV drug resistance testing.

In most European countries, HIV drug resistance testing has become a routine clinical tool. However, its practical implementation in a clinical context is demanding. The European HIV Drug Resistance Panel was established to make recommendations to clinicians and virologists on this topic and to propose quality control measures. The panel recommends resistance testing for the following indications: i) drug-naive patients with acute or recent infection; ii) therapy failure, including suboptimal treatment response, when treatment change is considered; iii) pregnant HIV-1-infected women and paediatric patients with detectable viral load when treatment initiation or change is considered; and iv) genotype source patient when post-exposure prophylaxis is considered. In addition, for drug-naive patients with chronic infection in whom treatment is to be started, the panel suggests that resistance testing should be strongly considered and recommends testing the earliest sample for drug resistance if suspicion of resistance is high or prevalence of resistance in this population exceeds 10%. The panel does not favour genotyping over phenotype, however it is anticipated that genotyping will be used more often because of its greater accessibility, lower cost and faster turnaround time. For the interpretation of resistance data, clinically validated systems should be used to the greatest extent possible. It is mandatory that laboratories performing HIV resistance tests take regular part in quality assurance programs. Similarly, it is necessary that HIV clinicians and virologists take part in continuous education and meet regularly to discuss problematic clinical cases. Indeed, resistance test results should be used in the context of all other clinically relevant information for predicting therapy response. The panel also encourages the timely collection of epidemiological information to estimate the impact of transmission of resistant HIV and the prevalence of HIV-1 non-B subtypes in the different European countries.

Treatment of HIV-related fluconazole-resistant oral candidosis with D0870, a new triazole antifungal.

OBJECTIVES: To evaluate the efficacy and tolerance of D0870 in the treatment of HIV-related fluconazole-resistant oro-oesophageal candidosis. DESIGN: Multicentre open study. PATIENTS: HIV-seropositive patients with oro-oesophageal candidosis despite at least 7 days of treatment with fluconazole at doses of 100 mg per day or more. METHODS: Patients received an initial dose of D0870 (150 mg), then 25 mg per day for 6 days. Symptoms and signs of candidosis were compared at entry and on days 3 and 7 of treatment. At each visit, samples were taken for safety monitoring and for in vitro susceptibility testing of Candida isolates. Limited pharmacokinetic samples were taken on days 1 and 7. RESULTS: Of 26 evaluable patients, 16 showed partial improvement, nine showed no improvement, and only one had full clearance of thrush by day 7. In vitro testing of the cleared patient's isolate suggested that it was susceptible to fluconazole. Symptoms of dysphagia cleared in 14 and improved in five of the 22 patients with presumptive oesophageal involvement at entry. Pharmacokinetic measurement showed wide variability in maximum D0870 levels recorded on day 1 (range, 0.07-0.34 mg/l) and susceptibility testing of isolates also showed a range of minimal inhibitory concentration values to D0870 (range, < 0.06-8 mg/l; median, 0.25 mg/l). When these data were combined with clinical response there was a strong suggestion that lack of symptomatic improvement was related to low plasma D0870 levels or to the presence of less D0870-susceptible isolates. Six patients were noted to have a fall in haemoglobin, three of whom were receiving concomitant therapy known to suppress bone marrow. Three patients reported headaches as adverse events that were attributed to study medication, but D0870 was well tolerated overall. CONCLUSIONS: D0870 shows promise in the treatment of fluconazole-resistant oro-oesophageal candidosis and was well tolerated, although efficacy in this difficult-to-treat patient group was probably limited due to the inadequate plasma levels achieved in this pilot study with the low doses of D0870 administered.

Treatment of severe staphylococcal infections with a rifampicin-minocycline association.

During an outbreak, 25 severely impaired patients (mean age 62) presented with severe infections due to Staphylococcus aureus resistant to oxacillin and aminoglycosides. All strains were isolated in pure culture and diagnostic procedures included transtracheal puncture and bone biopsy. Median MICs were: oxacillin 50 mg/l, gentamicin 12.5 mg/l, tetracycline 25 gm/l, vancomycin 0.195 mg/l, rifampicin 0.097 mg/l and minocycline 0.195 mg/l. All patients were treated with rifampicin (600 mg/day) and minocycline (200 mg or 400 mg/day) administered together intravenously or orally bid. Mean duration of treatment was 22 days (range 5 to 119). Overall results were 19/25 infections cured and one improved. Five were failures due mostly to emergence of Staph. aureus resistant to rifampicin. No side effects were noted. These preliminary results suggest that rifampicin plus minocycline may be useful in the treatment of severe infections due to multi-resistant Staph. aureus.

Ceftazidime as a single agent in the treatment of severe Pseudomonas aeruginosa infections.

Ceftazidime was administered intravenously in doses of 1 to 6 g/day to 21 patients with serious Pseudomonas aeruginosa infections (12 pulmonary, 6 septicaemias, 3 urinary tract infections). Mean MIC was 1.0 mg/l. Eighteen (86%) of the 21 patients responded satisfactorily (cured or improved). The selection or emergence of resistant organisms during treatment (mostly Candida, Staphylococcus aureus, and enterococci) was noted in 6 patients. Toxicity was minimal (eosinophilia and reversible mild liver function abnormalities).

Use of ceftazidime in severe Gram-negative infections--a preliminary study.

Ceftazidime was used to treat ten patients with serious Gram-negative bacillary infections. Seven patients had bronchopulmonary infections and three had urinary tract infections. In addition three patients were bacteraemic. Causative agents were: Pseudomonas aeruginosa 4, Escherichia coli 2, Proteus species 2, and Klebsiella pneumoniae 2. Doses ranged between 2 and 6 g/day. Nine out of ten patients responded favourably to ceftazidime (cure or improvement). Colonization with ceftazidime-resistant strains occurred in three cases. No evidence of nephrotoxicity was noted.