Impact of bedside diagnosis of influenza in the paediatric emergency ward.

OBJECTIVES: This prospective study performed in the paediatric emergency department of the University Hospital of Saint-Etienne aimed to measure the impact of the 24/7 bedside use of the Veritor™ System (Becton Dickinson) on the reduction of supplementary investigations, hospital stay and antimicrobial use. METHODS: Influenza virus A and B antigens were detected with a rapid influenza digital immunoassay (DIA) on nasopharyngeal aspirates (NPAs) sampled from the children consulting at the paediatric emergency department between January and March 2016 for influenza-like illness. The same NPA was tested by immunofluorescence and/or molecular routine assays. Before performing the DIA, the clinician filled in a questionnaire listing the tests that he/she would have prescribed in the absence of the rapid testing. The prescription of complementary investigations, antimicrobial treatments and hospital stay were also compared to those of the 3 previous years. RESULTS: A total of 514 children with flu-like symptoms were included. The use of the DIA at bedside decreased the prescription of blood puncture by 47.9% (21.2% to 6.6%), of chest X-rays by 69.0% (33.3% to 10.3%), of lumbar puncture by 77.8% (7.0% to 1.6%), of urine culture by 79.2% (23.3% to 4.9%), of antibiotic treatments by 70.1% (16.9% to 5.1%), and of hospital stay by 25.0% (27.2% to 20.4%), resulting in a reduction of medical costs estimated to more than €69 000 in a season. CONCLUSIONS: In addition to delivering a rapid aetiological diagnosis, this strategy saves medical costs and favours an antimicrobial stewardship strategy. However, further prospective studies are needed to confirm our findings.

Clinical severity and molecular characteristics of circulating and emerging rotaviruses in young children attending hospital emergency departments in France.

Group A rotavirus (RVA) is the leading cause of acute gastroenteritis in young children worldwide. A prospective surveillance network has been set up to investigate the virological and clinical features of RVA infections and to detect the emergence of potentially epidemic strains in France. From 2009 to 2014, RVA-positive stool samples were collected from 4800 children <5 years old attending the paediatric emergency units of 16 large hospitals. Rotaviruses were then genotyped by RT-PCR with regard to their outer capsid proteins VP4 and VP7. Genotyping of 4708 RVA showed that G1P[8] strains (62.2%) were predominant. The incidence of G9P[8] (11.5%), G3P[8] (10.4%) and G2P[4] (6.6%) strains varied considerably, whereas G4P[8] (2.7%) strains were circulating mostly locally. Of note, G12P[8] (1.6%) strains emerged during the seasons 2011-12 and 2012-13 with 4.1% and 3.0% prevalence, respectively. Overall, 40 possible zoonotic reassortants, such as G6 (33.3%) and G8 (15.4%) strains, were detected, and were mostly associated with P[6] (67.5%). Analysis of clinical records of 624 hospitalized children and severity scores from 282 of them showed no difference in clinical manifestations or severity in relation to the genotype. The relative stability of RVA genotypes currently co-circulating and the large predominance of P[8] type strains may ensure vaccine effectiveness in France. The surveillance will continue to monitor the emergence of new reassortants that might not respond to current vaccines, all the more so as all genotypes can cause severe infections in infants.

Contamination of healthcare workers' mobile phones by epidemic viruses.

Mobile phones (MPs) are potential reservoirs of nosocomial bacteria, but few data are available concerning viruses. We aimed to evaluate the presence of virus RNA from epidemic viruses including metapneumovirus, respiratory syncytial virus, influenza viruses, rotavirus (RV) and norovirus on the MPs used by healthcare workers (HCWs) and to relate it to hygiene measures. An anonymous behavioural questionnaire about MP use at hospital was administered to the HCWs of four adult and paediatric departments of a university hospital. After sampling personal (PMP) and/or professional MPs (digital enhanced cordless telephone, DECT), virus RNAs were extracted and amplified by one-step real-time reverse transcription-quantitative PCR. The molecular results were analysed in a masked manner in relation to the behavioural survey. Questionnaires from 114 HCWs (25 [corrected] senior physicians, 30 residents, 32 nurses, 27 nurses' assistants) working either in adult (n = 58) or paediatric (n = 56) departments were analysed. Medical personnel used their PMP more frequently than paramedical HCWs (33/65 vs. 10/59, p <0.001). MPs were used during care more frequently in adult wards than in paediatric ones (46/58 vs. 27/56, p <0.001). Virus RNA was detected on 42/109 (38.5%) collected MPs, with RV found on 39, respiratory syncytial virus on three and metapneumovirus on one. The presence of virus RNA was significantly associated with MPs from the paediatric HCWs (p <0.001). MPs routinely used in hospital, even during care, can host virus RNA, especially RV. Promotion of frequent hand hygiene before and after MP use, along with frequent cleaning of MPs, should be encouraged.

[Infantile scurvy: Two cases]. / Scorbut chez l'enfant: deux cas.

BACKGROUND: Scurvy is the classic and most severe form of vitamin C deficiency. This condition has become extremely rare among children in the industrialized countries. PATIENTS AND METHODS: We report the case of two boys presenting bone pain associated with haemorrhagic gingivitis, with perifollicular purpura of the lower limbs in one boy. The children had an unbalanced diet. Scurvy was associated with vitamin D and iron deficiency. The dermatological and radiological abnormalities seen were characteristic and a favourable outcome was rapidly obtained following supplementation. DISCUSSION: The possibility of this forgotten historical illness should not be overlooked in the presence of these dermatological and rheumatologic signs, since this can help avoid unnecessary or excessively aggressive investigations.

[An epidemiological study of early consultations of newborns in pediatric emergency units]. / Étude épidémiologique des consultations précoces de nouveau-nés aux services d'accueil des urgences pédiatriques.

BACKGROUND: The number of visits to the pediatric emergency services has increased in the past 20 years in France and around the world, especially for neonates (under 28 days of age). OBJECTIVES: Determine for neonates the reasons requiring medical consultation in the emergency pediatric unit of Saint-Etienne University Hospital (France) and isolate the proportion of "non-urgent" preventable consultations that could be managed outside of emergency units. METHOD: Epidemiological, retrospective study on computerized data on neonates who were referred to the pediatric emergency unit of the Saint-Étienne University Hospital from 1 January to 31 December 2011. Four composite criteria "child not addressed by a healthcare professional; severity score G1, G2, G3 based on an internal scale; no further review undertaken; and return home" were used to define "non-urgent" consultations. RESULTS: A total of 419 infants were included in the study. The leading reasons for consultations were crying (14.1%), vomiting (11.9%), chest tightness (10.7%), fever (8.1%), and diarrhea (7%). The main diagnoses were acute nasopharyngitis (11.5%), gastroesophageal reflux (10%), colic (8.1%), and excessive parental anxiety (7.6%). The percentage of "non-urgent" consultations was 52.4%. CONCLUSIONS: Final diagnoses are quite similar to the reasons for consultation. The baby's unexplained crying and the inexperience of young parents resulted in an irrational anxiety. This study highlights the need for parental support at home after discharge from the maternity ward and the use of large-scale educational initiatives.

[Incidence of rotavirus gastroenteritis among children under 5 years consulting a paediatrician or a general practitioner in France]. / Incidence des gastroentérites à rotavirus chez les enfants de moins de cinq ans consultant un pédiatre ou un médecin généraliste en France.

BACKGROUND: Rotavirus (RV) is the main infectious agent of severe acute gastroenteritis (AGE) in infants and children under 5 years. Given the recent availability of new vaccines, it is important to accurately assess the incidence of rotavirus gastroenteritis (GERV) and their medical and epidemiological consequences. METHODS: This work is the French part of study program called SPRIK, a multicenter, prospective, observational study conducted from October 2005 to May 2007 to estimate the annual incidence of GERV within children under 5 years visiting a general practitioner or pediatrician. It presents data collected by 41 general practitioners and 36 paediatricians located throughout the French metropolitan territory. A stool sample was taken for every child. Rotavirus presence was sought by the physician using a rapid immunochromatographic test. French results are presented in this article. RESULTS: A total of 1648 GEA episodes corresponding to 1463 eligible patients were included in the study mainly from December to May (peak in February-March). The incidence rate of GERV leading to consultations in general practice was 1357 cases per 100,000 patient-years (PY) (1.36%), with a 95% confidence interval of [1345-1368]. The peak incidence occurs before 2 years. GERV accounted for 21% of all GEA cases seen by paediatricians and general practitioners. Patients with GERV were younger (14.1 ± 10.8 versus 18.4 ± 13.9 months for other GEA, P<0.0001) and had more severe clinical symptoms: presence of fever (32.6% versus 20.0%, P<0.0001), behavioural symptoms (45.6% versus 20.8%, P<0.0001) and dehydration (48.7% versus 21.2%, P<0.0001). GERV episodes were considered severe in 79.7% of cases, using the Vesikari scale. More than 86% patients received oral rehydration during the episode and 13 patients (5.8%) were hospitalized. Nearly 80% GERV episodes were considered severe using the Vesikari scale. Main genotypes were G1P[8] rotavirus (44%) and G9P[8] rotavirus (35%) types. CONCLUSION: The incidence rate reported in this study is close to results of previous studies done in Europe. The frequency and severity relative to GERV support vaccination in very young children to reduce the burden associated with this pathology.

[Acute cannabis poisoning in a 10-month-old infant]. / Intoxication aiguë par cannabis chez un nourrisson de 10 mois.

We describe a case of accidental cannabis poisoning in a 10-month-old girl, who presented with impaired consciousness, with drowsiness and restlessness, generalized hypotonia, and inadequate smiles. No circulatory or respiratory problems were observed. Initial investigations were not informative (blood biology, CT scan, and cerebrospinal fluid examination), while the main causes of coma (meningoencephalitis, head trauma, metabolic disorders) were excluded. Questioning the parents led to suspecting accidental ingestion of a piece of cannabis, which was confirmed by the detection of high blood and urine levels of cannabinoid derivatives. Management was symptomatic and the clinical course, marked by the occurrence of agitation and irritability episodes lasting up to H18, led to complete regression of symptoms. Because of the high consumption in France, pediatric poisoning by cannabis seems increasingly common. The toxic levels in children are unknown however. Diagnosis is based on questioning and the search for cannabinoid derivatives in urine. In children, clinical symptoms are more expressive compared to adults, with neurological (drowsiness, agitation, abnormal behavior, ataxia, hypotonia, coma, and convulsions) or cardiopulmonary (tachycardia, bradypnea, apnea) or homeostatic presentations (hypothermia). Treatment in children is essentially symptomatic but sometimes requires active resuscitation. Recommendations are based on clinical monitoring the first 24h after intoxication and on medicosocial support.

[Impact of Rotavirus gastroenteritis requiring hospitalization or presenting to emergency room among children less than 5 years in France]. / Impact des gastroentérites à Rotavirus chez les enfants de moins de cinq ans hospitalisés ou consultant en services d'urgences en France.

BACKGROUND: In France, Rotavirus infections are responsible for approximately 300,000 cases of acute gastroenteritis (AGE) in children less than 5 years every year, 138,000 outpatient consultations and 18,000 hospitalizations. Surveillance for Rotavirus Infections in Hospitalized Kids (SHRIK) is a European prospective observational study conducted to assess the burden related to Rotavirus gastroenteritis (RVGE) in these children. METHODS: Patients less than 5 years visiting emergency rooms for AGE (U-AGE), who were hospitalized (H-AGE) or who developed RVGE 48 hours after hospitalization (N-AGE) were included in the study over a year. A stool sample was collected for every child and analyzed by ELISA. RESULTS: Results are presented for patients enrolled in France. A total of 755 eligible patients with AGE were included (357 for U-AGE, 372 for H-AGE and 26 for N-AGE). Among them, the proportion of RVGE was 49.1% (n=114) for U-AGE and 64.4% (n=186) for H-AGE. Most cases of RVGE (89%) involved children less than 2 years. GERV were frequently more severe than GEA non related to Rotavirus (NRVGE), according to the Vesikari scale, (68.4% against 41.9%, P<0.0001). Oral rehydration was performed for nearly 50% of RVGE patients before coming to hospital, versus 36.2% for NRVGE (P<0.002). All RV-positive strains were genotyped: the most frequent strains were G1P[8] (U-AGE, 42%; H-AGE, 46%) and G9P[8] (U-AGE, 38%; H-AGE, 31%). CONCLUSION: SHRIK study followed up all GEA visiting emergency room or requiring hospitalization for one year and showed that the burden of Rotavirus disease is high with a ratio over 70% of all hospital GEA during the winter peak.

[Distribution of neutralizing measles serum antibodies according to age in women of childbearing age in France in 2005-2006]. / Distribution en fonction de l'âge de la concentration sérique des anticorps neutralisants antirougeole chez les femmes en âge de procréer en France en 2005-2006.

UNLABELLED: Measles-vaccine coverage (MVC) increased significantly only beginning in 1983 based on the official recommendations. The majority of women born after 1983 should have vaccine-acquired rather than naturally derived immunity. Passively transferred measles antibodies (Mab) are expected to provide protection to offsprings during their 1st few months of life. OBJECTIVE: Compare neutralizing Mab titers according to age in women aged 12-40 years, i.e., born before and after 1983. METHODS: A multicenter seroepidemiological study was conducted in France in 2005-2006; 210 outpatient or hospitalized women were enrolled and classified into 4 age groups (12-18, 19-22, 23-30, and 31-40 years). Mab titers were assessed using a reference plaque reduction neutralization assay (protection threshold > 120 mIU/ml). RESULTS: Ninety-four percent of subjects had a Mabs titer greater than 120 mIU/ml. Women born before 1983 had significantly higher geometric mean titers (GMTs) of Mabs than those born after 1983(1358 mIU/ml vs. 731 mIU/ml [p<0.001]). The comparison of the 4 cohorts showed a significant decrease (p<0.001) in GMTs of Mab in the female population with increasing age (670, 771, 1173, and 1821 mUI/ml, respectively, in the 12-18, 19-22, 23-30, and 31-40 years age groups). For the 1st time in France, we show in women of childbearing age that in 2005-2006 neutralizing Mab GMTs were far above protective threshold for all age groups. Women in younger age groups (with high MVC) have significantly lower Mab titers. A lower passive transfer of Mab to their offsprings could result in a shorter period of measles protection and question the measles vaccine 1st dose at 1 year.

[Five cases of trichobezoars in children]. / Trichobézoard: à propos de 5 observations.

Trichobezoars are made up of concretions of ingested hair and food. A history of occlusive syndrome in a context of trichotillomania and psychological problems must lead to this diagnosis. Bezoars can be fortuitously recognised by palpation of an epigastric abdominal mass while investigating anemia or esophageal reflux. This deviance is particularly dangerous. The first case of this series illustrates the Rapunzel syndrome with many perforations and necrosis of the small bowel. The 4 others are strict intragastric bezoars, quickly identified by echography. Treatment is exclusively surgical, digestion by papain or endoscopic extraction being impossible. Psychological assistance is mandatory.

Development and evaluation of Chlamylege, a new commercial test allowing simultaneous detection and identification of Legionella, Chlamydophila pneumoniae, and Mycoplasma pneumoniae in clinical respiratory specimens by multiplex PCR.

This study describes the development and evaluation of a new commercial test, Chlamylege (Argene Inc.), which allows the simultaneous detection in respiratory samples of Chlamydophila pneumoniae, Mycoplasma pneumoniae, and most Legionella species, as well as PCR inhibitors, by using a multiplex PCR and microplate hybridization. The sensitivities of Chlamylege were 1 x 10(-3) IFU, 5 x 10(-2) color-changing units, and 1 CFU per reaction tube for C. pneumoniae, M. pneumoniae, and Legionella pneumophila, respectively. A cohort of 154 clinical samples from patients with documented respiratory infections was analyzed by the kit, including 2 samples from patients with C. pneumoniae infection, 9 samples from patients with M. pneumoniae infection, 19 samples from patients with Legionella species infection, and 114 samples that tested negative for the three pathogens. All the positive specimens were correctly detected and identified by the Chlamylege kit, and no false-positive result was observed with the negative samples. The kit was then evaluated in a pediatric prospective study that included 220 endotracheal aspirates, and the results were compared with those obtained by three single in-house PCR assays. Four specimens were found to be positive for C. pneumoniae and six were found to be positive for M. pneumoniae by using both strategies. The Chlamylege kit detected two additional samples positive for M. pneumoniae and one additional sample positive for a Legionella species other than L. pneumophila; these three samples were shown to be true positive by other techniques. These overall results demonstrate that the Chlamylege assay is sensitive, specific, and convenient for the rapid detection and identification of atypical pathogens in clinical samples from patients with respiratory infections.