Distribution of metals and radionuclides in the lichens Cladonia rangiferina and C. mitis from the past uranium mining region of Elliot Lake, Ontario, Canada.

The present study was performed in the Elliot Lake area (Ontario, Canada), a site of uranium mining and milling for nearly 40 years between 1950's and 1990's. Although mining activities ceased in the mid-1990's, the site hosts several tailings management areas (TMAs) which are under ongoing rehabilitation and monitoring. Several surveys using lichens as a biomonitoring tool were completed in the 1980s and the 1990s to assess the levels of contaminants. The present survey aimed to re-visit the historical surveys, and to determine the current status of environmental recovery of the area. Our survey consisted of sampling two lichen species, Cladonia rangiferina and C. mitis, in an area covering up to 50 km from the former mining operation and the TMAs. The results reported in this work indicated that the levels of metals and radionuclides, diagnostic of mining operations, have decreased over time: particularly, the U, Th and Pb levels in both lichen species dropped by about two orders of magnitude by the 2020's compared to the 1980's. Likewise, the Cs-137 levels in both lichen species reflect present day global background. The study provides a new set of present-day regional baseline elemental concentrations for other metals that are associated with mining (Cd, As, Ti, Cs). Finally, there were weak but statistically significant differences in the levels of some elements (U, Th, Cd) between the two lichens, suggesting these two species might have different capture mechanisms or retention abilities.

A review on the use of lichens as a biomonitoring tool for environmental radioactivity.

Lichens have been widely used as a biomonitoring tool to record the distribution and concentration of airborne radioactivity and pollutants such as metals. There are limitations, however: although pollutants can be preserved in lichen tissues for long periods of time, not all radioactive and inert elements behave similarly. The chemical species of elements at the source, once captured, and the mode of storage within lichens play a role in this biomonitoring tool. Lichens are a symbiotic association of an algal or cyanobacterial partner (photobiont) with a fungal host (mycobiont). Lichens grow independently of the host substrates, including rocks, soils, trees and human-made structures. Lacking a root system, lichen nutrient or contaminant uptake is mostly through direct atmospheric inputs, mainly as wet and dry deposition. As lichens grow in a large variety of environments and are resilient in harsh climates, they are adapted to capture and retain nutrients from airborne sources. The context of this review partially relates to future deployment of small modular reactors (SMRs) and mining in remote areas of Canada. SMRs have been identified as a future source of energy (electricity and heat) for remote off-grid mines, potentially replacing diesel fuel generation facilities. For licensing purposes, SMR deployment and mine development requires capabilities to monitor background contaminants (natural radioactivity and metals) before, during and after deployment, including for decommissioning and removal. Key aspects reviewed herein include: (1) how lichens have been used in the past to monitor radioactivity; (2) radiocontaminants capture and storage in lichens; (3) longevity of radiocontaminant storage in lichen tissues; and (4) limitations of lichens use for monitoring radiocontaminants and selected metals.

Early symptomatic neurosyphilis and ocular syphilis: A comparative study between HIV-positive and HIV-negative patients.

OBJECTIVES: Since the 2000s, there has been an increase in prevalence of neurosyphilis (NS) and ocular syphilis (OS). As data about symptomatic NS/OS is limited, this study aims to assess the characteristics of symptomatic NS/OS, according to HIV status. METHODS: We compared the clinical and biological presentation of early symptomatic NS/OS and its outcome in HIV-positive and HIV-negative patients. RESULTS: Ninety-six patients (93% men, 49% HIV-positive) were included from 2000 to 2016 in two centers, with 67 (69%) having OS, 15 (16%) NS, and 14 (14%) both. HIV-positive patients were younger (P=0.006) and more likely to be males having sex with males (P=0.00048) or to have a history of syphilis (P=0.01). Among 81 OS, there were 43 posterior uveitis (57%), and bilateral involvement was more common in HIV-positive patients (62% versus 38%, P=0.045). Among 29 NS there were 21 cases of cranial nerve involvement (72%), seven meningitis (24%) and 11 paresthesia (38%). Involvement of the VIIIth cranial nerve was the most common (16 cases). Treponemal tests were more commonly found positive in cerebrospinal fluid in HIV-positive patients (88% versus 76%, P=0.04). Visual acuity (VA) always improved after treatment (initial VA logMAR 0.8±0.8 versus 0.1±0.1 at 3 months), but 32% and 18% of the patients still had neurological or ocular impairment respectively six and 12 months after treatment. Non-treponemal serological reversion was observed in 43/50 patients (88%) at six months. CONCLUSION: HIV infection has no consequence on the outcome of NS and OS. Sequelae are common, emphasizing the importance of prevention, and screening, and questioning enhanced treatment.

[Normal childbirth: physiologic labor support and medical procedures. Guidelines of the French National Authority for Health (HAS) with the collaboration of the French College of Gynaecologists and Obstetricians (CNGOF) and the French College of Midwives (CNSF) - Newborn care in the delivery room]. / Accouchement normal : accompagnement de la physiologie et interventions médicales. Recommandations de la Haute Autorité de Santé (HAS) avec la collaboration du Collège national des gynécologues obstétriciens français (CNGOF) et du Collège national des sages-femmes de France (CNSF) ­ accueil du nouveau-né en salle de naissances.

OBJECTIVES: The purpose of this literature review is to make recommendations regarding the first steps and care provided to the healthy newborn. METHODS: Consultation of the Medline database, and of national and international guidelines. RESULTS: The initial assessment of the newborn should quickly determine whether resuscitation is necessary or not. Any anomaly requires the help of the pediatrician (Consensus agreement). For a newborn with no cardiorespiratory adaptation, delayed cord clamping may be considered more as a physiological modality of delivery, which may help prevent iron deficiency in the first months of life, without deleterious effects for the child or his/her mother, apart from a slightly increased risk of neonatal jaundice (gradeC). In order to avoid separating a woman and her child, it is recommended to postpone routine postnatal procedures, to allow for skin-to-skin contact between the mother and the newborn, if she wishes, according to a defined/specified surveillance protocol (grade B). Breastfeeding should be encouraged, and supported, especially the first time (Consensus agreement). In the absence of suggestive clinical signs, aspiration of the upper airways and systematic verification of the permeability of posterior nasal apertures and of the esophagus are not recommended (Consensus agreement). The prevention of hemorrhagic disease of the newborn by the oral administration of vitamin K1 to all healthy term babies begins in the delivery room, preferably in the presence of the parents and after having obtained their consent (Consensus agreement). CONCLUSION: Regarding the birth of a healthy newborn, it is strongly advised to avoid unnecessary technical actions and to favor the mother-child relationship in a safe environment.

[Normal childbirth: physiologic labor support and medical procedures. Guidelines of the French National Authority for Health (HAS) with the collaboration of the French College of Gynaecologists and Obstetricians (CNGOF) and the French College of Midwives (CNSF) -- Text of the Guidelines (short text)]. / Accouchement normal : accompagnement de la physiologie et interventions médicales. Recommandations de la Haute Autorité de Santé (HAS) avec la collaboration du Collège National des Gynécologues Obstétriciens Français (CNGOF) et du Collège National des Sages-Femmes de France (CNSF) ­ Texte des recommandations (texte court).

OBJECTIVE: The objective of these guidelines is to define for women at low obstetric risk modalities that respect the physiology of delivery and guarantee the quality and safety of maternal and newborn care. METHODS: These guidelines were made by a consensus of experts based on an analysis of the scientific literature and the French and international recommendations available on the subject. RESULTS: It is recommended to conduct a complete initial examination of the woman in labor at admission (consensus agreement). The labor will be monitored using a partogram that is a useful traceability tool (consensus agreement). A transvaginal examination may be offered every two to four hours during the first stage of labor and every hour during the second stage of labor or before if the patient requests it, or in case of a warning sign. It is recommended that if anesthesia is required, epidural or spinal anesthesia should be used to prevent bronchial inhalation (grade A). The consumption of clear fluids is permitted throughout labor in patients with a low risk of general anesthesia (grade B). It is recommended to carry out a "low dose" epidural analgesia that respects the experience of delivery (grade A). It is recommended to maintain the epidural analgesia through a woman's self-administration pump (grade A). It is recommended to give the woman the choice of continuous (by cardiotocography) or discontinuous (by cardiotocography or intermittent auscultation) monitoring if the conditions of maternity organization and the permanent availability of staff allow it and, after having informed the woman of the benefits and risks of each technique (consensus agreement). In the active phase of the first stage of labor, the dilation rate is considered abnormal if it is less than 1cm/4h between 5 and 7cm or less than 1cm/2h above 7cm (level of Evidence 2). It is then recommended to propose an amniotomy if the membranes are intact or an oxytocin administration if the membranes are already ruptured, and the uterine contractions considered insufficient (consensus agreement). It is recommended not to start expulsive efforts as soon as complete dilation is identified, but to let the presentation of the fetus drop (grade A). It is recommended to inform the gynecologist-obstetrician in case of nonprogression of the fetus after two hours of complete dilation with sufficient uterine dynamics (consensus agreement). It is recommended not to use abdominal expression (grade B). It is recommended to carry out preventive administration of oxytocin at 5 or 10 IU to prevent PPH after vaginal delivery (grade A). In the case of placental retention, it is recommended to perform a manual removal of the placenta (grade A). In the absence of bleeding, it should be performed 30minutes but not more than 60minutes after delivery (consensus agreement). It is recommended to assess at birth the breathing or screaming, and tone of the newborn to quickly determine if resuscitation is required (consensus agreement). If the parameters are satisfactory (breathing present, screaming frankly, and normal tonicity), it is recommended to propose to the mother that she immediately place the newborn skin-to-skin with her mother if she wishes, with a monitoring protocol (grade B). Delayed cord clamping is recommended beyond the first 30seconds in neonates, not requiring resuscitation (grade C). It is recommended that the first oral dose (2mg) of vitamin K (consensus agreement) be given systematically within two hours of birth. CONCLUSION: These guidelines allow women at low obstetric risk to benefit from a better quality of care and optimal safety conditions while respecting the physiology of delivery.

Area of technical uncertainty for susceptibility testing of amoxicillin/clavulanate against Escherichia coli: analysis of automated system, Etest and disk diffusion methods compared to the broth microdilution reference.

OBJECTIVES: The European Committee on Antimicrobial Susceptibility Testing (EUCAST) recently warned about an area of technical uncertainty (ATU) of amoxicillin/clavulanate (AMX/C) disk susceptibility testing against members of the Enterobacterales. Thus, we aimed to compare the reliability of three routine methods and to evaluate the impact of the ATU. METHODS: 286 Escherichia coli strains (including 159 AMX-resistant strains) were categorized for the two EUCAST AMX/C breakpoints by disk diffusion (Bio-Rad), the Phoenix automated system (Becton Dickinson) and the Etest (AES) compared to the broth microdilution reference method. RESULTS: By microdilution, 84.2% of strains were AMX/C-susceptible using the urinary breakpoint (MIC ≤32 mg/L) and 62.2% using the systemic breakpoint (MIC ≤8 mg/L), with 63.6% of MICs between 4 and 16 mg/L. For the systemic breakpoint, category agreement (CA) and very major error (VME) were unacceptable for the Etest (71.7% and 27.3%), disk (73.1% and 23.4% at 19-mm cut-off) and to a lesser extent for the Phoenix system (83.6% and 10.5%). For disks, an unacceptable VME rate was observed for diameters up to 22 mm, probably due to overcharged disks. For the Etest, VMEs were high at 6 mg/L (46/63) and 8 mg/L (22/29). For the urinary breakpoint, CA was more acceptable for disk (88.9%) and Etest (84.3%) but was unevaluable for Phoenix. CONCLUSION: AMX/C susceptibility testing of E. coli for systemic breakpoint was unreliable with the three routine methods, explained mainly by the high prevalence (~60%) of strains with microdilution MICs around the breakpoint (8 mg/L). Our data confirmed the EUCAST 19-20-mm ATU for disk and suggest introducing ATU for Etest MIC values of 6 and 8 mg/L.

[Antibiotic prophylaxis in urodynamics: Clinical practice guidelines using a formal consensus method]. / Antibioprophylaxie et bilan urodynamique : recommandations de bonne pratique par consensus formalisé.

OBJECTIVE: The aim of this work was to issue clinical practice guidelines on antibiotic prophylaxis in urodynamics (urodynamic studies, UDS). MATERIALS AND METHODS: Clinical practice guidelines were provided using a formal consensus method. Guidelines proposals were drew up by a multidisciplinary experts group (pilot group = steering group), then rated by a panel of 12 experts (rating group) using a formal consensus method, and then peer reviewed by a reviewing/reading group of experts (different from the rating group). RESULTS: Urine (bacterial) culture with antimicrobial susceptibility testing is recommended for all patients before UDS (strong agreement). In patients with no neurologic disease, the risk factors for tract urinary infection (UTI) after UDS are age > 70 years, recurrent UTI, and post-void residual volume > 100ml. In patients with neurologic disease, the risk factors for UTI after UDS are recurrent UTI, vesicoureteral reflux, and intermicturition pressure > 40cmH2O. If the urine culture is negative before UDS and there is no risk factor for UTI, antibiotic prophylaxis is not recommended (Strong agreement). If the urine culture is negative before UDS, but there are one or more risk factors for UTI, antibiotic prophylaxis is optional. If antibiotic prophylaxis is initiated, a single oral dose (3g) of fosfomycin-tromethamine two hours before UDS is recommended (Strong agreement). If there is bacterial colonization on UCB before UDS, antibiotic therapy is optional (Undecided). If prescribed, it should be adapted to the antimicrobial susceptibility of the identified bacterium or bacteria, started the day before and stopped after UDS (except for fosfomycin-tromethamine: a single dose the day before UDS is necessary and sufficient) (Strong agreement). In the event of UTI before UDS, the UTI should be treated and UDS postponed (Strong agreement). The proposed recommendations should not be changed for patients with a hip or knee replacement (Strong agreement). No antibiotic prophylaxis of bacterial endocarditis is necessary, including in high-risk patients with valvular heart disease (Strong agreement). CONCLUSION: These new guidelines should help to harmonize clinical practice and limit exposure to antibiotics. LEVEL OF EVIDENCE: 4.

Temocillin against Enterobacteriaceae isolates from community-acquired urinary tract infections: low rate of resistance and good accuracy of routine susceptibility testing methods.

Background: Temocillin is an old 'revived' antibiotic that may play an important role in the treatment of febrile urinary tract infection (UTI). Data regarding its activity against current Enterobacteriaceae isolates as well as the performance of routine susceptibility testing methods are, however, scarce. Objectives: To determine the MICs of temocillin for Enterobacteriaceae strains reflecting the current epidemiology and to analyse the accuracy of three commercial methods. Methods: Enterobacteriaceae isolates causing community-acquired UTI were prospectively collected from September 2015 to January 2017 in two French centres. Temocillin MIC was determined by agar dilution (AD) as the reference method and then compared with: (i) susceptibility testing by disc diffusion; (ii) MIC determination by Etest; and (iii) MIC estimation by the Vitek 2 automated system. Results: A total of 762 Enterobacteriaceae were analysed comprising 658 (86.4%) Escherichia coli and 37 (4.9%) ESBL-producing isolates. Susceptibility rate assessed by AD was 99.6% according to the 8 mg/L clinical breakpoint and was significantly lower against the ESBL-producing isolates than the non-ESBL-producing isolates (94.6% versus 99.9%, P < 0.01). The MIC50 and MIC90 for the total set were 3 and 6 mg/L, respectively. According to the 8 mg/L clinical breakpoint, the major error rate was <1% for disc diffusion and Etest, and significantly higher for Vitek 2 (4.3%, P < 0.01), but still low. No very major error was noticed. Conclusions: Temocillin showed a high level of activity against Enterobacteriaceae from community-acquired UTI and good to excellent reliability of routine methods for susceptibility testing in such a setting.

Children and screens: Groupe de Pédiatrie Générale (Société française de pédiatrie) guidelines for pediatricians and families.

The Groupe de Pédiatrie Générale (General Pediatrics Group), a member of the Société française de pédiatrie (French Pediatrics Society), has proposed guidelines for families and doctors regarding children's use of digital screens. A number of guidelines have already been published, in particular by the French Academy of Sciences in 2013 and the American Academy of Pediatrics in 2016. These new guidelines were preceded by an investigation into the location of digital screen use by young children in France, a survey of medical concerns on the misuse of digital devices, and a review of their documented benefits. The Conseil Supérieur de l'Audiovisuel (Higher Council on Audiovisual Technology) and the Union Nationale de Associations Familiales (National Union of Family Associations) have taken part in the preparation of this document. Five simple messages are proposed: understanding without demonizing; screen use in common living areas, but not in bedrooms; preserve time with no digital devices (morning, meals, sleep, etc.); provide parental guidance for screen use; and prevent social isolation.

Children and screens: A survey by French pediatricians.

INTRODUCTION: Screens are increasingly prevalent within families. The excessive use of screens by children has negative consequences. To measure the use of screens, we undertook an investigation among children being followed by pediatricians. METHODS: An invitation to participate was sent electronically to 1460 private practice pediatricians. They were asked to complete the questionnaire on screen use by children under 12 years of age during a consultation, according to statements made by parents. RESULTS: One hundred and forty-four pediatricians submitted completed questionnaires involving 428 children. Among the 197 children under 3 years of age, 92 had played with an interactive screen for a median duration of 30min during the preceding week; 29% of the children were alone at the time. One hundred and thirty-nine children had watched television for a median weekly duration of 75min. Of the 231 children 3-11 years of age, 108 had played with an interactive screen for a median time of 30min the day before the consultation, and 50% of them were alone at the time. One hundred and seventy-two children watched television for a median daily duration of 45min. There was a correlation between these children's screen time and their mother's (r=0.36). The television was on during meals and continuously in 35% and 21% of the families, respectively. CONCLUSIONS: Children start looking at screens early, too often watching unsuitable programs, and too often without a parent's present. Regardless of the child's age, pediatricians must ask parents how much time their children are viewing screens, advise them accordingly, and warn them of the consequences of excessive use.

Association of body weight with efficacy and safety outcomes in phase III randomized controlled trials of direct oral anticoagulants: a systematic review and meta-analysis.

Essentials The association of body weight and patient-important outcomes remains unknown. Phase III randomized controlled trials of direct oral anticoagulants (DOACs) were searched. Risk of outcomes varying among body weight subgroups is not attributable to anticoagulant type. Dose adjustment of DOACs, outside that recommended, is unlikely to improve the outcomes. Click to hear Dr Braunwald's perspective on antithrombotic therapy in cardiovascular disease SUMMARY: Background Concerns have arisen in direct oral anticoagulant (DOAC)-treated patients about safety and efficacy in extremes of body weight. The aims of this systematic review were to investigate the association of body weight and patient-important outcomes in patients treated with DOACs or warfarin, and to demonstrate the fixed-dose effect of DOACs. Methods MEDLINE and EMBASE were searched until November 2016. Phase III randomized controlled trials (RCTs) using DOACs in atrial fibrillation (AF) and acute venous thromboembolism (VTE) were included. Relative risk and 95% confidence interval were calculated. The pooled estimates were performed using a Mantel-Haenszel random effects model. Results A total of 11 phase III RCTs were included. Low body weight was associated with increased risk of thromboembolism compared with non-low body weight (relative risk [RR], 1.57; 95% confidence interval [CI], 1.34-1.85). High body weight was not associated with risk of thromboembolism compared with non-high body weight (RR, 0.88; 95% CI, 0.63-1.23). The subgroup of AF patients with high body weight had a lower risk of thromboembolism compared with non-high body weight (RR, 0.43; 95% CI, 0.28-0.67). Bleeding outcomes were comparable for all body weight comparisons. There were no clear interactions between types of anticoagulant in all outcomes. Conclusion The pooled effect of both the DOAC and comparison arms was likely to be attributable to differences in baseline thrombotic risk in each body weight category, rather than an effect of the type or dose of DOAC used for each indication. Dose adjustment of DOACs, outside that recommended in the package insert, is unlikely to improve safety or efficacy.

The comeback of trimethoprim in France.

Already used in various countries, trimethoprim (TMP) was withdrawn from the French market in 1990, but should be soon available again. This article reviews the experience of TMP use around the world and its current use in Europe. Label use and guidelines only recommend the use of TMP for the treatment of urinary tract infections (UTI). Compared with co-trimoxazole (Co-T), a combination of TMP and sulfamethoxazole (SMX), TMP has (a) a similar resistance rate among Escherichia coli strains (estimated between 10 and 20% in uncomplicated cystitis), (b) a similar clinical efficacy for cystitis prevention and treatment, (c) a lower toxicity (as severe toxicity adverse effects of Co-T come from its sulfonamide component), (d) limited data for the treatment of pyelonephritis and male UTIs, and (e) an important impact on the microbiota. TMP should thus be indicated in the third-line empirical treatment of acute uncomplicated cystitis (sparing fluoroquinolones and nitrofurantoin), in the prevention of recurrent acute cystitis when an antibiotic prophylaxis is required (possibly in first line), and in the treatment of documented acute cystitis at risk of complications. Updated data on the epidemiology of resistance to TMP per clinical pictures is now required. The bactericidal effect of TMP should also be confirmed on recent strains (although limited recent data suggests a bactericidia similar to that of Co-T) and its clinical efficacy should be evaluated in pyelonephritis and male UTI.

Outcome of patients with streptococcal prosthetic joint infections with special reference to rifampicin combinations.

BACKGROUND: Outcome of patients with streptococcal prosthetic joint infections (PJIs) is not well known. METHODS: We performed a retrospective multicenter cohort study that involved patients with total hip/knee prosthetic joint (THP/TKP) infections due to Streptococcus spp. from 2001 through 2009. RESULTS: Ninety-five streptococcal PJI episodes (50 THP and 45 TKP) in 87 patients of mean age 69.1 ± 13.7 years met the inclusion criteria. In all, 55 out of 95 cases (57.9 %) were treated with debridement and retention of the infected implants with antibiotic therapy (DAIR). Rifampicin-combinations, including with levofloxacin, were used in 52 (54.7 %) and 28 (29.5 %) cases, respectively. After a mean follow-up period of 895 days (IQR: 395-1649), the remission rate was 70.5 % (67/95). Patients with PJIs due to S. agalactiae failed in the same proportion as in the other patients (10/37 (27.1 %) versus 19/58 (32.7 %); p = .55). In the univariate analysis, antibiotic monotherapy, DAIR, antibiotic treatments other than rifampicin-combinations, and TKP were all associated with a worse outcome. The only independent variable significantly associated with the patients' outcomes was the location of the prosthesis (i.e., hip versus knee) (OR = 0.19; 95 % CI 0.04-0.93; p value 0.04). CONCLUSIONS: The prognosis of streptococcal PJIs may not be as good as previously reported, especially for patients with an infected total knee arthroplasty. Rifampicin combinations, especially with levofloxacin, appear to be suitable antibiotic regimens for these patients.

Long term outcome of patients with low level of cryoglobulin (<0.05g/L).

OBJECTIVES: To date, no studies have yet assessed the characteristics of non-HCV patients with low level of cryoglobulin (≤0.05 g/L). The aims of the current study were thus to: 1) determine the prevalence of cryoglobulin ≤0.05 g/L in patients with non-HCV cryoglobulin; and 2) compare clinical features and long term outcome, including organ complications and mortality rate, between non-HCV patients with cryoglobulin level ≤0.05 g/L and those exhibiting cryoglobulin level >0.05 g/L. METHODS: Among 6379 cryoglobulin testing, cryoglobulin was detected in 618 patients (9.69% of cases); of these 618 patients, 453 non-HCV patients were included in the study. The medical records of these patients were reviewed. RESULTS: Of the 453 non-HCV cryoglobulin-positive patients, 265 (58.6%) exhibited cryoglobulin level ≤0.05 g/L. We showed that patients with cryoglobulin level ≤0.05 g/L had: 1) less commonly: palpable purpura (p<0.001), digital ulcers (p=0.006), peripheral neurologic involvement (p=0.03) and renal impairment (p=0.03); and 2) lower median values of ESR (p<0.001) and C-reactive protein (p=0.001). The patients with cryoglobulin level ≤0.05 g/L less often experienced infections (p=0.04) and hematological malignancies (p=0.01); both groups did not differ regarding prevalence of connective tissue diseases and solid tumors. Mortality rate was as high as 13.6% in patients with cryoglobulin level ≤0.05 g/L; death was mainly due to: solid tumors (16.6%), cardiovascular complications (13.8%), hematological malignancies (11.1%), infections (8.3%), pulmonary/renal complications of cryoglobulin (8.3%) and connective tissue diseases (8.3%). CONCLUSION: Our study shows a high prevalence of cryoglobulin level ≤0.05 g/L in clinical practice. Our findings further underscore that non-HCV cryoglobulin level ≤0.05 g/L may be responsible for severe renal and neurological complications, leading to high morbidity and mortality in these patients. Thus, our data suggest that both appropriate therapy and close follow-up may be required to improve such patients' outcome.

Empirical therapies among adults hospitalized for community-acquired upper urinary tract infections: A decision-tree analysis of mortality, costs, and resistance.

BACKGROUND: Poor outcomes occur when patients with serious infections receive antibiotics to which the organisms are resistant. METHODS: Decision trees simulated in-hospital mortality, costs, incremental cost-effectiveness ratio per life year saved, and carbapenem resistance according to 3 empirical antibiotic strategies among adults hospitalized for community-acquired (CA) upper urinary tract infections (UTIs): ceftriaxone (CRO) plus gentamicin (GM) in the intensive care unit (ICU), imipenem (IMP), and individualized choice (IMP or CRO) based on clinical risk factors for CA- extended-spectrum ß-lactamase (ESBL). RESULTS: The estimated prevalence of CA-ESBL on admission was 5% (range, 1.3%-17.6%); 3% and 97% were admitted to the ICU and medical ward (MW), respectively. In the ICU, CRO plus GM was dominated; IMP was cost-effective (incremental cost-effectiveness ratio: €4,400 per life year saved compared with individualized choice). In the MW, IMP had no impact on mortality and was less costly (-€142 per patient vs CRO, -€38 vs individualized choice). The dominance of IMP was consistent in sensitivity analyses. Compared with CRO, colonization by carbapenem-resistant pathogens increased by an odds ratio of 4.5 in the IMP strategy. CONCLUSION: Among the ICU patients, empirical IMP therapy reduces mortality at an acceptable cost. Among MW patients, individualized choice or CRO is preferred to limit carbapenem resistance at a reasonable cost.

High bacterial titers in urine are predictive of abnormal postvoid residual urine in patients with urinary tract infection.

Urine bacterial titers (BTs) are influenced by bacterial and host factors. The impact of an abnormal postvoid residual (PVR) on BT in urine was investigated. A total of 103 inpatients with a urine growing Enterobacteriacae (≥ 10(2) CFU/mL) and a PVR measure were analyzed, mostly female (62%), elderly (mean age: 72 years), with urinary tract infection (25% of asymptomatic bacteriuria) due to Escherichia coli (85%). Fifty-two subjects (56%) had BT ≥ 10(6) CFU/mL; 48 (53%) had a PVR ≤ 100 mL, while 26 (25%) had a PVR >250 mL. PVR increased with BT, and a significant (P<0.0001) threshold was reached for 10(6) CFU/mL: 100mL mean PVR for patients with BT ≤ 10(5) CFU/mL versus 248 mL for patients with BT >10(5) CFU/mL. High PVR and BT were associated with complicated infections, concomitant bacteremia, and delayed apyrexia. Screening for patients with BT ≥ 10(6) CFU/mL is an easy way to identify patients at high risk for acute retention and voiding disorders.

Antibiotic resistance in adult female patients hospitalized for acute pyelonephritis: rates and predicting factors.

INTRODUCTION: The empiric treatment of acute pyelonephritis (APN) with third generation cephalosporins (3GC) or fluoroquinolones (FQ) has been challenged by Escherichia coli resistance reported by community surveillance networks. But these could overestimate resistance because they do not discriminate between uncomplicated and complicated, or between community and care-related infections. OBJECTIVES: We had for aim to: quantify resistance rates in hospitalized patients presenting with APN; identify subgroups with resistance <10% that could still be treated empirically with FQ or 3GC. PATIENTS AND METHODS: We retrospectively analyzed files of patients presenting with documented APN, hospitalized in an Infectious Diseases Department from October 2010 to December 2012. RESULTS: Hundred and fifty-six female patients (median age: 66, interquartile range: 37), were admitted for uncomplicated APN (36%) or APN (64%) at risk of complications by 1 (46%), 2 (40%), or 3 or more (14%) risk factors. Bacteremia was associated in 44% of uncomplicated and 8% of APN at risk of complications. E. coli was predominant (82%), resistant to 3GC in 6% of patients (including 4% ESBL) and to FQ in 15% of patients. The rate of resistance to FQ increased with the number of risk factors for complication, from 6% in uncomplicated APN, to 25% in patients with ≥3 risk factors. No enterobacteria was resistant to either 3GC or aminoglycosides. CONCLUSION: The resistance rates of 3GC and aminoglycosides were <10% in patients hospitalized for APN. FQ resistance rates reached 15% but only 6% in uncomplicated APN. Hence, FQ empiric regimen should now be restricted to the treatment of uncomplicated APN without severe sepsis.