[Underestimated impact of antibiotic misuse in outpatient children]. / Prescriptions inappropriées d'antibiotiques chez l'enfant en médecine de ville : raisons et conséquences.

CONTEXT: The judicious prescription of antibiotics has become a central focus of professional and public-health measures to combat the spread of resistant organisms. It also seems important to consider the other impacts and determinants of antibiotic misuse. OBJECTIVE: Evaluating the ambulatory antibiotic prescription for common infections in patients secondarily hospitalized as well as the consequences and determinants of this prescription. PATIENTS AND METHODS: Study conducted over a period of 6 months between May and November 2008, during which 52 children aged between 3 months and 15 years, hospitalized in the pediatric hospital of Aix-en-Provence, were recruited. The reason for the pediatric emergency department visit was persistent symptoms or new symptoms over 48 h of ambulatory antibiotic prescription. The ambulatory antibiotic prescription was compared with current practice guidelines, and clinical progression after hospitalization was also analyzed. Afterwards, the determinants of this overprescription in ambulatory practice were investigated through a telephone questionnaire. RESULTS: Seventy-five percent of the antibiotic prescriptions were inappropriate, 60 % of which could potentially have been avoided with had an adequate and recommended practices been followed. Only 25 % of the children were prescribed ambulatory diagnostic exams, whereas these exams confirmed the diagnosis at the hospital for 71 % of them. In addition, 15 % of the children presented secondary effects of the antibiotics at their admission. Among practitioners, 84 % recognized having difficulties on reevaluation of the antibiotic prescription at 48 h. A high proportion of them (71 %) believe that antibiotics should be initiated precociously in patients with underlying conditions such as diabetes. Furthermore, 33 % recognized that the perceived parents' expectation could be a determinant of prescription. Otherwise, 22 % of them had attended an antibiotic prescription educational program during the past year. DISCUSSION: Antibiotic prescription for children's common infections remains a difficult decision for practitioners. This could partly be explained by atypical clinical symptoms and the risk of rapid progression in pediatric medicine. However, the rate of inappropriate prescription of antibiotics is high in this population. Among the main consequences of this practice, one may note the appearance of antibiotic resistance, the occurrence of side effects, and delayed diagnoses as well as preventable hospitalizations. Although certain considerations, such as the problems re-evaluating the patient after 48 h, must be taken into account, better use of paraclinical examinations in general practice could help to reduce inappropriate antibiotic prescriptions. Further large-scale, prospective studies should be conducted on the existing practices and beliefs concerning ambulatory antibiotic prescription in order to adjust prevention strategies.

[Management of newborns with meconium-stained amniotic fluid: prospective evaluation of practice]. / Prise en charge des nouveau-nés naissant dans un liquide méconial: évaluation prospective des pratiques.

OBJECTIVE: Regional guideline for immediate tracheal suctioning (ITS) in vigorous and non-vigorous infants born through meconium-stained amniotic fluid (MSAF) has been established in 2003. The objective of this study was to evaluate guideline application. STUDY DESIGN: Prospective cohort. PATIENTS AND METHODS: The first part of the study was a short survey about ITS practices in maternity hospitals then, management and early evolution of babies born through particulate MSAF was evaluated by questionnaire. RESULTS: Among 6761 neonates, 199 (3%) were born with MSAF. Early clinical evaluation showed 52 (26%) non-vigorous neonates; 22 of them (42%) have had an ITS. One hundred and forty-seven neonates were vigorous (74%); 27 of them (18%) have had an ITS. Implementation of recommendations in non-vigorous babies was better in maternities of level III, while they were lower in maternities of level IIA for vigorous babies. Among 52 non-vigorous children, eight had a meconium aspiration syndrome (MAS), including five who had an ITS. One MAS occurred in vigorous babies but infection could not be excluded. CONCLUSION: Recommendations for ITS were implemented in 70% of cases but only in 42% of cases in non-vigorous babies. We have to improve formation and circulation of new recommendations.

Bacillus licheniformis septicemia in a very-low-birth-weight neonate: a case report.

Nosocomial infections in neonatal intensive care units are a preoccupying issue. Bacillus sp. can be pathogenic in immuno-compromised hosts, including premature infants. Central catheters and mechanical ventilation are potential sources of infection. We report for the first time a case of Bacillus licheniformis bacteremia in a premature infant. Recovery necessitated treatment with vancomycin and cefotaxime in combination with removal of the central catheter.

[Failure to thrive and psychomotor regression revealing vitamin B12 deficiency in 3 infants]. / Stagnation pondérale et régression psychomotrice révélant une carence en vitamine B12 chez 3 nourrissons.

The newborn's vitamin B12 storage exclusively comes from placenta transfer, later from animal food. We relate 3 observations of infants (3-11-13 months) with failure to thrive, anorexia, vomiting and for the two olders refusal of weaning, associated with psychomotricity regression and hypotony. Blood cell count showed a macrocytosis without anemia (case 2-3) and a severe microcytic anemia for the first case caused by a mild alpha-thalassemia, with megaloblastic bone marrow. Vitamin B12 levels were very low associated with increased methylmalonic acid and homocysteine serum levels which confirm the diagnostic . Cerebral imaging showed diffuse cortical atrophy. Cobalamin deficiency was caused by strict vegetarian diets mothers of breastfed infants (cases 2-3) and for younger by mother's unrecognized pernicious anemia. 3 mothers had no anemia and normal B12 's levels at diagnosis. Vitamin B12 supply lead to a rapid clinical and hematologic improvement. In two cases, neurologic recovery was incomplete. About one hundred case of B12 deficiency 's infant are reported, 2/3 are breast-fed by vegetarian mothers, and 1/4 have mothers with pernicious anemia. The failure to thrive is due to anorexia, refusal of weaning and partial villous atrophy. Neurologic manifestations are secondary to cerebral disorders, sometimes revealed by an exposure to anesthetic nitrous oxyd. The macrocytic anemia is inconstant. The etiologic research of developmental delay in an infant may include vitamin B12's deficiency, even if there is no haematologic signs, especially if breast-fedding 's mothers is vegetarian.

[Transcutaneous bilirubin measurement in preterm infants]. / Estimation de la bilirubinémie par méthode transcutanée chez le nouveau-né prématuré.

UNLABELLED: Transcutaneous bilirubinometry is an effective screening tool for neonatal jaundice in full-term babies. But its accuracy is not shown yet in preterm infants. METHODOLOGY: We carried out a prospective study in a neonatal intensive care unit. The study included 47 preterm infants. From birth, a transcutaneous bilirubin measurement (BTc) using the BiliCheck was made on the forehead of each newborn every 8 h. Blood sampling for determination of total serum bilirubin (BS) was combined with BTc: 1) if value of BTc was higher than limits values for phototherapy; 2) on the second day of life and 3) 4 hours after cessation of phototherapy. RESULTS: Mean gestational age was 30 week and mean birth weight was 1419 g. We studied 151 pairs of BTc and BS. Mean values obtained by BTc and BS were respectively 160.6+/-50 mumol/L and 190.6+/-61.4 mumol/L. A significant correlation between BTc and BS was found. But the limits of agreement were very wide. The negative predictive value (NPV) of BTc was above 90% in each group of gestational age. DISCUSSION: The need for phototherapy cannot be determined by BTc in preterm infants. But the BTc is reliable when its value is under the limits for phototherapy. CONCLUSION: With a very high incidence of neonatal jaundice (87%) in our cohort, a value of BTc under the limits for phototherapy has a good NPV in preterm infants.

[Pediatric medical emergencies: clinical classification on basis of severity of illness, distribution between work days and non-working days]. / Urgences médicales pédiatriques: classification clinique en stades de gravité, répartition entre jours fériés et ouvrables.

OBJECTIVES: Assess one year of activity in a pediatric medical emergency unit of a non-university hospital to detail the degree of gravity of patients admitted to pediatric wards and the distribution of non-programmed activity between and work days and non-work days. METHODS: Prospective classification into 5 degrees of emergency of all admitted children and count of non-programmed medical and surgical activity. RESULTS: A significantly growing number of consultations for minor problems was observed during non-work days. Most hospitalizations were for problems of a rather relative emergency nature. CONCLUSION: The creation of a "day-hospital" would allow evaluation and/or treatment of a large number of pediatric patients without requiring hospitalization. The problem of controlling the flow of consultations to the hospital remains a difficult problem. The many reasons leading to hospital consultation are poorly assessed. It appears indispensable to promote population "education" and development of closer physician's office-hospital collaboration.

[Subphrenic abscess due to ectopic appendicitis]. / Abcès sous-phrénique révélateur d'une appendicite ectopique.

BACKGROUND: Idiopathic subphrenic abscesses are uncommon in children. Standard chest X-rays may provide the suspicion of this diagnosis. Initial percutaneous drainage of the collection is usually performed. Surgery is required when the underlying cause remains unknown. CASE REPORT: A 12-year-old boy presented signs of pulmonary abscess. Chest X-rays, ultrasonography and computed tomography established the diagnosis of a right subphrenic abscess, which was percutaneously drained. Surgery disclosed an ectopic appendiceal perforation. CONCLUSION: In children, appendicitis is the main etiology of primary or postoperative subphrenic suppurations. Ectopic appendicitis is an important predisposing factor to this complication.

[Recurrent osteitis and Coxiella burnetii: the relation to chronic recurrent multifocal osteomyelitis]. / Ostéites récidivantes et Coxiella burnetti: relation avec l'ostéomyélite chronique récurrente multifocale.

UNLABELLED: Chronic recurrent multifocal osteomyelitis (CRMO) is a disorder of suspected--but unproved-infectious etiology. OBSERVATION: A girl presented with a typical CRMO involving successively the left fibula, radius, humerus and the right carpus. A Coxiella burnetii infection was indicated during the first attack. Two recurrences occurred in spite of suitable antibiotic treatment and with negative infectious investigation. Two months after stopping antibiotic treatment, a new recurrence associated with antibodies increase and positive bone culture occurred. CONCLUSION: Coxiella burnetii can initiate a CRMO. The mechanism involved is probably a delayed hypersensitivity. CRMO would therefore be the first type of reactive osteitis.

[Prenatal diagnosis of fetal goiter revealing iodine utilization defect]. / Goitre néonatal découvert in utero, révélateur d'un trouble de l'organification de l'iode.

We report on a case of fetal goitrous diagnosed on ultrasonogram done at 31 weeks of gestation. Thyroid maternal function was normal and no therapeutic was responsible. Hormonal test done on cord blood supported diagnosis of prenatal hypothyroidism. The infant was born prematurely at gestation age of 34 without antenatal treatment. He was eutrophic with clinical and biological signs of hypothyroidism and a large goiter. Therapy with thyroxine was instituted on the third day of life. At 9 months, growth and development are normal. Congenital hypothyroidism has an incidence of approximately 1 in every 4000-5000 live births. Rarely fetal goitrous hypothyroidism have been attributed to thyroid hormone dyshormonogenesis. When fetal goiter is diagnosed on ultrasonography, without maternal hypothyroidism or therapeutic and when hypothyroidism is confirmed on fetal blood, this diagnosis must be suspected.