Lyme borreliosis and other tick-borne diseases. Guidelines from the French scientific societies (II). Biological diagnosis, treatment, persistent symptoms after documented or suspected Lyme borreliosis.

The serodiagnosis of Lyme borreliosis is based on a two-tier strategy: a screening test using an immunoenzymatic technique (ELISA), followed if positive by a confirmatory test with a western blot technique for its better specificity. Lyme serology has poor sensitivity (30-40%) for erythema migrans and should not be performed. The seroconversion occurs after approximately 6 weeks, with IgG detection (sensitivity and specificity both>90%). Serological follow-up is not recommended as therapeutic success is defined by clinical criteria only. For neuroborreliosis, it is recommended to simultaneously perform ELISA tests in samples of blood and cerebrospinal fluid to test for intrathecal synthesis of Lyme antibodies. Given the continuum between early localized and disseminated borreliosis, and the efficacy of doxycycline for the treatment of neuroborreliosis, doxycycline is preferred as the first-line regimen of erythema migrans (duration, 14 days; alternative: amoxicillin) and neuroborreliosis (duration, 14 days if early, 21 days if late; alternative: ceftriaxone). Treatment of articular manifestations of Lyme borreliosis is based on doxycycline, ceftriaxone, or amoxicillin for 28 days. Patients with persistent symptoms after appropriate treatment of Lyme borreliosis should not be prescribed repeated or prolonged antibacterial treatment. Some patients present with persistent and pleomorphic symptoms after documented or suspected Lyme borreliosis. Another condition is eventually diagnosed in 80% of them.

Lyme borreliosis and other tick-borne diseases. Guidelines from the French Scientific Societies (I): prevention, epidemiology, diagnosis.

Lyme borreliosis is transmitted en France by the tick Ixodes ricinus, endemic in metropolitan France. In the absence of vaccine licensed for use in humans, primary prevention mostly relies on mechanical protection (clothes covering most parts of the body) that may be completed by chemical protection (repulsives). Secondary prevention relies on early detection of ticks after exposure, and mechanical extraction. There is currently no situation in France when prophylactic antibiotics would be recommended. The incidence of Lyme borreliosis in France, estimated through a network of general practitioners (réseau Sentinelles), and nationwide coding system for hospital stays, has not significantly changed between 2009 and 2017, with a mean incidence estimated at 53 cases/100,000 inhabitants/year, leading to 1.3 hospital admission/100,000 inhabitants/year. Other tick-borne diseases are much more seldom in France: tick-borne encephalitis (around 20 cases/year), spotted-fever rickettsiosis (primarily mediterranean spotted fever, around 10 cases/year), tularemia (50-100 cases/year, of which 20% are transmitted by ticks), human granulocytic anaplasmosis (<10 cases/year), and babesiosis (<5 cases/year). The main circumstances of diagnosis for Lyme borreliosis are cutaneous manifestations (primarily erythema migrans, much more rarely borrelial lymphocytoma and atrophic chronic acrodermatitis), neurological (<15% of cases, mostly meningoradiculitis and cranial nerve palsy, especially facial nerve) and rheumatologic (mostly knee monoarthritis, with recurrences). Cardiac and ophtalmologic manifestations are very rarely encountered.

Incidence of all-cause adult community-acquired pneumonia in primary care settings in France.

OBJECTIVES: To estimate the incidence of all-cause outpatient community-acquired pneumonia (CAP) in adults in France from a national prospective observational study of CAP management in general practice (CAPA). METHODS: Patients aged over 18 years presenting with signs or symptoms indicative of CAP associated with recent onset of unilateral crackles on auscultation and/or a new opacity on chest X-ray were included in the CAPA study. An ancillary survey (AIMSIS) aiming at identifying family physicians' difficulties in including patients and at collecting their opinion on the use of an electronic case report form, determined the number of non-included eligible patients. A three-step analysis was then performed, including computation of the total number of eligible patients, adjustment for seasonality, and extrapolation to the French FP population using indirect standardization to adjust for differences in characteristics between CAPA FPs and French FPs. RESULTS: Between September 2011 and July 2012, 267 (63%) CAPA investigators included 886 CAP patients. Most patients presented with mild CAP. The rates of hospitalization and one-month case fatality were 7% and 0.3%, respectively. Data from 336 (79%) AIMSIS investigators identified 641 additional patients and estimated at 234,023 the number of CAP patients per year (incidence of 4.7 per 1000 persons per year). CONCLUSIONS: Using a pragmatic case definition of CAP patients, this study estimated an incidence of 4.7 per 1000 persons per year that is in the lower half of the range of estimated incidences reported in primary care settings in industrialized countries.

Antimicrobial resistance in community-acquired urinary tract infections in Paris in 2015.

BACKGROUND: Urinary tract infection (UTI) is one of the most frequent community-acquired infection. Escherichia coli resistance has been on the rise since 2000s. METHODS: We conducted a prospective multicenter cohort study including adults who had a positive urine cytobacteriological examination (UCBE) performed in our Parisian suburb laboratory platform from October 2014 to March 2015. RESULTS: A total of 1223 patients were included: 995 (81.4%) women and 228 (18.6%) men. Gram-negative bacilli were isolated in 91% of cases: E. coli accounted for 69.4% of cases. Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) prevalence was 4.2%. Resistance of ESBL-producing E. coli strains to amoxicillin, fluoroquinolones, nitrofurantoin, and fosfomycin was respectively 100%, 80%, <5%, and <10%. Risk factors for bacteriuria caused by ESBL-PE were older age (OR=3.7 [1.99-14.4]; P=0.02), recurrent UTI (OR=3.7 [1.9-7.2]; P=0.05), immunosuppression (OR=9.2 [4.1-19.47]; P=0.01), recent hospitalization within the last three months (OR=4.5 [2.3-8.3]; P=0.05), and recent antibiotic therapy (OR=13.4 [6.29-31.9]; P<0.01). CONCLUSION: The prevalence of ESBL-PE bacteriuria seems to be 4%. Older age, immunosuppression, recurrent UTI, recent hospitalization, and antibiotic therapy are the main risk factors associated with ESBL-PE community-acquired UTI.

[Pertussis immunization within three adult populations concerned by cocoon strategy in Île-de-France]. / Vaccination contre la coqueluche au sein de trois populations d'adultes concernées par le cocooning en Île-de-France.

BACKGROUND: Pertussis is a highly contagious respiratory tract infection with a high morbi-mortality in non or insufficiently immunized infants. Cocoon strategy was implemented in France in 2004 in order to reduce the disease incidence. The main objective of the study was to estimate immunization coverage according to cocoon strategy among eligible adults in three different settings in Île-de-France. METHODS: A descriptive survey was carried out by means of the same questionnaire addressed to relatives of children hospitalized in pediatric wards, to adults living under the same roof as children enrolled in nursery school, and to grandparents who consulted general practitioners. The main outcome was pertussis vaccination of the adult before the child reached 6 months of age. Parent's and grandparent's knowledge about pertussis and medical advice received about cocooning were assessed. The statistical analysis searched for determinants of vaccination according to cocoon strategy. RESULTS: Between August 2014 and March 2015, 383 adults were included within the scope of the survey of whom 250 had a vaccination status that could be verified. Immunization coverage was 59%, 33% and 31% respectively in relatives of children hospitalized in pediatric wards, in adults living with children enrolled in nursery school, and in grandparents who consulted general practitioners offices. In the entire population, knowledge of the risk of pertussis was noted in 60%, 76% and 91% of cases. The main determinant of adequate and documented pertussis vaccination was "having received medical advice" that was present in 54%, 31% and 19% of cases, respectively. CONCLUSION: Cocoon strategy implementation has clearly progressed but remains insufficient. Emphasis needs to be placed on physicians' involvement in pertussis vaccination in adults eligible for cocoon strategy.

CAPECO: Cost evaluation of community acquired pneumonia managed in primary care.

BACKGROUND: Estimating the economic burden of community acquired pneumonia (CAP) managed in ambulatory setting is needed in France since no data are available. METHOD: A retrospective study (CAPECO) was conducted based on a prospective French study describing patients with suspected CAP managed in primary care (CAPA). The aim of the CAPECO study was to estimate and explain medical costs of a disease episode in CAP patients only followed in ambulatory care and in hospitalised patients. Primary endpoints were the direct medical costs, impact on productivity and costs of incident CAP over one year. Secondary endpoint was to describe predictive factors of costs, hospital admission and stay length. RESULTS: In this cohort of 886 patients, resulting in an incidence of CAP of 400 per 100,000 inhabitants per year, the mean direct medical cost of a disease episode of CAP was € 118.8 for strictly ambulatory patients with an equal weight for medical time, drugs, diagnostic procedures and tests. This direct cost was € 102.1 before admission for patients who were finally hospitalised. The mean cost of hospital admissions was € 3522.9. Main predictive factors of hospital admission and stay length were respectively a history of chronic respiratory disease and older age. Factors of direct medical cost were prescribing X-ray examination and having a positive X-ray. The impact of a disease episode on productivity was € 1980 (sd 1400) per ambulatory episode and € 5425 (sd 4760) per episode leading to hospital admission. CONCLUSION: Costs per ambulatory episode were modest but increased substantially in hospitalised patients, who were more numerous when chronic respiratory disorders were present and in the elderly. Indirect costs were significant. Deciders should thus consider both direct and indirect costs when assessing preventive interventions in the context of this disease.

Are French general practitioners consulted before travel to developing countries? A cross-sectional study conducted in a French airport.

BACKGROUND: General practitioners (GPs) could play a central role in preventing travel-related health issues. The aim of this study was to assess, in travellers departing to developing countries from a French airport, the proportion of individuals having sought GP counseling before departure and to identify determinants for having consulted a GP. METHODS: Cross-sectional study conducted between November 2012 and July 2013, in all adults living in France. Sociodemographic, health characteristics, type of travel and resources consulted before departure were collected. A descriptive analysis was performed. Determinants for having consulted a GP before departure were investigated using a logistic regression analysis. RESULTS: Of the 360 travellers included, 230 (64%) sought health counseling before departure. GPs were the main source of information for 134 (58%) travellers having sought health information and the only one for 49 (21%). Almost half of the travellers (48%) departing to sub-Saharan countries did not seek health counseling from a medical doctor (GP, non-GP specialist, specialist consulted in an international vaccination center or occupational physician). Individuals significantly more likely to travel without having consulted a GP were young and male, held foreign nationality, had travelled more than five times before, rarely consulted their GP and were travelling to a non-malarious area. CONCLUSION: GPs were the main but not the only source of information and counseling before traveling to a developing country. This study helps identify the characteristics of individuals likely to travel without having consulted a GP before departure.

[Vaccination against hepatitis B in children: survey on knowledge, opinions, and practices of general practitioners in Île-de-France in 2009]. / Vaccination des nourrissons contre l'hépatite B: connaissances, opinions et pratiques des médecins généralistes de l'Est parisien en 2009.

Vaccination against hepatitis B in infants has been recommended since 1994. However, the WHO target of eradicating the disease in Europe is compromised due to less than 50% coverage in France. A telephone survey conducted in the first quarter of 2009 on 300 general practitioners (GPs) randomly selected in 3 departments in eastern Île-de-France was used to study the knowledge, reported practices, and opinions on the vaccine in infants and the impact of the hexavalent vaccine's reimbursement. Two hundred and nine GPs agreed to answer. Among those taking care of infants (180), 74.4% reported offering them the vaccine. The GPs who did not practice complementary and alternative medicine (CAM), who knew of the reimbursement of the hexavalent and the recommendations, and who practiced in the suburbs rather than in Paris offered to vaccinate infants more frequently. Among GPs taking care of infants, 40.5% reported they had changed their practice since the reimbursement of the hexavalent vaccine. More than a quarter of GPs (26.2%) were opposed to the vaccination against hepatitis B in infants. They were older, practiced CAM more frequently, and were less familiar with the recommendations. Among the respondents, 79% had encountered the fear of side effects from the parents and among them 17.7% did not insist or postponed the discussion. In conclusion, in 2009, over a quarter of GPs were refractory to the vaccination proposal in infants but the hexavalent vaccine seems to have a significant impact on practices.

[Use of Rapid Antigen Detection Test (RADT) among general practitioner teachers at the Paris Descartes University: 2005-2007]. / Evolution de la pratique du test diagnostic rapide (TDR) de l'angine streptococcique parmi les médecins généralistes, maîtres de stage de la faculté de médecine Paris Descartes : 2005-2007.

UNLABELLED: The distribution of the Rapid Antigen Detection Test (RADT) and the National Health Insurance's information campaign should efficiently reduce the unjustified use antibiotic. However, a preliminary survey among GP trainers at the Paris Descartes University indicated that the RADT was seldom used. OBJECTIVES: This study had for aim to describe the RADT use trend among trainers since 2005 and the main obstacles to its widespread use, and to assess the Mac Isaac score use and antibiotic prescriptions. METHODS: Between February and May 2007, a survey was carried out among 66 GPs who were required to report their first ten patients over three years of age presenting with pharyngitis. RADT use and antibiotic prescriptions were compared with those of the 2005 survey. RESULTS: RADT use had decreased (52.5% [48.2-56.8] versus 57.5% [52.1-68.8], p<0.05). GPs did not use the RADT because they considered it "useless in decision making". Clinical findings were sufficient in most cases. The Mac Isaac score was not widely used by GPs (28.3%) and antibiotic prescription had increased except for macrolides which had decreased (10% vs 15%). Among patients with a negative RADT, 11.9% (vs 10.5% en 2005, p<0.001) were prescribed antibiotics. CONCLUSIONS: The RADT use decreased in two years among GP trainers. GPs still prescribe treatment according to clinical findings, most without using diagnostic tools.

[Evaluation of pulmonary function in the elderly. Intergroupe Pneumo Gériatrie SPLF-SFGG]. / Evaluation de la fonction respiratoire chez le sujet âgé. Intergroupe Pneumo Gériatrie SPLF-SFGG.

Aging is associated with a progressive decrease in lung function. As a consequence of aging, individual's reserve is diminished, but this decrease is heterogeneous between individual subjects. Many factors are involved in the overall decline in lung function. The prevalence of asthma in the elderly is estimated between 6 and 10%. Mortality due to COPD is increasing, especially among older subjects. Older subjects are at an increased risk of developing chronic diseases such as Parkinson's disease, which can have consequences for lung function. Under-nutrition is also common in the elderly and can produce sarcopenia and skeletal muscle dysfunction. The presentation of respiratory disorders may differ in the elderly, especially because of a lack of perception of symptoms such as dyspnea. The impact of bronchodilatators or corticosteroids on respiratory function has not been studied in the elderly. Drugs usually used for the treatment of hypertension or arrhythmias, which are often observed with aging, can have pulmonary toxicity. There is no difference between functional evaluation in younger and older subjects but it is more difficult to find predicted values for older patients. Performing pulmonary function tests in older patients is often difficult because of a higher prevalence of cognitive impairment and/or poor coordination. When assessing pulmonary function in the elderly, the choice of tests will be depend on the circumstances, with the use of voluntary manoeuvres dependent on the condition of the patient.