An educational intervention about the classification of penicillin allergies: effect on the appropriate choice of antibiotic therapy in pregnant women.

BACKGROUND: Most pregnant women who self-report penicillin allergy are not truly penicillin-allergic and this misunderstanding often leads to administration of inappropriate antibiotic therapy. Decision algorithms have been developed to guide antibiotic selection but major discrepancies have been reported between guidelines and clinical practice. We aimed to optimize the prescription of antibiotics for pregnant women who self-reported penicillin allergy, using an educational intervention about the classification of penicillin allergies that targeted gynecologists, anesthesiologists and midwives. METHODS: This quasi-experimental study assessed the effect of an educational intervention about the classification of penicillin allergy. For six months, a combination of two strategies was used, namely dissemination of printed educational materials and group education. The principal study endpoint was the appropriateness of the antibiotic therapy, defined in advance for each level of allergic risk. RESULTS: The pre-intervention phase included 903 women; one year after its conclusion, the post-intervention phase began and included 892 women. The prevalence of self-reported penicillin allergy was stable over the two periods (6.8% before vs 5.4% after, P=0.24). The clinical classification of penicillin allergies was more often used after the educational intervention (68% vs 100%, P<0.001). The appropriateness of the antibiotic therapy prescribed to self-reported penicillin allergic-women increased significantly between the two periods, from 5/29 (17.2%) to 18/27 (66.7%, P<0.001). CONCLUSION: An educational intervention about penicillin allergy classification was associated with an improvement in the choice of appropriate antibiotic therapy among women who had reported penicillin allergy.

Improvement in body composition following a supervised exercise-training program of adult patients with cystic fibrosis.

OBJECTIVES: Maintenance of optimal nutritional status is a crucial issue for cystic fibrosis (CF) patients. Here, we evaluate the effects of an 8-week exercise training (ET) program on body composition in CF patients. METHODS: This prospective pilot observational study was conducted in adult CF subjects in stable condition following their annual check-up. The ET program consisted of three sessions per week and included aerobic training (≥30min), muscle strengthening, circuit training, and relaxation. Exercise tolerance (6-minute walk test, 6MWT), pulmonary function, quadriceps isometric strength, and body composition (bioelectrical impedance analysis of fat-free mass [FFM], fat mass, and body cell mass) were analyzed before and immediately after the ET program. A control group of CF patients who preferred not to participate in the ET program received the same evaluations. RESULTS: A total of 43 CF patients were enrolled and offered the ET program; 28 accepted (aged 28±5 years, forced expiratory volume in 1s [FEV1] 48.8±19% predicted) and 15 declined the ET program but agreed to be part of the control group (matched for age and CF severity: 30.8±9 years, FEV1 51.8±16.5%). Pulmonary function was unchanged at the end of the ET program, but significant improvements were observed in 6MWT distance (from 520±96m to 562±105m, P<0.001) and muscle strength (331±141N to 379±168N, P<0.001). Although mean body mass index did not change, the ET group showed significantly increased FFM (43.85±8kg to 44.5±9.2kg, P=0.03) and a trend towards increased body cell mass (21.4±6 to 22.1±6.6kg, P=0.06). All other parameters were unchanged by ET. There were no significant correlations between the increase in FFM and the improvements in either 6MWT distance or muscle strength. The CF control group exhibited no significant changes in any parameters between evaluations. CONCLUSIONS: ET significantly improved FFM, but not body mass index, in CF patients. The results illustrate the superiority of bioimpedancemetry for assessing changes in body composition and reveal the importance of ET for improving not only exercise tolerance but also nutritional status in these patients.

High airborne level of Aspergillus fumigatus and presence of azole-resistant TR34/L98H isolates in the home of a cystic fibrosis patient harbouring chronic colonisation with azole-resistant H285Y A. fumigatus.

Azole-resistant Aspergillus fumigatus (ARAF) has been reported in the domestic environment of patients at risk for aspergillosis. Here, we assessed the mother's and father's homes of an 18-year-old cystic fibrosis patient harbouring chronic colonisation with H285Y CYP51A azole-resistant isolate, in order to explore the link between environmental exposure and ARAF infection. In one dwelling, a very high overall contamination level was found (710-7.240 CFU/m3), with a predominance of A. fumigatus (640-6.490 CFU/m3), and ARAF showing the TR34/L98H mutation was isolated. Mycological follow-up of the patient showed the persistence of H285Y isolates, but no acquisition of TR34/L98H isolates was observed. This could be due to the low proportion of TR34/L98H isolates (<3%), or the establishment of preventative measures and dwelling remediation taken after the environmental investigation. Our data underlines the value of an environmental assessment to establish preventative measures and limit the risk of A. fumigatus exposure and ARAF acquisition.

Biphasic lung injury during Streptococcus pneumoniae infection in a murine model.

OBJECTIVES: Streptococcus pneumoniae is the leading cause of community-acquired pneumonia. We aimed to analyze the epithelial response to S. pneumoniae-induced lung injury. METHODS: Using an in vitro model with 16HBE cells and experimental in vivo murine model of acute lung injury, we analyzed the epithelial response to S. pneumoniae. Lung epithelial cell monolayers were exposed to S. pneumoniae and permeability was assessed by transepithelial resistance (TER) measurement and organization and expression of junction proteins. Functional consequences were studied with an in vivo murine model measuring alveolar permeability, distal alveolar fluid clearance (DAFC), and the alveolar inflammatory response. RESULTS: In vitro, S. pneumoniae induced a dose-dependent decrease in transepithelial resistance, which was associated with significant modifications in the organization of junction proteins assessed by immunofluorescence staining and expression after 6hours of exposure. In vivo, S. pneumoniae induced a transient increase in alveolar permeability with an adequate increase in DAFC 6hours post infection. In a second phase, a permanent increased permeability was associated with a major decrease in DAFC. CONCLUSION: Overall, the epithelial response to S. pneumoniae followed a biphasic pattern with an initial reversible increase in permeability related to the alteration of tight and adherens junctions and a second phase associated with an epithelial injury with a major increase in permeability with a decreased DAFC reflecting an injured alveolar capillary barrier.

Diagnosis of primary antibody and complement deficiencies in young adults after a first invasive bacterial infection.

OBJECTIVES: Screening for primary immunodeficiencies (PIDs) in adults is recommended after two severe bacterial infections. We aimed to evaluate if screening should be performed after the first invasive infection in young adults. METHODS: Eligible patients were retrospectively identified using hospital discharge and bacteriology databases in three centres during a 3-year period. Eighteen to 40-year-old patients were included if they had experienced an invasive infection with encapsulated bacteria commonly encountered in PIDs (Streptococcus pneumoniae (SP), Neisseria meningitidis (NM), Neisseria gonorrhoeae (NG), Haemophilus influenzae (HI), or group A Streptococcus (GAS)). They were excluded in case of general or local predisposing factors. Immunological explorations and PIDs diagnoses were retrieved from medical records. Serum complement and IgG/A/M testings were systematically proposed at the time of study to patients with previously incomplete PID screening. RESULTS: The study population comprised 38 patients. Thirty-six had experienced a first invasive episode and a PID was diagnosed in seven (19%): two cases of common variable immunodeficiency revealed by SP bacteraemia, one case of idiopathic primary hypogammaglobulinaemia, and two cases of complement (C6 and C7) deficiency revealed by NM meningitis, one case of IgG2/IgG4 subclasses deficiency revealed by GAS bacteraemia, and one case of specific polysaccharide antibody deficiency revealed by HI meningitis. Two patients had previously experienced an invasive infection before the study period: in both cases, a complement deficiency was diagnosed after a second NM meningitis and a second NG bacteraemia, respectively. CONCLUSION: PID screening should be considered after a first unexplained invasive encapsulated-bacterial infection in young adults.

[Daily physical activity in adult patients with cystic fibrosis]. / Activité physique quotidienne de patients adultes atteints de mucoviscidose.

Assessment of daily physical activity (DPA) is a major element in the development of respiratory rehabilitation. The aim of this study was to evaluate the DPA and the daily energy expenditure (DEE) in adult patients with cystic fibrosis. Thirty adult patients (16 women, 14 men, mean age 27.1±8.4 years) with cystic fibrosis (FVC: 69.2±19%, FEV1: 55.1±24%, BMI: 20.5±3.6kg/m(2)), in stable condition were included in the study. The questionnaire allowed DPA to estimate DEE from the intensity and type of activity. This tool divides the DEE into four intensity levels: less than 1 Metabolic Equivalent Task (MET), greater than 1 and less than 3 METs, 3-5 METs, and greater than 5 METs. A shuttle test for estimating VO(2) peak was performed in all patients. The DEE reached 9478.4±3224.3kJ24h(-1) and was significantly and highly correlated with calculated peak VO(2) (l/min) (r=0.876, P=<0.001); 22% DEE was less than 3 METs, 10% between 3 and 5 METs et 2,5% greater than 5 METs; 65% DEE was less than 1 MET. There was a strong correlation between DEE and BMI (r=0.860, P=<0.001), a low correlation with FVC (r=0.423, P=0.02). This questionnaire is relevant for estimating DPA and DEE in patients with cystic fibrosis and is an interesting test to be used to evaluate changes in patients after pulmonary rehabilitation.

[Tolerance and efficacy of ceftazidime in combination with aztreonam for exacerbations of cystic fibrosis]. / Intérêt de l'association ceftazidime et aztréonam dans les exacerbations de mucoviscidose à Pseudomonas aeruginosa multirésistant.

BACKGROUND: Antibiotic therapy for acute pulmonary exacerbations in patients with cystic fibrosis is usually chosen based on the results of antimicrobial susceptibility. This can be difficult when bacteria are multiresistant. The objective of this retrospective study was to evaluate the tolerance and efficiency of ceftazidime and aztreonam combination (+/-tobramycin, +/-ciprofloxacin) in the treatment of acute exacerbations in cystic fibrosis patients who were chronically colonized with multiresistant P. aeruginosa. PATIENTS: Seventeen severe patients, with FEV(1)=1070+/-66 mL and BMI=18+/-0.6 kg/m(2), who had chronic colonisation with P. aeruginosa with intermediate sensitivity or resistance to ceftazidime and aztreonam, were studied between June 2003 and March 2007. Oxygen saturation, dyspnoea, weight, FEV(1), FVC, and tolerance were evaluated before and after antibiotic courses. RESULTS: Forty-two courses of treatment, administered between June 2003 and March 2007 were studied: Patients increased their FEV(1) and FVC (p=0.01). One antibiotic course was stopped after four days because of cutaneous side effects. The median delay until the next exacerbation was 101+/-10 days. These courses were compared with other combinations of antibiotics that the patients had received before. The combination of ceftazidime and aztreonam was more effective in patients receiving less than four courses per year for acute pulmonary exacerbation. CONCLUSION: In chronically P. aeruginosa colonised cystic fibrosis patients, ceftazidime and aztreonam combination (+/-tobramycin, +/-ciprofloxacin) is well tolerated and efficient. This treatment suggests a clinical and functional benefit is possible, even in patients with severe disease.

[Could a resident be a remote infectious disease specialist consultant? The Lille teaching hospital experience]. / Faut-il mettre un interne en infectiologie transversale ? L'expérience au centre hospitalier régional et universitaire de Lille.

Infectious diseases specialist consultants are usually senior physicians. At the Lille University Hospital, it was decided to associate an infectious disease (ID) resident to this remote infectious disease activity to improve his training in this field. He visited the emergency department daily, participated in weekly multidisciplinary meetings with medical staff, and was in first line to answer the phone which is the usual means for hospital doctors to ask specific questions. It was a very instructive experience for an ID resident because of the diversity of clinical cases in other departments and he often had to refer to medical literature. However, being a remote consultant could be difficult for an ID resident. He might be less well considered than a senior physician by the other specialists. To conclude, a remote infectious disease consultant can be an ID resident if he is experienced and supervised by a senior physician.

[Factors predicting mortality during an outbreak of Legionnaire's disease in the north of France]. / Epidémie de légionellose dans le Pas-de-Calais (2003--2004): analyse descriptive et facteurs prédictifs d'une évolution défavorable.

Between November 2003 and January 2004 in the North of France a large outbreak of legionnaire's disease affected 85 patients. The clinical, biological and radiological characteristics of the patients were investigated to determine factors associated with mortality. Two populations were defined and compared: patients who died within 28 days and those who survived. Eighty-five patients were included in this study. The median age was 75 years. The median fever was 39.3 +/- 0.1 degrees. Fifteen patients (17.6%) had at least 3 underlying co-morbidities. Cough, dyspnoea, confusion and diarrhoea were found in respectively 46, 68, 47, and 15% of the patients. The median of urea was 0.7 +/- 0.05 g/L, creatinine 16 +/- 1.5 mg/L, CRP 332 +/- 15 mg/L. On the chest X-ray, lung infiltrates were present in 64% and multilobar in 40%. The overall mortality rate was 21%. In univariate analysis, diabetes mellitus, dyspnoea, urea>0.90 g/l and CRP>350 mg/l were predictive factors of mortality. In multivariate analysis, diabetes mellitus, urea>0.90 g/l, and bilateral infiltrates on chest X ray were retained as independent risk factors for death.