Impact of two-level filtering on emergency medical communication center triage during the COVID-19 pandemic: an uncontrolled before-after study.

BACKGROUND: Rapid access to emergency medical communication centers (EMCCs) is pivotal to address potentially life-threatening conditions. Maintaining public access to EMCCs without delay is crucial in case of disease outbreak despite the significant increased activity and the difficulties to mobilize extra staff resources. The aim of our study was to assess the impact of two-level filtering on EMCC performance during the COVID-19 outbreak. METHODS: A before-after monocentric prospective study was conducted at the EMCC at the Nantes University Hospital. Using telephone activity data, we compared EMCC performance during 2 periods. In period one (February 27th to March 11th 2020), call takers managed calls as usual, gathering basic information from the caller and giving first aid instructions to a bystander on scene if needed. During period two (March 12th to March 25th 2020), calls were answered by a first-line call taker to identify potentially serious conditions that required immediate dispatch. When a serious condition was excluded, the call was immediately transferred to a second-line call taker who managed the call as usual so the first-line call taker could be rapidly available for other incoming calls. The primary outcome was the quality of service at 20 s (QS20), corresponding to the rate of calls answered within 20 s. We described activity and outcome measures by hourly range. We compared EMCC performance during periods one and two using an interrupted time series analysis. RESULTS: We analyzed 45,451 incoming calls during the two study periods: 21,435 during period 1 and 24,016 during period 2. Between the two study periods, we observed a significant increase in the number of incoming calls per hour, the number of connected call takers and average call duration. A linear regression model, adjusted for these confounding variables, showed a significant increase in the QS20 slope (from - 0.4 to 1.4%, p = 0.01), highlighting the significant impact of two-level filtering on the quality of service. CONCLUSIONS: We found that rapid access to our EMCC was maintained during the COVID-19 pandemic via two-level filtering. This system helped reduce the time gap between call placement and first-line call-taker evaluation of a potentially life-threatening situation. We suggest implementing this system when an EMCC faces significantly increased activity with limited staff resources.

Impact of the COVID-19 lockdown period on adult musculoskeletal injuries and surgical management: a retrospective monocentric study.

The coronavirus disease 2019 (COVID-19) pandemic has led to the worldwide implementation of unprecedented public protection measures. On the 17th of March, the French government announced a lockdown of the population for 8 weeks. This monocentric study assessed the impact of this lockdown on the musculoskeletal injuries treated at the emergency department as well as the surgical indications. We carried out a retrospective study in the Emergency Department and the Surgery Department of Nantes University Hospital from 18 February to 11 May 2020. We collected data pertaining to the demographics, the mechanism, the type, the severity, and inter-hospital transfer for musculoskeletal injuries from our institution. We compared the 4-week pre-lockdown period and the 8-week lockdown period divided into two 4-week periods: early lockdown and late lockdown. There was a 52.1% decrease in musculoskeletal injuries among patients presenting to the Emergency Department between the pre-lockdown and the lockdown period (weekly incidence: 415.3 ± 44.2 vs. 198.5 ± 46.0, respectively, p < .001). The number of patients with surgical indications decreased by 33.4% (weekly incidence: 44.3 ± 3.8 vs. 28.5 ± 10.2, p = .048). The policy for inter-hospital transfers to private entities resulted in 64 transfers (29.4%) during the lockdown period. There was an increase in the incidence of surgical high severity trauma (Injury Severity Score > 16) between the pre-lockdown and the early lockdown period (2 (1.1%) vs. 7 (7.2%), respectively, p = .010) as well as between the pre-lockdown and the late lockdown period (2 (1.1%) vs. 10 (8.3%), respectively, p = .004). We observed a significant increase in the weekly emergency department patient admissions between the early and the late lockdown period (161.5 ± 22.9, 235.5 ± 27.7, respectively, p = .028). A pronounced decrease in the incidence of musculoskeletal injuries was observed secondary to the lockdown measures, with emergency department patient admissions being halved and surgical indications being reduced by a third. The increase in musculoskeletal injuries during the late confinement period and the higher incidence of severe trauma highlights the importance of maintaining a functional trauma center organization with an inter-hospital transfer policy in case of a COVID-19s wave lockdown.

Association between excreta management and incidence of extended-spectrum ß-lactamase-producing Enterobacteriaceae: role of healthcare workers' knowledge and practices.

BACKGROUND: The spread of extended-spectrum ß-lactamase-producing Enterobacteriaceae (ESBL-PE) in healthcare environments has become a major public health threat in recent years. AIM: To assess how healthcare workers (HCWs) manage excreta and the possible association with the incidence of ESBL-PE. METHODS: Eight hundred HCWs and 74 nurse-supervisors were questioned through two self-report questionnaires in order to assess their knowledge and practices, and to determine the equipment utilized for excreta management in 74 healthcare departments. Performance on equipment utilized, knowledge and practices were scored as good (score of 1), intermediate (score of 2) or poor (score of 3) on the basis of pre-established thresholds. Linear regression was performed to evaluate the association between HCWs' knowledge/practices and the incidence of ESBL-PE. FINDINGS: Six hundred and eighty-eight HCWs (86%) and all nurse-supervisors participated in the survey. The proportions of respondents scoring 1, 2 and 3 were: 14.8%, 71.6% and 17.6% for equipment; 30.1%, 40.6 % and 29.3% for knowledge; and 2.0%, 71.9% and 26.1% for practices, respectively. The single regression mathematic model highlighted that poor practices (score of 3) among HCWs was significantly associated with increased incidence of ESBL-PE (P = 0.002). CONCLUSIONS: A positive correlation was found between HCWs' practices for managing excreta and the incidence of ESBL-PE, especially in surgical units. There is an urgent need for development of public health efforts to enhance knowledge and practices of HCWs to better control the spread of multi-drug-resistant bacteria, and these should be integrated within infection control programmes.

Are third-generation cephalosporins associated with a better prognosis than amoxicillin-clavulanate in patients hospitalized in the medical ward for community-onset pneumonia?

OBJECTIVES: We aimed to assess whether treatment with ceftriaxone/cefotaxime is associated with lower in-hospital mortality than amoxicillin-clavulanate in pati0ents hospitalized in medical wards for community-onset pneumonia. METHODS: We conducted a retrospective and multicentre study of patients hospitalized in French medical wards for community-onset pneumonia between 2002 and 2015. Treatments with ceftriaxone/cefotaxime or amoxicillin-clavulanate were defined by their start in the emergency department for a duration of 5 days or more with no other ß-lactam. A logistic regression analysis was performed on the overall population, and a propensity score analysis was restricted to patients treated with either ceftriaxone/cefotaxime or amoxicillin-clavulanate. RESULTS: 1698 patients (median age, 80 y) were included, of which 716 and 198 were treated with amoxicillin-clavulanate and ceftriaxone/cefotaxime, respectively. In-hospital mortality was 10% (9-12%). In multivariate analysis, factors associated with in-hospital mortality were treatment with ceftriaxone/cefotaxime (aOR 2.9; (1.4-5.7)), pneumonia severity index class 4 or 5 (aOR 7.8 (4.3-15.7)), do-not-resuscitate order (aOR 8.7 (5.2-14.6)) and fluid therapy (aOR 6.3 (2.5-15.1)). The propensity score analysis was performed on 178 patients treated with ceftriaxone/cefotaxime matched with 178 patients treated with amoxicillin-clavulanate; no significant association between treatment with ceftriaxone/cefotaxime and in-hospital mortality was found (OR 1.5 (0.7-3.0)). CONCLUSION: In the largest study aiming to compare amoxicillin-clavulanate and ceftriaxone/cefotaxime in community-onset pneumonia, ceftriaxone/cefotaxime was not associated with lower in-hospital mortality than amoxicillin-clavulanate. Our results suggest that ceftriaxone/cefotaxime should not be preferred over amoxicillin-clavulanate for patients hospitalized in medical wards with community-onset pneumonia.

Prognostic performance of early absence of pupillary light reaction after recovery of out of hospital cardiac arrest.

INTRODUCTION: Loss of pupillary light reactivity (PLR) three days after a cardiorespiratory arrest is a prognostic factor. Its predictive value upon hospital admission remains unclear. Our objective was to determine the prognostic value of the absence of PLR upon hospital admission in patients with out-of-hospital cardiac arrest. METHODS: We prospectively included all out-of-hospital cardiac arrests occurring between July 2011 and July 2017 treated by a mobile medical team (MMT) based on data from a French cardiac arrest registry database. PLR was evaluated upon hospital admission and the outcome on day 30. The prognosis was classified as good for Cerebral Performance Category (CPC) 1 or 2, and poor for CPC 3-5 or in case of death. RESULTS: Data from 10151 patients was analysed. The sensitivity and specificity of the absence of PLR for a poor outcome were 72.2% (71.2-73.2) and 68.8% (66.7-70.1), respectively. We identified several variables modifying the sensitivity values and the false positive fraction of a factor, ranging from 0.49 (0.35-0.69) for the Glasgow Coma Scale to 2.17 (1.09-2.48) for pupillary asymmetry. Among those living with CPC 1 or 2 on day 30 (n = 1990; 19.6%), 621 (31.2% (29.2-33.3)) had no PLR upon hospital admission. In the multivariate analysis, loss of PLR was associated with a poor outcome (OR = 3.1 (2.7-3.5)). CONCLUSIONS: Loss of pupillary light reactivity upon hospital admission is predictive of a poor outcome after out-of-hospital cardiac arrest. However, it does not have sufficient accuracy to determine prognosis and decision making.

Tetracycline use in the community may promote decreased susceptibility to quinolones in Escherichia coli isolates.

We previously found that the hospital use of tetracyclines is associated with quinolone resistance in hospital isolates of Enterobacteriaceae. Tetracyclines are heavily used in the community. Our aim was to assess whether their use in the community favors quinolone resistance in community isolates of Escherichia coli. Monthly data of community antibiotics use and E. coli quinolone resistance in a 1.3 million inhabitant French area were obtained from 2009 to 2014, and were analyzed with autoregressive integrated moving average (ARIMA) models. Quinolone use decreased from 10.1% of the total antibiotic use in 2009 to 9.3% in 2014 (trend, - 0.016; p-value < 0.0001), while tetracycline use increased from 16.5% in 2009 to 17.1% in 2014 (trend, 0.016; p < 0.0001). The mean (95% confidence interval) monthly proportions of isolates that were non-susceptible to nalidixic acid and ciprofloxacin were 14.8% (14.2%-15.5%) and 9.5% (8.8%-10.1%), respectively, with no significant temporal trend. After adjusting on quinolone use, tetracycline use in the preceding month was significantly associated with nalidixic acid non-susceptibility (estimate [SD], 0.01 [0.007]; p-value, 0.04), but not with ciprofloxacin non-susceptibility (estimate [SD], 0.01 [0.009]; p-value, 0.23). Tetracycline use in the community may promote quinolone non-susceptibility in E. coli. Decreasing both tetracycline and quinolone use may be necessary to fight against the worldwide growth of quinolone resistance.

Systematic review: human gut dysbiosis induced by non-antibiotic prescription medications.

BACKGROUND: Global prescription drug use has been increasing continuously for decades. The gut microbiome, a key contributor to health status, can be altered by prescription drug use, as antibiotics have been repeatedly described to have both short-term and long-standing effects on the intestinal microbiome. AIM: To summarise current findings on non-antibiotic prescription-induced gut microbiome changes, focusing on the most frequently prescribed therapeutic drug categories. METHODS: We conducted a systematic review by first searching in online databases for indexed articles and abstracts in accordance with PRISMA guidelines. Studies assessing the intestinal microbiome alterations associated with proton pump inhibitors (PPIs), metformin, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, statins and antipsychotics were included. We only included studies using culture-independent molecular techniques. RESULTS: Proton pump inhibitors and antipsychotic medications are associated with a decrease in α diversity in the gut microbiome, whereas opioids were associated with an increase in α diversity. Metformin and NSAIDs were not associated with significant changes in α diversity. ß diversity was found to be significantly altered with all drugs, except for NSAIDs. PPI use was linked to a decrease in Clotridiales and increase in Actinomycetales, Micrococcaceae and Streptococcaceae, which are changes previously implicated in dysbiosis and increased susceptibility to Clostridium difficile infection. Consistent results showed that PPIs, metformin, NSAIDs, opioids and antipsychotics were either associated with increases in members of class Gammaproteobacteria (including Enterobacter, Escherichia, Klebsiella and Citrobacter), or members of family Enterococcaceae, which are often pathogens isolated from bloodstream infections in critically ill patients. We also found that antipsychotic treatment, usually associated with an increase in body mass index, was marked by a decreased ratio of Bacteroidetes:Firmicutes in the gut microbiome, resembling trends seen in obese patients. CONCLUSIONS: Non-antibiotic prescription drugs have a notable impact on the overall architecture of the intestinal microbiome. Further explorations should seek to define biomarkers of dysbiosis induced by specific drugs, and potentially tailor live biotherapeutics to counter this drug-induced dysbiosis. Many other frequently prescribed drugs should also be investigated to better understand the link between these drugs, the microbiome and health status.

Systematic analysis of the relationship between antibiotic use and extended-spectrum beta-lactamase resistance in Enterobacteriaceae in a French hospital: a time series analysis.

The influence of hospital use of antibiotics other than cephalosporins and fluoroquinolones on extended-spectrum beta-lactamase (ESBL) resistance among Enterobacteriaceae is poorly known. Our objective was to explore the association between ESBL and hospital use of various classes of antibacterial agents. The relationship between monthly use of 19 classes of antibacterial agents and incidence of nosocomial ESBL-producing Enterobacteriaceae in a French hospital was studied between 2007 and 2013. Five antibiotic classes were significantly and independently associated with ESBL resistance. Uses of tetracyclines (link estimate ± SE, 0.0066 ± 0.0033), lincosamides (0.0093 ± 0.0029), and other antibacterial agents (0.0050 ± 0.0023) were associated with an increased incidence, while nitrofurantoin (-0.0188 ± 0.0062) and ticarcillin and piperacillin with or without enzyme inhibitor (-0.0078 ± 0.0031) were associated with a decreased incidence. In a multivariate model including 3rd- and 4th-generation cephalosporins, fluoroquinolones, amoxicillin, and amoxicillin-clavulanate, 3rd- and 4th-generation cephalosporins (0.0019 ± 0.0009) and fluoroquinolones (0.0020 ± 0.0008) were associated with an increased ESBL resistance, whereas amoxicillin and amoxicillin-clavulanate were not. Hospital use of tetracyclines and lincosamides may promote ESBL resistance in Enterobacteriaceae. Nitrofurantoin and ticarcillin and piperacillin with or without enzyme inhibitor should be considered as potential alternatives to broad-spectrum cephalosporins and fluoroquinolones to control the diffusion of ESBL resistance.

Chemotherapy-driven dysbiosis in the intestinal microbiome.

BACKGROUND: Chemotherapy is commonly used as myeloablative conditioning treatment to prepare patients for haematopoietic stem cell transplantation (HSCT). Chemotherapy leads to several side effects, with gastrointestinal (GI) mucositis being one of the most frequent. Current models of GI mucositis pathophysiology are generally silent on the role of the intestinal microbiome. AIM: To identify functional mechanisms by which the intestinal microbiome may play a key role in the pathophysiology of GI mucositis, we applied high-throughput DNA-sequencing analysis to identify microbes and microbial functions that are modulated following chemotherapy. METHODS: We amplified and sequenced 16S rRNA genes from faecal samples before and after chemotherapy in 28 patients with non-Hodgkin's lymphoma who received the same myeloablative conditioning regimen and no other concomitant therapy such as antibiotics. RESULTS: We found that faecal samples collected after chemotherapy exhibited significant decreases in abundances of Firmicutes (P = 0.0002) and Actinobacteria (P = 0.002) and significant increases in abundances of Proteobacteria (P = 0.0002) compared to samples collected before chemotherapy. Following chemotherapy, patients had reduced capacity for nucleotide metabolism (P = 0.0001), energy metabolism (P = 0.001), metabolism of cofactors and vitamins (P = 0.006), and increased capacity for glycan metabolism (P = 0.0002), signal transduction (P = 0.0002) and xenobiotics biodegradation (P = 0.002). CONCLUSIONS: Our study identifies a severe compositional and functional imbalance in the gut microbial community associated with chemotherapy-induced GI mucositis. The functional pathways implicated in our analysis suggest potential directions for the development of intestinal microbiome-targeted interventions in cancer patients.

Escherichia coli antibiotic resistance in emergency departments. Do local resistance rates matter?

Ciprofloxacin and cotrimoxazole are recommended to treat uncomplicated pyelonephritis and uncomplicated cystitis, respectively, provided that local resistance rates of uropathogens do not exceed specified thresholds (10 and 20 %, respectively). However, Escherichia coli resistance rates in Emergency Departments (ED) remain poorly described. Our objectives were to assess E. coli ciprofloxacin and cotrimoxazole resistance rates in EDs of a French administrative region, and to determine if resistance rates differ between EDs. This was a retrospective study of E. coli urine isolates sampled in ten EDs between 2007 and 2012. The following risk factors for resistance were tested using logistic regression: ED, sex, age, sampling year, sampling month. A total of 17,527 isolates were included. Ciprofloxacin local resistance rates (range, 5.3 % [95 % CI, 4.0-7.1 %] to 11.7 % [95 % CI, 5.2-23.2 %]) were ≤10 % in nine EDs in 2012. Five EDs were risk factors for ciprofloxacin resistance, as were male sex, age and sampling in April or October. Cotrimoxazole local resistance rates (range, 13.3 % [95 % CI, 6.3-25.1 %] to 20.4 % [95 % CI, 18.9-22.0 %]) were ≤20 % in seven EDs in 2012. Five EDs were risk factors for cotrimoxazole resistance, as were age, sampling between October and December, and sampling in 2011 and 2012. We found a significant variability of E. coli ciprofloxacin and cotrimoxazole resistance rates among EDs of a small region. These differences impact on the feasibility of empirical treatment of urinary tract infections with ciprofloxacin or cotrimoxazole in a given ED. Continuous local survey of antibacterial resistance in ED urinary isolates is warranted to guide antibacterial therapy of urinary tract infections.

Systematic review: the role of the gut microbiota in chemotherapy- or radiation-induced gastrointestinal mucositis - current evidence and potential clinical applications.

BACKGROUND: Gastrointestinal mucositis is defined as inflammation and/or ulcers of the gastrointestinal tract occurring as a complication of chemotherapy and radiation therapy, and affects about 50% of all cancer patients. AIM: To assess the role of gut microbiota in the pathogenesis of gastrointestinal mucositis and the potential for manipulations of the microbiota to prevent and to treat mucositis. METHODS: Search of the literature published in English using Medline, Scopus and the Cochrane Library, with main search terms 'intestinal microbiota', 'bacteremia', 'mucositis', 'chemotherapy-induced diarrhoea', 'chemotherapy-induced mucositis', 'radiotherapy-induced mucositis'. RESULTS: The gut microbiota plays a major role in the maintenance of intestinal homoeostasis and integrity. Patients receiving cytotoxic and radiation therapy exhibit marked changes in intestinal microbiota, with most frequently, decrease in Bifidobacterium, Clostridium cluster XIVa, Faecalibacterium prausnitzii, and increase in Enterobacteriaceae and Bacteroides. These modifications may contribute to the development of mucositis, particularly diarrhoea and bacteraemia. The prevention of cancer therapy-induced mucositis by probiotics has been investigated in randomised clinical trials with some promising results. Three of six trials reported a significantly decreased incidence of diarrhoea. One trial reported a decrease in infectious complications. CONCLUSIONS: The gut microbiota may play a major role in the pathogenesis of mucositis through the modification of intestinal barrier function, innate immunity and intestinal repair mechanisms. Better knowledge of these effects may lead to new therapeutic approaches and to the identification of predictive markers of mucositis.

Increasing use of third-generation cephalosporins for pneumonia in the emergency department: may some prescriptions be avoided?

Third-generation cephalosporins are used to treat inpatients with community-acquired pneumonia. Some of these prescriptions may be avoided, i.e. replaced by agents less likely to promote ESBL-mediated resistance. Our objectives were to assess the recent trend of third-generation cephalosporins use for pneumonia in the emergency department, and the proportion of avoidable prescriptions. This was a retrospective study of patients treated for community-acquired pneumonia in an emergency department, and subsequently hospitalized in non ICU wards. Third-generation cephalosporin prescriptions were presumed unavoidable if they met both criteria: (i) age ≥ 65 yr or comorbid condition, and (ii) allergy or intolerance to penicillin, or failure of penicillin first-line therapy, or treatment with penicillin in three previous months. Prescriptions were otherwise deemed avoidable. The proportion of patients treated with a third generation cephalosporin increased significantly from 13.9 % (6.9-24.1 %) in 2002 to 29.5 % (18.5-42.6 %) in 2012 (OR = 1.07 [1.01-1.14] , P = 0.02). This increase was independent from other factors associated with the prescription of a third-generation cephalosporin (immunocompromising condition, antibacterial therapy in three previous months, fluid resuscitation and REA-ICU class). Treatment with third-generation cephalosporin was avoidable in 118 out of 147 patients (80.3 % [72.7-86.2 %]). On day 7 after admission in the ED, treatment with third-generation cephalosporins was stopped or de-escalated in, respectively, 17 % and 32 % of patients. Antibiotic stewardship programs should be implemented to restrict the third-generation cephalosporins use for pneumonia in the emergency department.

How to reduce antibiotic consumption for community-acquired pneumonia?

BACKGROUND: The difficulty to diagnose community-acquired pneumonia (CAP) and the lack of scientific data regarding the optimal duration of antibiotic therapy are responsible for overprescribing antibiotics. OBJECTIVE: The authors had for objective to perform a systematic review of the international medical literature on strategies aimed at reducing antibiotic consumption for CAP. METHODS: We performed a Pubmed search using the keywords CAP, antibiotic use, duration of antibiotic therapy, procalcitonin, short-course treatment, and biomarkers. We then made a critical review of the selected articles. RESULTS: Our review identified two strategies used to reduce antibiotic consumption for CAP. The first one was based on procalcitonin (PCT) use. This strategy, even though reducing the duration of antibiotic therapy, does not seem optimal since it is associated with longer antibiotic treatment than recommended by the Infectious Diseases Society of America. Moreover, this strategy is associated with an increased cost in biochemical tests. The other strategy is based on a 2-step clinical reassessment: 1) during the first 24 hours of hospitalization, to confirm the diagnosis of CAP and 2) during hospitalization, to shorten the duration of antibiotic therapy according to the patient's clinical status. CONCLUSION: Clinical reassessment, currently little studied compared to PCT guidance algorithm, seems to be promising to reduce antibiotic consumption for CAP. Especially since it was never compared to PCT guidance strategy in a randomized clinical trial.

Recent changes in bacteremia in patients with cancer: a systematic review of epidemiology and antibiotic resistance.

Bacteremia remains a major cause of life-threatening complication in patients with cancer. Significant changes in the spectrum of microorganisms isolated from blood culture have been reported in cancer patients over the past years. The aim of our systematic review was to inventory the recent trends in epidemiology and antibiotic resistance of microorganisms causing bacteremia in cancer patients. Data for this review was identified by searches of Medline, Scopus and Cochrane Library for indexed articles and abstracts published in English since 2008. The principal search terms were: "antimicrobial resistance", "bacteremia", "bacterial epidemiology", "bloodstream infection", "cancer patients", "carbapenem resistance", "Escherichia coli resistance", "extended-spectrum ß-lactamase producing E. coli", "febrile neutropenia", "fluoroquinolone resistance", "neutropenic cancer patient", "vancomycin-resistant Enterococcus", and "multidrug resistance". Boolean operators (NOT, AND, OR) were also used in succession to narrow and widen the search. Altogether, 27 articles were selected to be analyzed in the review. We found that Gram-negative bacteria were the most frequent pathogen isolated, particularly in studies with minimal use of antibiotic prophylaxis. Another important trend is the extensive emergence of antimicrobial-resistant strains associated with increased risk of morbidity, mortality and cost. This increasing incidence of antibiotic resistance has been reported in Gram-negative bacteria as well as in Gram-positive bacteria. This exhaustive review, reporting the recent findings in epidemiology and antibiotic resistance of bacteremia in cancer patients, highlights the necessity of local continuous surveillance of bacteremia and stringent enforcement of antibiotic stewardship programs in cancer patients.

[Three recurrent episodes of Tako-Tsubo cardiomyopathy precipitated by an emotional stressful event: a case report]. / Trois épisodes récurrents de Tako-Tsubo secondaires à un choc émotionnel : à propos d'un cas clinique.

Tako-Tsubo cardiomyopathy, first described in 1990 by Sato in Japan, has recently gained increasing consideration when reported in non-Japanese patients, including the United States and Europe. Typical presentation mimics acute coronary syndrome, with acute chest pain and/or dyspnoea, associated to electrocardiographic changes and moderate cardiac biomarkers release, but in which coronary angiography reveals no coronary arteries lesions and echocardiography or left ventriculography shows a reversible left ventricle systolic dysfunction. Prognosis is good, in contrast to acute coronary syndrome, provided that the patients survive the possible life-threatening acute presentation, with correction of the left ventricle systolic dysfunction within several days or weeks. As noted in several reviews, 3.5% to 10% of the patients have a recurrence during the first few years after the initial presentation. Here, we described a case of a 60-year-old female who had three episodes of Tako-Tsubo always preceded by severe emotional stress suggesting a potential common etiopathogenesis.

Why is antimicrobial de-escalation under-prescribed for urinary tract infections?

PURPOSE: To assess the frequency of de-escalation in inpatients treated for community-acquired urinary tract infection and the frequency of conditions legitimating not de-escalating therapy. METHODS: A retrospective study of inpatients (age >15 years) at a large academic hospital who were empirically treated for urinary tract infections due to Escherichia coli susceptible to at least one of the following antibacterial agents: amoxicillin, co-amoxiclav, and cotrimoxazole. De-escalation was defined as the replacement of the empirical broad-spectrum therapy by amoxicillin, co-amoxiclav, or cotrimoxazole. RESULTS: Eighty patients were included. De-escalation was prescribed for 32 of 69 patients for whom it was possible from both a bacteriological and clinical point of view (46 %, 95 % CI, 34-59 %). Initial treatment was switched to amoxicillin (n = 21), co-amoxiclav (n = 2), or cotrimoxazole (n = 8). Thirteen conditions justifying not de-escalating antibacterial therapy were detected in 11 of 48 patients who were not de-escalated (23 %, 95 % CI, 12-37 %): shock, n = 5; renal abscess, n = 1; obstructive uropathy, n = 4; bacterial resistance or clinical contraindication to both cotrimoxazole and ß-lactams, n = 3. CONCLUSIONS: De-escalation is under-prescribed for urinary tract infections. Omission of de-escalation is seldom legitimate. Interventions aiming to de-escalate antibacterial therapy for UTIs should be actively implemented.