[Elderly patients presenting with fever and respiratory problems in an intensive care unit. Diagnostic, therapeutic and prognostic impact of a systematic infectious disease consultation]. / Patients âgés fébriles avec signes respiratoires dans un service d'urgences. Impact diagnostique, thérapeutique et pronostique d'une consultation systématique d'infectiologie.

OBJECTIVE: To measure the impact of an infectious disease consultation on the morbidity and mortality in patients aged over 75 presenting with fever and respiratory signs and treated with antibiotics in an intensive care unit. METHOD: Retrospective study comparing two groups of patients having been seen or not by an infectious disease specialist within the first 24 hours of hospitalisation. The data available before prescription of the antibiotherapy by the intensive care physician were collected, together with the diagnostic and therapeutic proposals of the infectious disease specialist. Morbidity and mortality were assessed from the medical files and nurses charts and included: duration of fever and hospitalisation, complications with antibiotherapy and venous catheters and the cause or causes of death. RESULTS: 169 patients were included, 115 of whom had been seen (study group) and 54 who had not bee seen (control group) by an infectious disease specialist. Sixty-six percent of the infectious disease specialists (76/115) proposed a differential diagnosis, although a diagnostic re-assessment was effective for only 22% of the patients in the control group (p< 0.01). A 50% reduction in antibiotic prescriptions was observed in the study group. The duration of hospitalisation was greater in the study group than in the control group (a mean of 10 versus 7 days, p<0.01), but was unrelated to the consultation with a specialist. The same result was observed with the complications of venous catheterism (16 versus 2 cases, p =0.04). The rate of mortality was of 13% in both groups. CONCLUSION: The over-zealous diagnoses of infection are the primary cause of over-prescription of antibiotics. Despite the population studied, considered as fragile, the 50% reduction in antibiotics is without any negative prognostic impact.

[Motives for the prescription of antibiotics in the emergency department of the University Hospital Center in Nice. A prospective study]. / Motifs de prescriptions des antibiotiques dans le service des urgences du centre hospitalier universitaire de Nice. Enquête prospective.

OBJECTIVES: Since April 1999, we have set-up an infectious disease consultation in the emergency unit of the University Hospital in Nice. Unjustified antiobiotherapy is often initiated. We therefore conducted a survey to study the motives and validity of antibiotic prescriptions. METHOD: This prospective study was conducted in two phases. The first consisted in asking the emergency physicians prescribing antibiotics to fill-in a questionnaire giving information on the diagnosis established and the antiobiotherapy proposed. In the second phase, the diagnoses and corresponding treatments were submitted to 4 experts who assessed the acceptability of the diagnoses and the antibiotics prescribed. The experts only had access to the clinical and para-clinical data available. Moreover, their therapeutic judgement was based on previously published consensuses. RESULTS: The 6-month survey collected 117 questionnaires that could be analysed. The rate of error in diagnosis was of 33% (39/117). Thoracic x-rays could not be interpreted in 11% of cases. In single variant analysis, factors of erroneous diagnosis were due to its interpretation by an internist, the diagnostic category of "broncho-pulmonary infections" and the lack of documentation. In multi variant analysis, only the lack of documentation was related to erroneous diagnosis (OR = 5.5; IC 95% (2.03; 15.30), p < 0.0002). The rate of antibiotherapy not adapted to the diagnosis made by the physician was of 32% (37/117). In 24 cases the modalities of the prescription were incorrect and in 13 cases the prescription was unjustified. Only the status of the prescriber (internist) was statistically associated with an antibiotherapy not adapted to the diagnosis (OR = 2.2; IC 95% (0.93; 5.26), p < 0.05). CONCLUSION: Unjustified antibiotherapy in an emergency unit is generally due to erroneous diagnosis of infection. The lack of documentation and inexperience of the prescribers appear to be the two elements contributing to unjustified antibiotherapy.

[A rare case of severe pulmonary artery hypertension. Thrombosing pulmonary microangiopathy due to tumor]. / Une hypertension artérielle pulmonaire sévère de cause rare: la microangiopathie pulmonaire tumorale thrombosante.

We report a case of acute respiratory insufficiency with acute cor pulmonale and a fatal outcome. Right cardiac catheterisation enabled a diagnosis of precapillary pulmonary arterial hypertension to be made with a mean pulmonary arterial pressure of 61 mmHg and a pulmonary capillary pressure of 12 mHg. An autopsy was carried out and this revealed a microscopic pulmonary tumour emboli with lymphangitis carcinomatosis. In particular, it showed an association of fibrocellular proliferation at the level of the intima in the small calibre pulmonary arteries and arterioles permitting the unusual diagnosis of thrombosing pulmonary microangiomathy due to tumour. The physiopathological mechanism of this particular form of pulmonary tumour emboli is discussed; it would be secondary to an activation of the coagulation systems by the embolic tumour cells. Once activated, it is the lesions in the intima and not the carcinoma cells which generate the pulmonary arterial hypertension by vascular obstruction.