Point prevalence survey of antibiotic use in French hospitals in 2009.

OBJECTIVES: To evaluate the feasibility of a point prevalence survey for monitoring antibiotic use in a voluntary sample of French hospitals. METHODS: Demographic and medical data were collected for all inpatients. Additional characteristics regarding antimicrobial treatment, type of infection and microbiological results were collected only for patients receiving antimicrobials. RESULTS: Among 3964 patients in 38 hospitals, 343 (8.7%) received antimicrobial prophylaxis and 1276 (32.2%) antimicrobial therapy. The duration of surgical antimicrobial prophylaxis was >1 day in 41 out of 200 (21%) of the cases. Among patients with antimicrobial therapy, 959 (75.2%) received ß-lactams (including 34.8% penicillins with ß-lactam inhibitors, 22.1% third-generation cephalosporins and 7.8% carbapenems) and 301 (23.6%) received fluoroquinolones (50% orally). A total of 518 (40.6%) patients were treated with more than one drug and 345 (27.2%) were treated for >7 days. Patients treated for hospital-acquired infections (39.2%) were more likely to receive combinations (47.6% versus 34.4%, P < 0.01), carbapenems (14.4% versus 2.6%, P < 0.01), glycopeptides (14.4% versus 3.7%, P < 0.01) and antifungals (17% versus 5.3%, P < 0.01) for a longer duration (7.8 versus 6 days, P < 0.01). Fifty-six patients (4.4%) were treated for >7 days and did not have any microbiological sample drawn. The time allocated for the survey represented 18.3-25.0 h for 100 patients. CONCLUSIONS: The data provide directions for further interventions, such as better use of diagnostic tools, decreasing the treatment duration and the use of combinations. In addition, the survey shows that, although cumbersome, it is feasible to improve the representativeness of national data in European surveys.

[Reversing ICU-acquired immunosuppression: an innovative biomarker-guided therapeutic strategy for decreasing sepsis mortality and nosocomial infection rate]. / Biomarqueurs et thérapeutiques individualisées dans la prise en charge de l'immunosuppression acquise en réanimation.

Septic syndromes (systemic inflammatory response associated with infection) remain a major although largely under-recognized health care problem and represent the first cause of mortality in intensive care units. Regarding immune response, it is now agreed that sepsis induces an anti-inflammatory process, acting as a negative feedback. This inhibitory mechanism becomes deleterious as nearly all immune functions are rapidly compromised. The magnitude and persistence over time of this immunosuppression is correlated with nosocomial infections and mortality. Decreased HLA-DR expression on monocytes/increased percentage of regulatory T cells are biomarkers identifying patients at risk who could benefit from immunotherapy. This review attempts to integrate these new facts into an up-to-date account of sepsis pathophysiology.

[Use of the French medico-administrative database (PMSI) to detect nosocomial infections in the University hospital of Lyon]. / Intérêt de l'utilisation des données du Programme médicalisé des systèmes d'information (PMSI) pour la surveillance des infections nosocomiales aux Hospices Civils de Lyon.

BACKGROUND: Surveillance is an effective element in the fight against nosocomial infections, but the monitoring methods are often cumbersome and time consuming. The detection of infection in computerized databases is a means to alleviate the workload of health care teams. The objective of this study was to evaluate the performance of using discharge summaries in medico-administrative databases (PMSI) for the identification of nosocomial infections in surgery, intensive care and obstetrics. METHODS: The retrospective assessment study included patients who were hospitalized in general surgery, intensive care and obstetrics at different periods of time in 2006 and 2007 depending on the wards. Patients were monitored according to standard protocols which are coordinated at the regional level by the Southeast coordinating centre (CCLIN). The performance of identifying cases of nosocomial infection from discharge diagnoses coded by using the International Classification of Diseases (tenth revision) was evaluated by a study of sensitivity, specificity, positive and negative predictive values with their 95% confidence intervals. RESULTS: Using a limited number of diagnostic codes, the sensitivity and specificity were, respectively, 26.3% (95% CI 13.2-42.1) and 99.5% (95% 98.8-100.0) for the identification of surgical site infections. By expanding the number of diagnostic codes, the sensitivity and specificity were 78.9% (95% CI 65.8-92.1) and 65.7% (95% CI 61.0-70.3). The sensitivity and specificity for case identification of nosocomial infections in intensive care were 48.8% (95% CI 42.6-55.0) and 78.4% (95% CI 76.1-80.1), and were 42.9% (95% CI 25.0-60.7) and 87.3% (95% CI 85.2-89.3) for identification of postpartum infections. CONCLUSION: The PMSI is not a sufficiently efficient method in terms of sensitivity to be used in surveillance of nosocomial infections. A reassessment of the PMSI must be considered, with changes in coding of comorbidity that occurred in 2009.

Automated surveillance in French ICUs: is it feasible? Results from a survey in French ICUs participating in a surveillance network.

A survey was undertaken to evaluate the level of computerization in intensive care units (ICUs) within a French network dedicated to the surveillance of healthcare-associated infections, antimicrobial use (AMU) and antimicrobial resistance (AMR) in ICUs (REA-REZO). Ninety-eight ICUs responded, and patient records were computerized in 57%, antimicrobial prescriptions were computerized in 59% and AMR epidemiology was computerized in 72%. AMU and AMR feedback was provided to the ICU itself for 77% and 65% of ICUs, respectively, and feedback was provided to the national surveillance for 79% and 65% of ICUs, respectively. This study suggests that the level of computerization in ICUs requires further improvement.

Exogenous acquisition of Pseudomonas aeruginosa in intensive care units: a prospective multi-centre study (DYNAPYO study).

BACKGROUND: Pseudomonas aeruginosa remains one of the most common nosocomial pathogens in intensive care units (ICUs). Although exogenous acquisition has been widely documented in outbreaks, its importance is unclear in non-epidemic situations. AIM: To elucidate the role of exogenous origin of P. aeruginosa in ICU patients. METHODS: A chronological analysis of the acquisition of P. aeruginosa was performed using samples collected in 2009 in the DYNAPYO cohort study, during which patients and tap water were screened weekly. Molecular relatedness of P. aeruginosa isolates was investigated by pulsed-field gel electrophoresis. Exogenous acquisition was defined as identification of a P. aeruginosa pulsotype previously isolated from another patient or tap water in the ICU. FINDINGS: The DYNAPYO cohort included 1808 patients (10,402 samples) and 233 water taps (4946 samples). Typing of 1515 isolates from 373 patients and 375 isolates from 81 tap water samples identified 296 pulsotypes. Analysis showed exogenous acquisition in 170 (45.6%) of 373 patients. The pulsotype identified had previously been isolated from another patient and from a tap water sample for 86 and 29 patients, respectively. The results differed according to the ICU. CONCLUSION: Exogenous acquisition of P. aeruginosa could be prevented in half of patients. The overall findings of this survey support the need for studies on routes of transmission and risk assessment approach to better define how to control exogenous acquisition in ICUs.

Experience of European intensive care physicians with infections due to antibiotic-resistant bacteria, 2009.

A survey was performed among European intensive care physicians to obtain information about their perception and experience with selected antibiotic-resistant bacteria. Seventy-eight out of 95 (82%) participants considered having to deal with infections due to antibiotic-resistant bacteria in the intensive care unit where they work was a major or significant problem. Methicillin-resistant Staphylococcus aureus (MRSA) and third-generation cephalosporin-resistant Enterobacteriaceae were the most frequently reported antibiotic-resistant bacteria with 69 (73%) and 67 (71%) participants reporting having treated at least one patient with such an infection during the preceding six months, respectively. Antibiotic-resistant Gram-negative bacteria, including carbapenem-resistant Enterobacteriaceae, were more frequently reported than any selected antibiotic-resistant Gram-positive bacteria, with the exception of MRSA. Fifty (53%) participants declared having treated at least one patient infected with a bacterium totally or almost totally resistant to available antibiotics during the past six months, with 8 participants having treated more than 10 such patients and 13 having treated from 3 to 10 such patients.

Antibioprophylaxis in surgery and interventional medicine (adult patients). Update 2017.

Infection is a risk for any intervention. In surgery, for example, pathogenic bacteria are found in more than 90% of operative wounds during closure. This exists whatever the surgical technique and whatever the environment (the laminar flow does not entirely eliminate this risk). These bacteria are few in number but can proliferate. They find in the operative wound a favourable environment (haematoma, ischaemia, modification of oxido-reduction potential...) and the intervention induces anomalies of the immune defences. In the case of the installation of foreign material, the risk is increased. The objective of antibiotic prophylaxis (ABP) is to prevent bacterial growth in order to reduce the risk of infection at the site of the intervention. The preoperative consultation represents a privileged moment to decide on the prescription of a ABP. It is possible to define the type of intervention planned, the associated risk of infection (and therefore the necessity or not of ABP), the time of prescription before surgery and any allergic antecedents which may modify the choice of the selected antibiotic molecule.

[Is there any microbiologically-based specificity of the management of catheter related infections?]. / Y a-t-il des spécificités dans la prise en charge des infections liées aux cathéters suivant la microbiologie ?

After microbiological identification, several points are to be taken into account: microbiological results, clinical signs of severity, catheter withdrawal or not. French and American recommendations are very different for coagulase negative staphylococci. Catheter withdrawal and antibiotic treatment are recommended by all the authors for coagulase positive staphylococci infections. There is no a clear guideline or studies on Enterobacteriaceae or Pseudomonas infections. Catheter removal and antifungal treatment are recommended for Candida infection.

[Necrotizing bacterial skin and software tissue infection with muscular involvement revealing of cancer of the colon]. / Dermohypodermite bactérienne nécrosante (DHBN) avec atteinte musculaire à Clostridium septicum révélatrice d'un cancer du côlon.

We report the case of a 38-year-old woman with a necrotizing bacterial skin and soft tissue infection with muscular involvement. The clinical picture was similar to a gaseous gangrene of the right lower limb with a septic shock and multiple organ failure, without predisposing factor such as trauma, and necessitating a hip amputation. The primary site of the disease was a perforated colic adenocarcinoma with peritoneal and retroperitoneal infection. The association of necrotizing skin and soft tissue infection with muscular involvement due to Clostridium septicum to a neoplasma is classical and in front of such an infection a neoplasma should be researched.

Antibiotic use and good practice in 314 French hospitals: The 2010 SPA2 prevalence study.

OBJECTIVES: We aimed to assess antibiotic prescriptions to identify potential targets for improvement. METHODS: We conducted a point prevalence survey (November 2010) of antibiotic use in 314 voluntary hospitals recruited by the French Infectious Diseases Society (SPILF) and the National Observatory for Epidemiology of Bacterial Resistance to Antimicrobials (ONERBA). Data were entered online, immediately analyzed and exported. RESULTS: The prevalence of antibiotic use was 19.5% (9059/46,446patients). A higher prevalence was observed in the infectious disease (58.4%), hematology (58%), and intensive care (48.7%) units. The three most frequently used antibiotic classes were aminopenicillins (23.8%), fluoroquinolones (17.9%), and 3rd-generation cephalosporins (16.7%). A monotherapy was prescribed to 64% of patients. The reasons for the antibiotic prescription were written in the medical records of 74% of patients and 62% were consistent with the local guidelines. CONCLUSION: Our results are similar to that of other studies. Various local targets for improvement have been identified to help hospitals define a better antibiotic stewardship.

Possible involvement of multiple cytochrome P450S in fentanyl and sufentanil metabolism as opposed to alfentanil.

Fentanyl, sufentanil, and alfentanil are commonly used as opioid analgesics. Alfentanil clearance has previously been shown to exhibit an important interindividual variability, which was not observed for fentanyl or sufentanil. Differences in pharmacokinetic parameters of alfentanil have previously been associated with the wide distribution of CYP3A4, the only known hepatic cytochrome P450 monooxygenase (CYP) involved in the conversion of alfentanil to noralfentanil. Little is known about the involvement of CYP enzymes in the oxidative metabolism of fentanyl and sufentanil. Microsomes prepared from different human liver samples were compared for their abilities to metabolize fentanyl, sufentanil and alfentanil, and it was found that disappearance of the three substrates was well correlated with immunoreactive CYP3A4 contents but not with other CYPs, including CYP1A2, CYP2A6, CYP2C8, CYP2C9, CYP2D6 and CYP2E1. Specific known inhibitors of CYP enzymes gave similar results, whereas the use of recombinant human CYP enzymes expressed in yeast provided information about the possible involvement of other CYPs than CYP3A4 in the biotransformation of fentanyl and sufentanil. The possible in vivo interaction of fentanyl and sufentanil with other drugs catalyzed by CYP3A4 is also discussed.

Corynebacterium JK: surgical infections in non-immunosuppressed patients.

Infection caused by Corynebacterium JK (CJK) has been recently described in immunocompromised patients. To evaluate the frequency of CJK infection among surgical and trauma intensive care patients, all patients with CJK isolations at clinical sites were reviewed. The criteria used were the presence of bacterial infection symptoms, isolation from significant sites and the efficiency of a vancomycin treatment. Eight patients were studied; 3 of them were considered infected, while 5 were judged only colonized. It is concluded that CJK infections can be a clinical problem in surgical trauma patients.

Nosocomial pulmonary infection by antimicrobial-resistant bacteria of patients hospitalized in intensive care units: risk factors and survival.

The objectives of this study were to identify the risk factors of nosocomial pulmonary infection (NPI) in intensive care units (ICUs) associated with antimicrobial-resistant bacteria (NPI-ARB) and to compare survival after NPI-ARB with NPI due to antimicrobial-sensitive bacteria (NPI-ASB). We analysed data from a surveillance network monitoring nosocomial infections in 27 mixed ICUs in the south-east of France. NPI surveillance data were recorded for 628 patients with documented NPI. The patients were stratified into 2 groups by type of pneumonia: NPI-ASB (445 patients) vs. NPI-ARB (183 patients). Variables associated with NPI-ARB were identified++ by multivariate logistic regression. Survival was calculated using the Kaplan-Meier method. A medical condition for ICU admission [odds ratio (OR) 1.98, 95% confidence interval (95% CI) 1.35-2.91], transfer from another hospital ward [OR 1.66, 95% CI (1.14-2.42)], a colonized central venous catheter [OR 3.47, 95% CI (1.46-8.21)], a stay of [eight days [OR 1.02, 95% CI (1.01-1. 05)] and mechanical ventilation [OR 2.10, 95% CI (1.31-3.36)] were independent risk factors of NPI-ARB. Median survival was 35 days after NPI-ARB and 32 days after NPI-ASB (P=0.92). Survival after bacterial NPI was not associated with antimicrobial susceptibility.

Evaluation of current practices in surgical antimicrobial prophylaxis in primary total hip prosthesis--a multicentre survey in private and public French hospitals.

Deep wound infection is a rare but dreaded postoperative complication after total hip prosthesis (THP) procedures but its incidence can be reduced by systemic antimicrobial prophylaxis. The objective of the present study was to evaluate whether antimicrobial prophylaxis for elective primary THP in patients without any history of hip infection, in orthopaedic wards, participating on a voluntary basis, in French public hospitals and private institutions, complies with published guidelines. Three types of data were collected from anaesthetic and surgical records (November 2000-January 2001) in participating hospitals: (1) administrative data on the hospitals and orthopaedic wards, (2) data on patients, (3) data on compliance of practices with five critical criteria derived from published French guidelines. These criteria concerned administration of prophylaxis, choice of antimicrobial agent, dose of first injection, timing of administration and total length of prophylaxis. Thirty institutions sent data files on 1257 THPs to the coordination centre. Compliance exceeded 80% for all criteria except one (interval between first and second injection). Cumulative compliance with the five criteria was 66.9%. Major compliance failures were an inappropriate interval between the first injection and incision, and total antimicrobial prophylaxis exceeding 48 h. Cumulative compliance was 87.9% in teaching hospitals, 61.8% in general hospitals and 67.7% in private institutions (P<1 x 10(-6)). It was slightly higher when the annual number of interventions was > or =100 (69.4 versus 62.3%; P<0.02). Although the protocol for antimicrobial prophylaxis in THP was clear and easy, one-third of practices did not conform with all five standards. Knowledge of the results by the participating institutions should encourage them to set up working groups to draft care protocols for THP and other surgical interventions, in order to improve practice and perhaps reduce costs.

[Preliminary results in standardization of flow cytometry protocols for monocytic HLA-DR measurement and their application in the follow up of septic shock]. / Standardisation de la mesure de l'antigène HLA-DR monocytaire par cytométrie en flux: résultats préliminaires et application dans le suivi des chocs septiques.

In septic shock, the diminished HLA-DR expression on monocytes has been proposed as a marker of immunoparalysis that correlates with an increased risk for fatal outcome. The present study was designed to determine whether some differences in protocol procedures could lead to discrepant results in HLA-DR measurement. After establishing a reliable protocol, the second objective was to illustrate the immunoparalysis in patients with septic shock. HLA-DR measurement on monocytes was determined by means of flow cytometry in 54 healthy donors and 16 patients with septic shock. We demonstrated that storage temperature, storage duration before staining and red cells lysis constitute crucial steps in HLA-DR measurement. The precision results with coefficients of variation below 5%, were quite convincing for a manual immunoassay. At 48 hours after diagnosis of septic shock, we found severely decreased percentages of monocytes expressing HLA-DR in septic patients (24 +/- 4%, mean +/- SEM) in comparison with healthy donors (90 +/- 1%), p < 0.001). Furthermore, the persistence of a low level of monocytic HLA-DR (less than 50 %) at day 9 after admittance was associated with patients who died. This study illustrates the state of immunoparalysis in patients with septic shock and supports the potential interest in measuring HLA-DR expression on monocytes. However, multicenter studies are now needed to validate this parameter. Based on our analytical results, we conclude that a critical issue in such studies will be the capacity in each center to perform standardized measurement of HLA-DR. It should be remembered that this determination requires the definition of a common analytical procedure between laboratories participating in the trial.

[Serum amyloid protein A (SAA) and HDL. Clinical implication and surgical resuscitation]. / Protéine sérique amyloïde A (SAA) et HDL. Implication clinique en réanimation chirurgicale.

The variation of Apo SAA has been studied in parallel with HDL disturbances in septic patients to try to define the role of SAA in these lipoproteins abnormalities. 14 septic patients hospitalized in a surgical intensive care unit have been studied. In these patients, the determination of cholesterol, HDL-cholesterol, Apo AI, Apo B, Apo SAA and CRP and lipoprotein electrophoresis have been made between the 4th and the 7th day after admission in the unit. A control group includes 10 patients undergoing an elective knee surgery. Our results show that SAA elevation (480 +/- 250 mg/l) are much greater than CRP ones (137 +/- 38 mg/l) with no correlation between the 2 proteins specially in patients with hepatic failure. As reported by others, we find a diminution of total cholesterol (3.0 +/- 1.2 mmol in our series) and HDL-cholesterol (0.39 +/- 0.18 mmol). Apo AI is dramatically decreased (0.50 +/- 0.29 g/l) such as a negative acute phase protein. The polyacrylamide gel electrophoresis of lipoproteins confirms the HDL decrease and reveals an abnormal migration of this class of lipoprotein in 8 cases/14 cases (4 accelerations and 4 double-bands). From the results, this HDL modification does not seem to correlate with SAA elevation; immunoblotting experiments lead to the same conclusion. The data are discussed and compared to other findings of the literature.

[Tracheal rupture in closed cervicothoracic injuries]. / Ruptures trachéales au cours des traumatismes fermés cervico-thoraciques.

Two cases are reported of tracheal fracture occurring during blunt cervico-thoracic trauma. The first case emphasized the impossibility of passing a tracheal tube below the fracture preoperatively, without the fibreoptic or rigid tracheoscope which has the added advantage of making an accurate diagnosis of the fracture. The clinical and paraclinical signs could only lead to a suspicion of the diagnosis, but not its confirmation. The second case showed the use of different ventilatory means during and after surgery (separate lung ventilation, jet ventilation, high frequency ventilation) in case of proximal fractures. The monitoring of intratracheal pressure should be used so as to have the best ventilation for the lowest pressures in the suture zone.

[Regional anticoagulation with citrate in hemodialysis in patients with a high risk for hemorrhage]. / Anticoagulation régionale par le citrate au cours de l'hémodialyse chez les patients à haut risque hémorragique.

During haemodialysis in the patient at high risk for bleeding, heparin cannot be safely used to prevent clotting in the dialysis assembly. Among numerous procedures proposed to reduce the risk for bleeding, Pinnick et al. (N Engl J Med, 308: 258, 1983) proposed the use of citrate as the sole anticoagulant. Citrate toxicity and efficiency were studied during 44 haemodialyses carried out in thirteen patients with a high risk for bleeding or with active bleeding. Three patients had hepatic failure. Two types of citrate solution were used, the trisodium form of citrate (102 mmol.l-1 citrate) or the monosodium form (306 mmol.l-1 citrate). The solutions were infused with a calibrated, pressure insensitive pump, before the dialysis unit at a flow rate of 600 ml.h-1 and 200 ml.h-1 respectively. Sufficient citrate was infused to maintain a clotting time of the blood line and dialyser of more than 18 min. Standard 10% calcium chloride was infused at a constant rate of 7 mg.min-1 into the blood being returned to the patient. The patients were dialysed for 4 h for each haemodialysis with a single-pass system. The dialyses were uncomplicated; no active bleeding was noted. The patient's clotting time was significantly reduced during haemodialysis (18.1 +/- 8.9 min to 14.5 +/- 6.3 min; p less than 0.001). Two-hundred and twenty serum citrate levels were measured. Only nine were above the toxic value of 2 mmol.l-1. No clinical evidence of a decrease in ionized calcium was found: there was no change in the corrected QT intervals and blood pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

[A severe form of heat stroke in a long-distance runner]. / Une forme grave du coup de chaleur chez un coureur de fond.

A case of a severe heat stroke is reported in a 30 yr old white man while running a long-distance race. At the time of admission, moderate hyperthermia (40 degrees C) and coma were two major symptoms found at physical examination. Within 24 h, the clinical picture evolved to multiple organ failure with marked rhabdomyolysis, acute renal failure with hyperkalaemia and lactic acidosis. At this time, were also found a consumptive coagulopathy and acute hepatic failure. After numerous complications, most of them infectious, the patient was discharged after four months in ICU and admitted in a physical rehabilitation department. Muscle biopsy performed three years after the heat stroke showed an abnormal reactivity to caffeine, but a normal reaction to halothane. The relationship between malignant hyperthermia and heat stroke remains uncertain.

[Acute respiratory insufficiency in sickle cell disease]. / Insuffisance respiratoire aigu au cours de la crise drépanocytaire.

Two cases are reported of acute respiratory failure occurring during sickling crises. In the first one, the crisis was characterised by priapism, and in the other one, by abdominal pain. The different causes of these respiratory effects are discussed: infection, fat embolism, pulmonary infarct, haemodynamic pulmonary oedema, as was probably the case in the first patient, or non haemodynamic pulmonary oedema due to sickling, as during conventional treatment of a sickling crisis (oxygen, antibiotics, blood transfusion, cytapheresis). Invasive investigations may contribute to keeping up the clinical picture, because of hypoxic sickling. The water equilibrium of these patients must be monitored with great care. Worsening of the patient's condition despite 48 h of correct treatment must lead to the search for a specific cause.