Subcutaneously administered antibiotics: a national survey of current practice from the French Infectious Diseases (SPILF) and Geriatric Medicine (SFGG) society networks

A national survey was performed to explore antibiotic prescription by the subcutaneous (sc) route among French infectious diseases and geriatric practitioners. Among the participating physicians, 367 (96.1%) declared administering sc antibiotics at some point. Ceftriaxone was prescribed sc by all but one, and ertapenem, teicoplanin, aminoglycosides and amoxicillin by 33.2%, 39.2%, 35.1% and 15.3%, respectively. The sc route was resorted to mainly in case of unavailable oral, intravenous or intramuscular routes, especially during palliative care. Pain, skin necrosis and lack of efficacy were the main adverse effects, reported by 70.8%, 12.8% and 19.9% of practitioners, respectively. Further studies are needed to precise the indications, modalities and tolerance of sc antibiotic use.

Aminoglycosides use in patients over 75 years old

OBJECTIVE

to describe aminoglycoside use and nephrotoxicity in patients older than 75 years.

DESIGN

retrospective multicenter study.

SETTING

hospital department, rehabilitation, long-term care center.

POPULATION

patients ≥75 years old treated by aminoglycosides.

RESULTS

184 patients, mean age: 84.4 years (range: 75-101). One hundred and twenty-seven patients received other nephrotoxic drug(s). Gentamicin (70%) and amikacin (30%) were used and the once-daily dosing was preferred (92%). Average treatment period was 2.75 (1-10) days for amikacin and 4.4 (1-30) for gentamicin with average dosage 13.5 and 3.5 mg/kg/day, respectively. The monitoring of maximal plasmatic concentration (Cmax) was done in 37 patients, 9 of them had probabilistic treatment. Only one had a Cmax fulfilling the objective of French recommendations (gentamicin >30 mg/l, amikacin >60 mg/l). When infection was documented, the objective of Cmax >10 × minimal inhibitory concentration of the strain was reached for 27%. Minimal plasmatic concentration was checked in 38% of cases, with adequate value (gentamicin <0.5 mg/l, amikacin <2.5 mg/l) for 37%. At the end of aminoglycoside course, 40 patients increased their serum creatinine >25% of the baseline value. In multivariate analysis, this was associated with treatment length ≥3 days and concomitant use of nephrotoxic drugs.

CONCLUSION

aminoglycosides dosing used in elderly patients probably need therapeutic drug monitoring and dose adjustment. Aminoglycosides are used to treat severe infections. One of the most important side effects is nephrotoxicity in oldest patients. To minimise nephrotoxicity, short treatments are necessary and avoiding others nephrotoxic drugs could be relevant.

[Recommendations of the Infectious Disease Committee of the French Association of Urology. Diagnosis, treatment and monitoring candiduria]

The candiduria are frequently encountered in urology. We present the recommendations of the Infectious Diseases Committee of the French Association of Urology for diagnosis, treatment and monitoring of urinary tract infections. C. albicans is the most frequently isolated species, representing 60% of the isolates. Immunosuppression, diabetes mellitus, age extremes of life, the presence of catheters or procedures on the urinary tract are risk factors for Candida urinary tract infection. The candiduria is usually asymptomatic and does not need treatment. Only 4-14% of patients with candiduria have symptoms of urinary infection. It is necessary before choosing candiduria isolated on a first urinalysis to eliminate contamination by conducting a second harvest. In patients surveyed, the removal of the material allows the resolution of the candiduria nearly half the time and represents the first step of management. Oral fluconazole is the recommended treatment for cystitis (400 mg on day 1 and 200 mg daily for 7 to 14 days). In cases of pyelonephritis without associated candidemia, the first-line therapy is fluconazole (3-6 mg/kg/day) for 14 days or amphotericin B at a dose of 0.5 to 0.7 mg/kg/day with or not associated to flucytosine when potentially resistant strain (C. glabrata).

Candiduria in those over 85 years old: a retrospective study of 73 patients

OBJECTIVE

Candiduria is a common finding in the growing population of very old patients that has not been previously studied. The objective was to study candiduria in the population aged 85 and over, including an estimation of the incidence, factor of acquisition, and evaluation of treatment and mortality.

METHODS

Retrospective monocentric study. Materials medical charts of patients aged of 85 and over who have candiduria diagnosed at Nimes University Hospital.

RESULTS

The prevalence of candiduria in the hospitalized very old patients was 8.9%. More than half of strains isolated were C. albicans (59%). Mean age was 89.7 years old with 53 women and 20 men. Urinary catheter (55%) and prior antibiotic use (67%) were commonly found. Fifteen patients with candiduria were treated, consistently with fluconazole. Patients treated had higher Mini Mental Test score than the others. A high C-reactive protein level, Mac Cabe score or Charlson's score >7 were associated with 6 months mortality.

CONCLUSION

Episodes of candiduria in oldest old were associated with frailty and vulnerability of the patient. The medical decision for antifungal treatment is usually difficult to make but it did not seem to influence mortality.

Pont épiphysaire longitudinal déformant du premier métatarsien ou « métatarse delta »

PURPOSE OF THE STUDY

The longitudinal epiphyseal bracket (LEB) or delta bone is a rare congenital ossification anomaly generally observed in finger or toe phalanges but occasionally in the metatarsus or metacarpus. LEB is initially composed of cartilage forming a bracket linking the proximal and distal epiphyses and causing defective growth of the primary ossification focus. Changes in bone growth secondary to the presence of a LEB would be the cause the angle malformations and length discrepancies observed in these subjects. This raises significant therapeutic problems and repeated surgical interventions when the diagnosis is not established early enough. The clinical presentation of LEB of the first metatarsus is similar to metatarsus adductus or hallux varus primus. The particular aspect on the plain x-ray enables the diagnosis.

MATERIAL AND METHODS

We operated five feet presenting LEB of the first metatarsus in three children aged on average 23 months (range 8 months to 3 years 10 months). The cartilage bracket was removed, followed by metatarso-phalangeal centromedullary pinning. We studied the course of the angle and length deformities and report outcome at mean follow-up of 4 years 11 months (range 2 years to 3 years 10 months).

RESULTS

Clinical improvement with correction of the angle deformities was observed in all feet. The length discrepancies did not resolve completely. The degree of correction depended on the age at the time of surgery.

DISCUSSION

In light of the results obtained in this series and considering the negative prognosis of late surgical management, it would be advisable to obtain a plain x-ray of the foot in all children presenting metatarsus adductus associated with a short first ray.