Ecstasy : la deuxième vague…

La molécule de MDMA (3,4-méthylènedioxyméthamphétamine ou ecstasy) a plus de 100 ans. Sa consommation a explosé dans les années 1990, essentiellement dans un cadre « festif » ou « récréatif ». Elle a ensuite considérablement diminué au début des années 2000 et connaît actuellement un regain d’intérêt certain. Sa consommation a volontiers été considérée comme anodine avant qu’il n’apparaisse clairement qu’elle pouvait provoquer des décès, en l’absence même de « surdose ». Les mécanismes de toxicité sont multiples, complexes et imparfaitement élucidés. L’interaction avec les principaux neuromédiateurs est certaine. L’ecstasy est classée dans les produits empathogènes. Sa consommation vise à favoriser les relations sociales. De nombreux effets secondaires sont possibles. Les conditions de consommation, en ambiance confinée, avec une activité physique soutenue et prolongée favorisent la survenue des effets secondaires. Les effets secondaires bénins sont tolérés et considérés comme étant le « prix à payer » dans la recherche des effets psychogènes. En raison de son tropisme, les principales complications de la consommation d’ecstasy sont psychiatriques et neurologiques, mais aussi cardiovasculaires, respiratoires et métaboliques. Cependant, les formes graves de l’intoxication sont marquées par un tableau d’hyperthermie maligne responsable de complications multiples et pouvant conduire au décès. Tous les auteurs insistent sur la possibilité de complications, de formes graves, voire de décès après la consommation d’une dose unique de MDMA. Il n’y a pas de traitement spécifique. Le traitement symptomatique est au premier plan. Hydratation et sédation sont les clés de ce traitement.

Impact of an antimicrobial stewardship programme to optimize antimicrobial use for outpatients at an emergency department

BACKGROUND

Antimicrobial stewardship programmes (ASPs) have been effective in optimizing antibiotic use for inpatients. However, an emergency department's fast-paced clinical setting can be challenging for a successful ASP.

AIM

In April 2015, an ASP was implemented in our emergency department and we aimed to determine its impact on antimicrobial use for outpatients.

METHODS

This was a single-centre study comparing the quality of antibiotic prescriptions between a one-year period before ASP implementation (November 2012 to October 2013) and a one-year period after its implementation (June 2015 to May 2016). For each period, antimicrobial prescriptions for all adult outpatients (hospitalized for <24h) were evaluated by an infectious disease specialist and an emergency department physician to assess compliance with local prescribing guidelines. Inappropriate prescriptions were then classified.

FINDINGS

Before and after ASP, 34,671 and 35,925 consultations were registered at our emergency department, of which 25,470 and 26,208 were outpatients. Antimicrobials were prescribed in 769 (3.0%) and 580 (2.2%) consultations, respectively (P < 0.0001). There were 484 (62.9%) and 271 (46.7%) (P < 0.0001) instances of non-compliance with guidelines before and after ASP implementation. Non-compliance included unnecessary antimicrobial prescriptions, 197 (25.6%) vs 101 (17.4%) (P<0.0005); inappropriate spectrum, 108 (14.0%) vs 54 (9.3%) (P=0.008); excessive treatment duration, 87 (11.3%) vs 53 (9.1%) (P>0.05); and inappropriate choices, 11 (1.4%) vs 15 (2.6%) (P>0.05).

CONCLUSION

The implementation of an ASP markedly decreased the number of unnecessary antimicrobial prescriptions, but had little impact on most other aspects of inappropriate prescribing.

Deliberate drug poisonings admitted to an emergency department in Paris area - a descriptive study and assessment of risk factors for intensive care admission

OBJECTIVE

Each year, approximately 165,000 poisonings are managed in the emergency departments (ED) in France. We performed a descriptive analysis of self-poisoned patients admitted to a university hospital ED in the Paris metropolitan area (France) aimed at investigating their outcome and the risk factors for transfer to the intensive care unit (ICU).

PATIENTS AND METHODS

We retrospectively reviewed patients' records and performed multivariate logistic regression analysis to identify risk factors for ICU admission.

RESULTS

During 4 years, 882 self-poisoned patients (median age, 38 years [IQR, 26-47]; sex-ratio, 1M/3F) were admitted to the ED, representing 0.7% of all referred patients. Poisonings mainly resulted from multidrug exposures (53%), including benzodiazepines (78%), serotonin reuptake inhibitors (17%), acetaminophen (13%), antipsychotics (9.5%), imidazopyridines (9.5%), antihypertensive drugs (3%), and polycyclic antidepressants (1.3%). Ethanol was involved in 20% of the exposures. Patients were briefly (<24h) monitored in the ED (55%), transferred to the psychiatric department (30%), medical ward (2%) or ICU (6%), and took an irregular discharge (7%). Among the patients transferred to the ICU, 25% were mechanically ventilated and only one died. Risk factors for ICU admission included antihypertensive (Odds ratio (OR), 40.6; 95%-confidence interval (CI), 7.5-221.9) or antipsychotic drug ingestion (OR, 5.3; CI, 2.0-14.4), male gender (OR, 3.3; CI, 1.30-8.8), and consciousness impairment (OR, 2.1; CI, 1.8-2.5 per point lost in Glasgow coma score).

CONCLUSIONS

Deliberate drug exposure represents a frequent cause of ED admission. Psychotropic drugs are most commonly involved. Transfer to the ICU is rare and predicted by male gender, drug class, and coma depth.