ANTIFON-CLIC®, a new clinical decision support system for the treatment of invasive aspergillosis: is it clinically relevant?

BACKGROUND

Invasive aspergillosis (IA) is increasing especially in new groups of patients. Despite advances in management, morbidity and mortality related to IA remain high. Thus, Clinical Decision Support System (CDSS) dedicated to IA are needed to promote the optimal antifungal for each group of patients.

PATIENTS AND METHODS

This was a retrospective multicenter cohort study involving intensive care units and medical units. Adult patients who received caspofungin, isavuconazole, itraconazole, liposomal amphotericin B, posaconazole, or voriconazole, for the treatment of IA were eligible for enrollment. The primary objective was the concordance between the clinician's prescription and the prescription recommended by the CDSS. The secondary objective was the concordance according to different hospitals, departments, and indications.

RESULTS

Eighty-eight patients (n=88) from three medical hospitals were included. The overall concordance was 97% (85/88) including 100% (41/41) for center A, 92% (23/25) for center B, and 95% (21/22) for center C. There was no significant difference in concordance among the hospitals (P=0.973), the departments (P=1.000), and the indications (P=0.799). The concordance was 70% (7/10) for isavuconazole due to its use as an empirical treatment and 100% (78/78) for the other antifungals.

DISCUSSION

The concordance rate was high whatever the hospital, the department, and the indication. The only discrepancy was attributed to the use of isavuconazole as an empirical treatment which is a therapeutic option not included in the CDSS.

CONCLUSIONS

This new CDSS dedicated to IA is meeting the clinical practice. Its implementation in routine will help to support antifungal stewardship.

Quel impact des évolutions du circuit du médicament sur l’activité de dispensation durant la permanence pharmaceutique ?

INTRODUCTION

Pharmaceutical permanence (PP), outside the working hours of an in-house pharmacy (PUI), allows to guarantee the continuity of care in health-care institutions. A retrospective review of urgent drug dispensing was carried out in the light of changes in the drug circuit.

MATERIALS AND METHOD

The analysis of drug dispensations was performed over a period from 2011 to 2019. The average number of drugs dispensed per shift, annual dispensations, and their variation by day of the week were studied. The increase is statistically significant and is found on both weekdays and weekends. Each drug was identified according to its Anatomical Therapeutic Chemical (ATC) classification. Data on the activities of our institution (number of hospitalizations, average length of stay) were also collected.

RESULTS

In 2011, an average of 36 medications were dispensed per on-call period, compared with 77 in 2019 (a doubling of activity). The increase is statistically significant and is found on both weekdays and weekends. Neurological drugs and anti-infectives represent on average 43 % of the drugs dispensed. At the same time, there was a decrease in average length of stay and an increase in hospitalizations (-10 % and +16 % respectively).

DISCUSSION

The increase in the average number of medications dispensed per shift is notable. It reflects a strong and gradual increase in activity, which was increased when the full vacuum cabinets (FVCs) were introduced, which improved the quality and safety of the pharmaceutical circuit. The revision of the allocations and the information of prescribers on the drug circuit will optimize the activity and refocus it on the pharmaceutical analysis of urgent needs.

Compliance with carbapenem guidelines in a university hospital

OBJECTIVE

We aimed to evaluate carbapenem prescription compliance with guidelines for nosocomial and community-acquired infections.

PATIENTS AND METHODS

We conducted a prospective study over a four-month period at our university hospital. We included all adult and pediatric hospitalized patients who had received at least one dose of carbapenem. Data was collected from patients' medical records (hard copy and computerized data; CristalLink software). Compliance with guidelines was assessed by two infectious disease specialists. Assessment criteria included indication, antibiotic choice, dosage, and treatment duration.

RESULTS

We included 152 patients in the study (65.4% of men). Carbapenem prescription was appropriate for 76.3% of prescriptions. The use of carbapenems was considered appropriate for 73.9% of empirical prescriptions and for 77.8% of documented prescriptions. Non-compliance with guidelines was mainly due to prescriptions for community-acquired infections. Antibiotic de-escalation could not be initiated in 40.3% of patients and was only initiated in 51.7% of patients for whom it could be considered. Although the average treatment duration was 7.5 days, 23.7% of patients received carbapenems for more than 10 days.

CONCLUSION

These results highlight the need for a strong carbapenem stewardship program in our hospital.

Vesicle permeabilization by purified soluble oligomers of prion protein: a comparative study of the interaction of oligomers and monomers with lipid membranes

The conversion of normal cellular prion protein (PrP) into its pathological isoform, scrapie PrP, may occur at the cell surface or, more probably, in late endosomes. The early events leading to the structural conversion of PrP appear to be related to the presence of more or less stable soluble oligomers, which might mediate neurotoxicity. In the current study, we investigate the interaction of alpha-rich PrP monomers and beta-rich size-exclusion-chromatography-purified PrP oligomers with lipid membranes. We compare their structural properties when associated with lipid bilayers and study their propensities to permeabilize the membrane at physiological pH. We also study the influence of the N-terminal flexible region (residues 24-103) by comparing full-length PrP(24-234) and N-terminally truncated PrP(104-234) oligomers. We showed that both 12-subunit oligomers cause an immediate and large increase in the permeability of the membrane, whereas equivalent amounts of monomeric forms cause no detectable leakage. Although the two monomeric PrP constructs undergo an alpha-to-beta conformational change when bound to the negatively charged membrane, only the full-length form of monomeric PrP has a weak fusogenic effect. Finally, the oligomers affect the integrity of the membrane differently from the monomers, independently of the presence of the N-terminal flexible domain. As for other forms of amyloidogenesis, a reasonable mechanism for the toxicity arising from PrP fibrillization must be associated with low-molecular-weight oligomeric intermediates, rather than with mature fibrils. Knowledge of the mechanism of action of these soluble oligomers would have a high impact on the development of novel therapeutic targets.

[Changing medical practices and nosocomial infection rates in French maternity units from 1997 to 2000]

OBJECTIVES

In this study we describe the changes in medical practices and nosocomial infection rates in obstetrics observed through a surveillance network in the South East of France.

MATERIAL AND METHOD

The maternity units which belong to this network participated in voluntary surveillance using the network's methodology. The criteria for the diagnosis of nosocomial infections were in accordance with the methods described by the Centers for Disease Control and Prevention.

RESULTS

101240 pregnancies including 18503 caesareans (18.3%) were included in the network from 1997 to 2000. During the study period, nosocomial infection rates following caesarean section and vaginal delivery decreased respectively from 7.8% to 4.3% (p < 0.001) and from 2.2% to 0.9% (p < 0.001). This evolution was compared with the evolution of collected risk factors.

CONCLUSION

In spite of the methodology limits, general value of surveillance and infection control programs in maternity units has been confirmed by the results of this surveillance network. During the study period, both obstetrics-related risk factors for nosocomial infection and observed hospital-acquired infection rates were dramatically reduced, what prove an improvement of quality of care in maternity units.

[Acute pulmonary edema during nicardipine and salbutamol therapy for preterm labor in twin pregnancy]

We report the case of a 38-year-old parturient at 30 weeks 2 days term of a multiple pregnancy who experienced acute pulmonary edema more than 48 hours after tocolytic treatment with nicardipine and salbutamol. The patient was transferred from a level 1 perinatal center to a level 3 perinatal center by the Grenoble mobile intensive care unit in application of the in utero transfer protocol for preterm labor before 33 weeks with twin pregnancy. This case illustrates the risk of tocolytic treatment and potential adverse effects in the event of preterm labor on twin pregnancy. The question of associating a second tocolytic after failure of the first is also raised.

Gestion des risques infectieux liés aux piscines et bains collectifs à usage médical

There is no specific legislation concerning pools and others medical hydrotherapy equipments relating hygiene and security rules. For this reason, the hydrotherapy pools use the public swimming pools legislation.

METHOD

This article is based on literature review (database Medline and Embase--manual research).

RESULTS

This article offers a review of pool associated infections along with the description of the measures designed to minimise the possible transmission of infection during hydrotherapy activities such as: Technical measures: pool and premises conception, water treatments, feed tanks, air quality. Hygiene rules for patients and hospital staff and pathologies which are contra-indications to hydrotherapy activities. Microbiological and physico-chemical monitoring.

DISCUSSION

The infectious risk remains low with therapeutic pools. However, the development of specific legislation and surveillance should be enhanced.

CONCLUSION

All these measures are part of the quality assurance program that must be implemented to control the safety of these installations.

Iron supplementation for unexplained fatigue in non-anaemic women: double blind randomised placebo controlled trial

OBJECTIVE

To determine the subjective response to iron therapy in non-anaemic women with unexplained fatigue.

DESIGN

Double blind randomised placebo controlled trial.

SETTING

Academic primary care centre and eight general practices in western Switzerland.

PARTICIPANTS

144 women aged 18 to 55, assigned to either oral ferrous sulphate (80 mg/day of elemental iron daily; n=75) or placebo (n=69) for four weeks.

MAIN OUTCOME MEASURES

Level of fatigue, measured by a 10 point visual analogue scale.

RESULTS

136 (94%) women completed the study. Most had a low serum ferritin concentration; <or= 20 microg/l in 69 (51%) women. Mean age, haemoglobin concentration, serum ferritin concentration, level of fatigue, depression, and anxiety were similar in both groups at baseline. Both groups were also similar for compliance and dropout rates. The level of fatigue after one month decreased by -1.82/6.37 points (29%) in the iron group compared with -0.85/6.46 points (13%) in the placebo group (difference 0.95 points, 95% confidence interval 0.32 to 1.62; P=0.004). Subgroups analysis showed that only women with ferritin concentrations <or= 50 microg/l improved with oral supplementation.

CONCLUSION

Non-anaemic women with unexplained fatigue may benefit from iron supplementation. The effect may be restricted to women with low or borderline serum ferritin concentrations.

Asymmetric induction in the [4+2]cycloaddition of cyclopentadiene and furan to chiral derivatives of fumaric acid

[4+2]Cycloaddition reactions of cyclopentadiene (1a) and furan (1b) to N,N'-fumaroyldi[(2R)-bornane-10,2-sultam] (2) and to N,N'-fumaroyldi[(2R)-bornane-10,2-(2'-phenyl-pyrazol-3'-one)] (3) are presented. A correlation between the solvent polarity and the logarithm of the diastereoisomer ratio (dr) was found for the uncatalyzed [4+2]cycloaddition of 1a to 3.

The Distance to the Soft Gamma Repeater SGR 1627-41

We report millimeter observations of the line of sight to the recently discovered soft gamma repeater SGR 1627-41, which has been tentatively associated with the supernova remnant (SNR) G337.0-0.1. Among the eight molecular clouds along the line of sight to SGR 1627-41, we show that SNR G337.0-0.1 is probably interacting with one of the most massive giant molecular clouds (GMCs) in the Galaxy, at a distance of 11 kpc from the Sun. Based on the high extinction to the persistent X-ray counterpart of SGR 1627-41, we present evidence for an association of this new soft gamma repeater (SGR) with the SNR G337.0-0.1; they both appear to be located on the near side of the GMC. This is the second SGR located near an extraordinarily massive GMC. We suggest that SGR 1627-41 is a neutron star with a high transverse velocity ( approximately 1000 km s-1) escaping the young ( approximately 5000 yr) SNR G337.0-0.1.

An economic approach to the MIC

The determination of the Inhibitory Concentration in Diffusion (ICD) is proposed as an alternative to the agar dilution Minimal Inhibitory Concentration (MIC) that is time-consuming and cumbersome for routine use. Based on the technique of the disk diffusion test, it consists in calculating a continuous variable, the ICD, corresponding to the antibiotic concentration in the agar at the edge of the inhibition zone. Six antibiotics were tested (ampicillin, cefotaxime, erythromycin, gentamicin, nalidixic acid and rifampicin) each against 17 to 51 strains of enterobacteria, Staphylococcus aureus and Enterococcus spp. and six other antibiotics (cefsulodin, ceftazidime, imipenem, piperacillin, ticarcillin and tobramycin), against 13 to 25 strains of Pseudomonas aeruginosa. A total of 284 antibiotic-strain combinations were tested. Three different antibiotic charges were obtained for each antibiotic by cutting commercial disks in two and four equal pieces. The ICD was calculated for each strain from the size of inhibition zones around a full disk, a half and a quarter of a disk. Concurrently, the MIC was performed, using a conventional agar dilution method. There was a good correlation between the two methods and reproducibility for the ICD proved to be correct. This reliable technique is very efficient both in terms of laboratory time and cost of materials and could be proposed for widespread use in clinical laboratories.

Mathematical model of the interactions between Micrococcus spp. and Pseudomonas aeruginosa on agar surface

The interactions between six different Micrococcus species and two strains of Pseudomonas aeruginosa were studied on an agar surface. This type of interaction on solid surface could act as a model of situations occurring either in the environment, in food or in man. The hypothesis of an amensalistic relationship between a Micrococcus spp. and Pseudomonas aeruginosa, due essentially to Ps. aeruginosa bacteriolytic enzymes, is retained as the basis for a mathematical model of the variations of the colony surface of Micrococcus spp. (S) with respect to the distance (d) from Ps. aeruginosa cells. The diffusion of the bacteriolytic substance in agar explains the limitation of the growth of the Micrococcus spp. This model S = Smax (1-e-md2) is shown to be adapted to all the interactions studied.

[Post-antibiotic effect of three aminoglycosides against Klebsiella pneumoniae]

This paper introduces a new method to quantify post antibiotic effect. This method was applied to the study of the effect of three aminoglycosides antibiotics on seven strains of Klebsiella pneumoniae. The antimicrobial was removed by filtration, washing with peptone broth and neutralization by heparin. Growth curves were monitored by automated measurement of optical density with Urimat-ATB (bioMérieux). The inoculum fluctuation bias was eliminated with the help of a mathematical analysis of results. Absence of carry-over was controlled for each bacteria-antibiotic combination. A significant post antibiotic effect was observed with the three antibiotics after 2 hours exposure to a concentration equivalent to 2 x MIC. There was no significant difference between the 3 aminoglycosides tested.

A randomised controlled trial of a low-molecular-weight heparin (Enoxaparin) to prevent deep-vein thrombosis in patients undergoing vascular surgery

The incidence of postoperative deep vein thrombosis (PDVT) after aortic surgery and lower limb revascularisation has not been assessed by a large prospective study. In a prospective randomised trial the effect of a low-molecular-weight heparin fragment, Enoxaparin (ENX) 4200 anti factor Xa IU once daily was compared to that of unfractionated heparin (UFH) 7500 IU twice daily. Two hundred and thirty-three consecutive patients were classified into three groups, aortic or aortoiliac and aneurysmectomy (n = 75), aorto-femoral bypass for atherosclerotic disease (n = 71), and femoropopliteal or femorodistal bypass (n = 87). Patients were analysed for development of deep vein thrombosis by Duplex scanning and, if positive, by venography between the seventh and tenth postoperative day. PDVT was present in 10 patients in the ENX group and in four patients in the UFH group (8.2 and 3.6% respectively, NS). The incidence of PDVT was 8% after aortic or aortoiliac aneurysmectomy, 7% after aortofemoral revascularisation, and 3.4% after femoropopliteal or femorodistal bypass. The overall incidence of PDVT after aortic surgery was 7.5% (95% CI 5.4-9.7). There was no pulmonary embolism. Intra-operative blood loss and postoperative bleeding events did not differ significantly between the ENX and UFH groups. After 1 month follow-up, no clinical event or death could be related to PDVT or pulmonary embolism. In conclusion, in vascular surgery ENX is as safe and effective in the prevention of PDVT as is UFH.

Two cases of severe infection with beta-haemolytic group A streptococci associated with a toxic-shock-like syndrome

Two cases of severe infection due to Streptococcus pyogenes associated with a toxic-shock-like syndrome (TSLS) and also with serious soft-tissue infection are described. Serotyping and detection of A, B and C exotoxins were carried out on strains isolated from blood cultures and skin samples. The strain of serotype M1 T1, which produced 10 ng/ml of exotoxin A and also synthesised exotoxins B and C, caused severe TSLS associated with major skin lesions. The second strain of serotype M12 T12, which produced only 1 ng/ml of exotoxin A and synthesised exotoxin B, was associated with clinical manifestations of adult respiratory distress syndrome. The relationship between the magnitude of exotoxin production and the severity of clinical manifestations cannot be established from these two cases.

Treatment of mediastinitis in children after cardiac surgery. A study of 20 cases

Twenty-three cases of mediastinitis after cardiac surgery in children were treated by us between 1973 and 1976. Three patients died within 6 hours of admission. Treatment used in the tweny other cases are discussed. The mean age of the patients was three years and three months. The mediastinitis was evident an average of twelve days after extracoporeal circulation. A staphylococus was always responsible for the infection. Treatment was a combination of surgery, antibiotics and respiratory and nutritional supplies. The surgical treatment consisted of a careful mediastinal cleansing with resection of the sternal edges. In fifteen patients the thorax was closed after surgery, and an irrigation system installed using a solution of 4% Dakin in physiologic saline. Recovery was simple in 5 patients. In the 10 other patients of this group the thorax had to be reopened; one patient died after 90 days from Serratia marcescens endocarditis. The thorax was left open initially in five patients: one patient of this group died from candida endocarditis. All patients needed endotracheal ventilation through a nasotracheal tube (7 to 90 days of ventilation). Treatment with bactericidal antibiotics was pursued for three months and a monotherapy was kept for nine months. After reviewing the observed complications, our methods and results are compared with others in the literature.