Compliance with the current recommendations for prescribing antibiotics for paediatric community-acquired pneumonia is improving: data from a prospective study in a French network

International audienceBACKGROUND: Lower respiratory tract infection is a common cause of consultation and antibiotic prescription in paediatric practice. The misuse of antibiotics is a major cause of the emergence of multidrug-resistant bacteria. The aim of this study was to evaluate the frequency, changes over time, and determinants of non-compliance with antibiotic prescription recommendations for children admitted in paediatric emergency department (PED) with community-acquired pneumonia (CAP).METHODS: We conducted a prospective two-period study using data from the French pneumonia network that included all children with CAP, aged one month to 15 years old, admitted to one of the ten participating paediatric emergency departments. In the first period, data from children included in all ten centres were analysed. In the second period, we analysed children in three centers for which we collected additional data. Two experts assessed compliance with the current French recommendations. Independent determinants of non-compliance were evaluated using a logistic regression model. The frequency of non-compliance was compared between the two periods for the same centres in univariate analysis, after adjustment for confounding factors.RESULTS: A total of 3034 children were included during the first period (from May 2009 to May 2011) and 293 in the second period (from January to July 2012). Median ages were 3.0 years [1.4-5] in the first period and 3.6 years in the second period. The main reasons for non-compliance were the improper use of broad-spectrum antibiotics or combinations of antibiotics. Factors that were independently associated with non-compliance with recommendations were younger age, presence of risk factors for pneumococcal infection, and hospitalization. We also observed significant differences in compliance between the treatment centres during the first period. The frequency of non-compliance significantly decreased from 48 to 18.8 % between 2009 and 2012. The association between period and non-compliance remained statistically significant after adjustment for confounding factors. Amoxicillin was prescribed as the sole therapy significantly more frequently in the second period (71 % vs. 54.2 %, p < 0.001).CONCLUSIONS: We observed a significant increase in the compliance with recommendations, with a reduction in the prescription of broad-spectrum antibiotics, efforts to improve antibiotic prescriptions must continue

Conformité des prescriptions antibiotiques avec les recommandations de bonne pratique dans les pneumopathies aigües communautaires aux urgences pédiatriques

Contexte. L'utilisation inappropriée d'antibiotiques a conduit à l'émergence et la dissémination de bactéries multi-résistantes. Dans la démarche de bon usage des antibiotiques, l'Agence française de sécurité sanitaire des produits de santé a publié en 2005 des recommandations sur les infections respiratoires basses de l'enfant. L'objectif de cette étude était d'évaluer la conformité des prescriptions antibiotiques dans les pneumopathies aiguës communautaires avec ces recommandations. Méthode. Étude prospective, non interventionnelle, réalisée dans trois services d'urgences pédiatriques de centre hospitalier universitaire, incluant les cent premiers enfants successifs présentant une pneumopathie confirmée radiologiquement, à partir du 1er janvier 2012. La conformité était évaluée sur la nature de la molécule, la voie d'administration et la posologie. Résultats. 294 enfants ont été inclus. 18,6% des prescriptions ont été jugées non conformes. La nature de la molécule était l'élément de non-conformité le plus fréquent (92,4%). La ceftriaxone et l'amoxicilline-acide clavulanique étaient les molécules non-conformes les plus prescrites (respectivement 24,5% et 22,4%). Conclusion. L'application des recommandations reste perfectible. La sensibilisation précoce des étudiants aux résistances antibiotiques et l'instauration d'audit de prescription peuvent être des pistes d'amélioration.NANTES-BU Médecine pharmacie (441092101) / SudocSudocFranceF

Étude prospective de faisabilité d'un algorithme de prise en charge du traumatisme crânien léger de l'enfant de plus de 2 ans au Centre hospitalier universitaire de Nantes

Les traumatismes crâniens légers, pathologies les plus fréquentes chez l'enfant, peuvent être responsables de lésions intracrâniennes graves. Le scanner reste l'examen de référence pour les détecter, mais coûteux et irradiant, il convient de le limiter. Nous avons réalisé une étude prospective unicentrique, sur 187 enfants de plus de 2 ans pour tester la faisabilité de l'arbre décisionnel de prise en charge de ces traumatismes, proposé par Nathan Kuppermann et parue au journal The Lancet en 2009, qui tend à restreindre le recours au scanner en se basant sur des facteurs cliniques prédictifs. Nous avons montré que ce protocole présente une excellente faisabilité car il n'augmente pas le nombre de TDM ni d'hospitalisations prescrites et permet d'inclure 2 patients par jour, avec une bonne observance du protocole, et une bonne acceptation des familles des patients avant d'éventuels projets multicentriques de validation externe. De plus, nous avons confirmé qu'avec une sensibilité de 100%, l'algorithme proposé par N.Kuppermann et al semble performant pour n'ignorer aucune lésion intracrânienneNANTES-BU Médecine pharmacie (441092101) / SudocSudocFranceF

Prise en charge de l'érysipèle en médecine générale

Infection d'incidence croissante depuis quelques années, l'érysipèle à fait l'objet, en janvier 2000, d'une conférence de consensus " Erysipèle et fasciite nécrosante : prise en charge " autorisant son traitement ambulatoire en l'absence de facteurs de gravité et sous couvert d'une surveillance clinique rapprochée par le médecin généraliste. Afin d'évaluer l'impact de ces recommandations en médecine générale, nous avons réalisé une étude rétrospective auprès des médecins généralistes de Loire Atlantique et de Vendée. Les données démographiques et cliniques des 460 cas d'érysipèle relevés sont comparables aux données de la littératures. Les réponses obtenues permettent, cependant, d'observer quelques différences quant à la prise en charge des malades par rapport à la dernière conférence de consensus, notamment en ce qui concerne l'antibiothérapie utilisée, les prescriptions d'anticoagulants, de traitements locaux ou les demandes d'échographies doppler et autres examens complémentaires.NANTES-BU Médecine pharmacie (441092101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Risk factors for unexpected infant death among very premature infants in France

International audienceBACKGROUND: Prematurity is one of the risk factors for sudden unexpected infant death (SUID), a phenomenon that remains poorly explained. MATERIALS AND METHODS: The analysis of specific factors associated with SUID among very premature infants (VPI) was performed through a retrospective review of data collected in the French SUID registry from May 2015 to December 2018. The factors associated with SUID among VPI were compared with those observed among full-term infants (FTI). Results are expressed as means (standard deviation [SD]) or medians (interquartile range [IQR)]. RESULTS: During the study period, 719 cases of SUID were included in the registry, 36 (incidence: 0.60 ‰) of which involved VPI (gestational age: 29.2 [2] weeks, 1157 [364]) g] and 313 (0.18 ‰) involved FTI (gestational age: 40 [0.8] weeks, 3298 [452] g). The infants’ postnatal age at the time of death was similar in the two groups: 15.5 (12.2-21.8) vs. 14.5 (7.1-23.4) weeks. We observed low breastfeeding rates and a high proportion of fathers with no occupation or unemployment status among the VPI compared to the FTI group (31% vs. 55 %, p = 0.01 and 32% vs. 13 %, p = 0.05, respectively). Among the VPI, only 52 % were in supine position, and 29 % were lying prone at the time of the SUID (compared to 63 % and 17 %, respectively, in the FTI group). CONCLUSION: This study confirms prematurity as a risk factor for SUID with no difference in the SUID-specific risk factors studied except for breastfeeding and socioeconomic status of the fathers. VPI and FTI died at similar chronological ages with a high proportion of infants dying in prone position. These results argue for reinforcement of prevention strategies in cases of prematurity

Non-immunization associated with increased risk of sudden unexpected death in infancy: A national case–control study

International audienceObjective: In the context of vaccine scepticism, our study aimed to analyse the association between immunization status and the occurrence of sudden unexpected death in infancy (SUDI). Study design: A multi-centre case–control study was conducted between May 2015 and June 2017 with data from the French national SUDI registry (OMIN) for 35 French regional SUDI centres. Cases were infants under age 1 year who died from SUDI and who were registered in OMIN. Controls, matched to cases by age and sex at a 2:1 ratio, were infants admitted to Nantes University Hospital. All immunization data for diphtheria (D), tetanus (T), acellular pertussis (aP), inactivated poliovirus (IPV), Haemophilus influenzae b (Hib), hepatitis B (HB) and 13-valent pneumococcal conjugate vaccine (PCV13) were collected by a physician. Cases and controls were considered immunized if at least one dose of vaccine was administered. Results: A total of 91 cases and 182 controls were included. The median age was 131 days (interquartile range 98–200.0) and the sex ratio (M/F) was about 1.1. For all vaccines combined (D-T-aP-IPV-Hib and PCV13), 22 % of SUDI cases versus 12 % of controls were non-immunized, which was significantly associated with SUDI after adjustment for potential adjustment factors (adjusted odds ratio 2.01 [95 % confidence interval 1.01–3.98, p = 0,047]). Conclusions: Non-immunization for D-T-aP-IPV-Hib-HB and PCV13 was associated with increased risk of SUDI. This result can be used to inform the general public and health professionals about this risk of SUDI in case of vaccine hesitancy

Prevalence of positive toxicology analysis from the French national registry for sudden unexpected infant death (Tox-MIN)

International audienceBackground: Sudden unexpected infant death (SUID) remains the leading cause of postnatal mortality in many countries. French and international guidelines recommend a thorough examination with toxicology studies.Objectives: The main objective was to determine the prevalence of toxic detection and positive analyses. The secondary objectives were to describe the different toxics and compare children with positive (Tox+) and negative results (Tox-) with other SUID risk factors.Design and methods: We used the data registered from May 2015 to December 2018 by the French national SUID registry (OMIN). It collects data for all SUID cases admitted to any of the 35 participating French SUID referral centers.Results: Of the 624 SUID cases registered in the OMIN, a post-mortem toxicological analysis was performed in 398 infants. Thirty-six patients (9%) were positives for expected (Etox+ (n = 19 [53%], e.g., resuscitation drugs, regular treatments) and unexpected (UTox+) (n = 17 [47%]) toxics. The unexpected toxics were opioids (n = 8), cannabis (n = 4), cocaine (n = 3), cotinine (n = 2), carbon monoxide (n = 2), caffeine (n = 2), alcohol (n = 1) and GHB (n = 1). UTox + infants had a different seasonal distribution (p = .03), a higher incidence of inappropriate sleeping position and bedding at the time of death (respectively OR 3.8, p = .037 - OR 5.4, p = .026); inadequate body hygiene (OR 10.6, p = .0005), a younger maternal age (p = .045) and a higher rate of maternal drug abuse (OR 21.9, p = .0008).Conclusion: The high rate of positive results warrants routine toxicology testing. The imputability of identified molecules is complicated by the presence of other known risk factors for SUID

Do Abused Young Children Feel Less Pain?

International audienceThe objective of this study was to investigate whether acute pain in abused children was under recognized by doctors and nurses compared to children evaluated for accidental injuries. We hypothesize that an abused child's reaction to physical pain could be an additional symptom of this challenging diagnosis. For the observational prospective case control study in an emergency department, children were eligible when: younger than six years old, the reported trauma occurred within the previous seven days, the trauma comprised a bone injury or burn, and the child was able to express his or her pain. The case group comprised children for whom the medical team reported their abuse suspicions and supporting information to a court, and whose cases of abuse were subsequently confirmed. The control group consisted of children with a plausible cause for their injury and no obvious signs of abuse. The children were matched according to their age and type of trauma. The pain was assessed by doctors and nurses before analgesic administration using a certified pain scale. Among the 78 included children, pain was significantly less recognized in the abused children vs. the controls (relative risk=0.63; 95% CI: 0.402-0.986; p=0.04). We observed a discrepancy between the nurses' and doctors' scores for the pain assessments (Kappa coefficient=0.59, 95% CI: 0.40-0.77). Our results demonstrate that pain expression in abused children is under recognized by medical staff. They also suggest that abused children may have reduced pain expression after a traumatic event. Paying particular attention to the pain of abused children may also optimize the analgesic treatment

National Variations in Recent Trends of Sudden Unexpected Infant Death Rate in Western Europe

International audienceObjective: To study recent epidemiologic trends of sudden unexpected death in infancy (SUDI) in Western Europe. Study design: Annual national statistics of death causes for 14 Western European countries from 2005 to 2015 were analyzed. SUDI cases were defined as infants younger than 1 year with the underlying cause of death classified as “sudden infant death syndrome,” “unknown/unattended/unspecified cause,” or “accidental threats to breathing.” Poisson regression models were used to study temporal trends of SUDI rates and source of variation. Results: From 2005 to 2015, SUDI accounted for 15 617 deaths, for an SUDI rate of 34.9 per 100 000 live births. SUDI was the second most common cause of death after the neonatal period (22.2%) except in Belgium, Finland, France, and the UK, where it ranked first. The overall SUDI rate significantly decreased from 40.2 to 29.9 per 100 000, with a significant rate reduction experienced for 6 countries, no significant evolution for 7 countries, and a significant increase for Denmark. The sudden infant death syndrome/SUDI ratio was 56.7%, with a significant decrease from 64.9% to 49.7% during the study period, and ranged from 6.1% in Portugal to 97.8% in Ireland. We observed between-country variations in SUDI and sudden infant death syndrome sex ratios. Conclusions: In studied countries, SUDI decreased during the study period but remained a major cause of infant deaths, with marked between-country variations in rates, trends, and components. Standardization is needed to allow for comparing data to improve the implementation of risk-reduction strategies