Bactéries multirésistantes et voyage [Multidrug-resistant bacteria and travel]

Antimicrobial resistance is a global problem which affects also tropical countries. Travelers to these regions expose themselves to the risk of being colonised and infected with multidrug-resistant bacteria. The region visited, the occurrence of diarrhoea and the use of antibiotics are the principal risk factors leading to colonisation with multidrug-resistant Enterobacteriaceae, which can affect up to 80% of travellers. Colonisation with meticillin resistant Staphylococcus aureus and vancomycin resistant enterococci are often due to contacts with the health care system of the visited country. For the practitioner evaluating a patient returning from abroad it is important to consider the risk of infection with multidrug-resistant bacteriae. Screening for these bacteriae in the stool or by mucocutaneous swabs can be discussed in certain situations

Observational study on the consumption of recreational drugs and alcohol by Swiss travelers.

BACKGROUND: Studies carried out on specific travelers' groups such as students describe an increase in the consumption of alcohol and drugs during travel and vacation time. The present study investigates the risk behaviors (alcohol and drugs) in a general adult population in Switzerland travelling abroad who visited a travel clinic before departure. METHODS: This retrospective study was conducted in a travel clinic between January 2006 and December 2008. 14,496 patients came to the clinic for a pre-travel consultation. 3,537 of them answered a questionnaire about their life habits in Switzerland and during their last trip. The only exclusion criterion was an age inferior to 18 years old.The consumption habits of drugs and at-risk alcohol intake (8 standard drinks (SD) per week for women and 15 SD for men) was analyzed according to gender, sex, destination and profession. Predictors of adopting a risky behavior between habits in Switzerland and during their previous trip were also analyzed. RESULTS: 7% (229/3477) of participants declared having at-risk alcohol consumption in Switzerland and 14% (473/3275 [95% CI 13-16]) during their trip. 9% (332/3527) of the participants used drugs in Switzerland and 5% (178/3481) during their trip. Risk factors for at-risk alcohol consumption during a trip were: at-risk alcohol consumption in Switzerland (OR 31[95% CI 21-45]), smoking (1.7 [95% CI 1-2]), use of drugs in Switzerland (OR 2.2 [95% CI 2-3]), leisure travel (OR 1.6 [95% CI 1-2]) and managerial professions (OR 1.8 [95% CI 1-3]). Risk factors for the use of drugs during a trip were: alcohol consumption in Switzerland (OR 2.1 [95% CI 1-4]), smoking (OR 1.9 [95% CI 1-3]), and use of drugs in Switzerland (OR 29.7 [95% CI 19-45]). CONCLUSIONS: At-risk alcohol consumption and, to a lesser extent, use of drugs, affect a large number of travelers which expose them to health problems during a trip. Exploring the alcohol and drugs consumption patterns of people visiting a travel clinic should be part of the pre-travel routine consultation and would allow to identifying people who would benefit most from a specific prevention

Vaccins de voyage : quel horizon ? [Travel vaccines: what is in the pipeline?]

While no vaccine is on the horizon to prevent traveler's diarrhea, progress has been made in the field of malaria and dengue fever. In both cases, the objective is not primarily the prevention among travelers but rather the reduction of morbidity and mortality in populations living in endemic areas. The immune mechanisms protecting against parasitosis are not well understood, which further complicates vaccine development. The fact that veterinary vaccines against the parasites causing cysticercosis and echinococcosis are available for animals, justifies a certain optimism that vaccines against parasitosis will also be available for humans in the future. We report on recent developments in dengue, malaria, schistosomiasis, and hookworm vaccines

Setting up an outpatient parenteral antimicrobial therapy (OPAT) unit in Switzerland: review of the first 18 months of activity.

Outpatient parenteral antimicrobial therapy (OPAT) has been recognised as a useful, cost-effective and safe alternative to inpatient treatment, but no formal OPAT unit existed in Switzerland until recently. In December 2013 an OPAT unit was established at Lausanne University Hospital. We review here the experience of this new OPAT unit after 18 months of activity. Patient characteristics, clinical activities and outcomes were recorded prospectively. Need and acceptance was evaluated as number of OPAT courses administered and number of patients refusing OPAT. Safety and efficacy were evaluated as: (1) adverse events linked to antimicrobials and catheters, (2) re-admission to hospital, (3) rate of treatment failures and (4) mortality. Over 18 months, 179 courses of OPAT were administered. Acceptance was high with only four patients refusing OPAT. Urinary tract infections with resistant bacteria and musculoskeletal infections were the most common diagnoses. Self-administration of antibiotics using elastomeric pumps became rapidly the most frequently used approach. Sixteen patients presented with adverse events linked to antimicrobials and catheters. OPAT-related readmissions occurred in nine patients. The overall cure rate was 94 %. This study shows that OPAT is very well accepted by patients and medical staff, even in a setting which has not used this type of treatment approach until now. Self-administration using elastomeric pumps proved to be particularly useful, safe and efficient. OPAT offers a good alternative to hospitalisation for patients presenting with infections due to resistant bacteria that cannot be treated orally anymore and for difficult to treat infections

Adequate plasma drug concentrations suggest that amoxicillin can be administered by continuous infusion using elastomeric pumps.

Elastomeric pumps can be useful for the administration of antibiotics in the outpatient setting. To determine amoxicillin degradation in elastomeric pumps, as well as the effectiveness of amoxicillin treatment administered by elastomeric pumps. Antibiotic degradation was measured in elastomeric pumps filled with 6 g of amoxicillin in 240 mL of NaCl 0.9% by drawing samples at 12 h intervals when stored in the fridge for 48 h and when worn around the waist for 24 h. Subsequently nine patients were treated with continuous infusions of 8 or 12 g of amoxicillin per day. Plasma amoxicillin concentrations were measured on each visit to the outpatient parenteral antibiotic therapy unit. Clinical outcome was verified 3 months after the end of treatment. Amoxicillin degradation in elastomeric pumps reached 10% after 48 h in the fridge and an additional 30% when worn around the waist for 24 h. Mean plasma drug concentrations achieved with 12 g of amoxicillin per day were 18.5 mg/L (95% CI 13.5-23.5), which is largely above the MIC of amoxicillin-susceptible bacteria. Nine patients treated for various complicated infections were cured and had no unexpected adverse effects. Adequate plasma drug concentrations and favourable clinical outcomes suggest that amoxicillin can be administered by continuous infusion using elastomeric pumps. This treatment modality does not fulfil formal requirements regarding pharmaceutical stability, but the resulting safety impact in patients is probably limited. Therapeutic drug monitoring and a close clinical follow-up are recommended if this route of administration is chosen

Nouvelles approches pour la prévention de la malaria chez le voyageur [New approaches of malaria prevention for travelers]

Malaria is declining in many tropical countries. This reduction challenges our usual preventive strategies. In moderate to low risk areas, the Swiss guidelines recommend a stand-by emergency treatment. Controversies between experts are numerous though. Professionals at the Travel Clinic in Lausanne has explored shared-decision making through three clinical studies. The first showed that travelers visiting moderate to low risk malaria areas prefer a standby emergency treatment rather than chemoprophylaxis. The second study investigates the use of rapid diagnostic tests by travelers. The third focuses on the prospects of tropical telemedicine. Involving the traveler into the debate is a priority, until a vaccine becomes available

Patient satisfaction in an outpatient parenteral antimicrobial therapy (OPAT) unit practising predominantly self-administration of antibiotics with elastomeric pumps.

Self-administration of antibiotics using elastomeric pumps has become the most frequently used treatment modality at the outpatient parenteral antimicrobial therapy (OPAT) unit of the University Hospital of Lausanne. However, it remains unknown how comfortable patients feel using this mode of treatment. A questionnaire was offered to all patients treated at the OPAT unit between June 2014 and December 2015. The questionnaire was distributed to 188 patients and 112 questionnaires were returned. Seventy-one patients were treated by self-administration, 21 attended the OPAT unit on a daily basis, and 20 received their antibiotics from home-care nurses. Overall, 83-97% of the patients gave the highest possible scores to the four items evaluating their global satisfaction. Subjects treated by self-administration gave a significantly better rating to 6 of the 17 semi-quantitative questions than the patients treated at the OPAT unit or by home-care nurses. There was no item which was more poorly rated by patients treated by self-administered OPAT than by the other treatment groups. In conclusion satisfaction was high in all patients treated by OPAT. The particularly high satisfaction of patients treated by self-administration of antibiotics with elastomeric pumps suggests that a significant number of patients are happy to take over some responsibility for their treatment. Patients' capacity to appropriate their care themselves should not be underestimated by health care professionals

Efficacy and safety of continuous infusions with elastomeric pumps for outpatient parenteral antimicrobial therapy (OPAT): an observational study.

This study aimed to evaluate the efficacy and safety of continuous antimicrobial infusion using elastomeric pumps in an outpatient setting, while simultaneously documenting circulating antibiotic concentration exposure achieved with this mode of administration. Clinical outcomes, adverse events and antibiotic plasma concentrations were recorded for all patients treated by continuous infusion with elastomeric pumps at the outpatient parenteral antimicrobial therapy (OPAT) unit of the University Hospital of Lausanne between December 2013 and January 2017. The study was registered under ClinicalTrials.gov identifier NCT03221140. One hundred and fifty outpatients were treated by continuous intravenous infusions using flucloxacillin (70 patients), cefepime (36), vancomycin (32) and piperacillin/tazobactam (12). The calculated free fractions of each antibiotic were above the epidemiological cut-off values for resistance (ECOFF) of the treated microorganisms in 92% of measurements. Cure was achieved in 143 patients (95%) 3 months after the end of treatment. Four patients needed unexpected readmission and three had a relapse. In none of the patients with unsuccessful treatment was the ratio of free antibiotic plasma concentration/ECOFF <1. Sixteen patients (11%) had an adverse event, none of them being of severity grade 4 or 5. Continuous infusions of flucloxacillin, cefepime, vancomycin and piperacillin/tazobactam using elastomeric pumps seem to be an effective and safe approach to treat outpatients. The number of treatment successes was very high and adverse events occurred at a similar rate as reported by other OPAT centres. The measured antibiotic plasma concentrations confirmed adequate drug concentration exposure for the vast majority of patients