C. Gras-Le Guen

Valeur diagnostique des critères de suspicion d’infection néonatale précoce : bilan dix ans après les recommandations de l’Anaes

BACKGROUND Because clinical symptoms and biological markers are neither sensitive nor specific, newborns are frequently suspected of having an infection. In France, 30-50% of newborns are suspected of having early-onset sepsis (EOS) and many of them undergo laboratory tests and empirical antibiotic treatments while awaiting results. The aim of this study was to evaluate the diagnostic value of various suspicion criteria for EOS as recommended by the Anaes since 2002, and the value of umbilical cord blood procalcitonin (PCT), currently assayed in our maternity ward. MATERIAL AND METHODS This 4-year retrospective study in the CHU of Nantes included hospitalized newborns with suspected early neonatal infection. Infection status was established according to the Anaes definitions and clinical evolution. RESULTS The study included 2151 newborns. Among anamnestic criteria, only prematurity significantly increased the risk of EOS (relative risk of 3.1; 95% CI 1.4-7.0). The relative risk of infection for a symptomatic newborn was 12.2 (95% CI 4.9-30.2; P<0.0001). Laboratory test results were the most predictive criteria. The relative risk to be infected was 291.6 (95% CI 70.7-1,214.0; P<0.0001) with a blood cord PCT value>0.6 ng/L. The positive post-test probability was 28% (95% CI: 23-33) and the negative post-test probability was close to 0 (95% CI: 0-0). CONCLUSION Clinical criteria of postnatal life adaptation are more predictive of early-onset neonatal infection than anamnestic criteria are. The blood cord PCT value could be a helpful marker in the identification of infected newborns. PCT measured in umbilical cord blood could be included in a general algorithm in order to identify as soon as possible newborns with a high risk of EOS.

Prise en charge de la bronchiolite aiguë du nourrisson de moins de 1 an : actualisation et consensus médical au sein des hôpitaux universitaires du Grand Ouest (HUGO)

BACKGROUND AND OBJECTIVES While our European and North American colleagues have recently updated their recommendations, the 2000 Consensus Conference remains the main guideline on management of acute viral bronchiolitis in France. We aimed to establish an updated inter-regional protocol on management of acute viral bronchiolitis in infants. METHOD Pediatricians, pediatric pulmonologists, and emergency physicians of the Grand Ouest University Hospitals (France) gathered to analyze the recent data from the literature. RESULTS Criteria to distinguish childhood asthma from acute viral bronchiolitis were established, then prescriptions of diagnostic tests, antibiotics, and chest physiotherapy were defined and reserved for very limited situations. Similarly, the modalities of oxygen therapy prescription and nutritional support were proposed. Finally, other therapeutics such as nebulized hypertonic saline seem promising, but their place in the treatment of acute bronchiolitis in infants remains unclear. CONCLUSION This work has provided new proposals for management of acute viral bronchiolitis and helped standardize practices within the Grand Ouest University Hospitals. This local organization could lay the keystone for working toward guidelines initiated by learned societies at the national level.

Antibioprophylaxie chirurgicale : les grands principes, état des lieux et exemple d’harmonisation des pratiques

Resume L’antibioprophylaxie chirurgicale a fait preuve de son efficacite dans la reduction des infections du site operatoire. Les recommandations existantes pour les adultes font cependant l’objet d’une mauvaise compliance. L’antibioprophylaxie chirurgicale representant une part importante des prescriptions antibiotiques, il est pourtant important d’en respecter les grands principes (spectre le plus etroit possible, duree courte, molecule peu utilisee en therapeutique, etc.) afin de limiter son impact sur l’ecologie bacterienne. Un bref etat des lieux des pratiques pediatriques dans 5 hopitaux universitaires francais nous a permis de mettre en evidence des variations parfois importante en termes de choix de molecule ou de duree. A travers l’experience d’harmonisation des pratiques au CHU de Nantes, il est apparu que la mise au point de recommandations nationales est un prealable indispensable pour harmoniser les pratiques mais qu’elle doit s’accompagner d’une reflexion multidisciplinaire au sein de chaque hopital si on veut ameliorer leur acceptabilite et leur application.Surgical antibiotic prophylaxis has demonstrated its effectiveness in reducing surgical site infections. Existing recommendations for adults are however subject to poor compliance. Surgical antibiotic representing a significant proportion of antibiotic prescriptions, it is then important to respect its general principles (narrow spectrum, short duration, choosing molecules different than the ones used in therapeutics, etc.) to limit its impact on the bacterial ecology. A brief survey of pediatric practices in five French university hospitals has allowed us to highlight some significant changes in terms of choice of molecule or duration. Through the experience of harmonizing practices at the University Hospital of Nantes, we showed that the development of national guidelines is a prerequisite to harmonize practices but must be accompanied by a multidisciplinary reflexion within each hospital in order to improve their acceptability and application.

Antibioprophylaxie en chirurgie orthopédique pédiatrique

Resume La chirurgie osteo-articulaire de l’enfant comporte certaines specificites qui justifient des recommandations propres (chirurgie de rachis, reconstruction post-tumorectomie). Les enfants les plus a risque d’infection du site operatoire sont ceux atteints de comorbidites ou subissant des chirurgies longues. Les germes cibles de l’antibioprophylaxie sont ceux de la flore cutanee avec en chef de file le staphylocoque dore. La cefazoline est l’antibiotique de choix pour les chirurgies osteo-articulaires. Le depistage et la decontamination du staphylocoque dore notamment resistant a la meticilline peuvent se discuter notamment dans les centres a forte incidence d’infection postoperatoire a SARM. L’adaptation de l’antibioprophylaxie a la flore urinaire des patients atteints de pathologie neuromusculaire peut egalement se justifier au cas par cas avant les chirurgies de rachis.

Méthodologie de l'analyse des soins sub-optimaux

1Clinique médicale et service d’urgences pédiatriques, Hôpital Mère-Enfant, 8 quai Moncousu, 44000 Nantes, France 2Unité d’urgences pédiatriques et de maladies infectieuses, Hôpital R. Salengro, CHU de Lille, Université de Lille-2, 2, avenue Oscar-Lambret, 59037 Lille, France 3Inserm U149, hôpital Saint-Vincent-de-Paul, 74, avenue Denfert-Rochereau, 75014 Paris, France 4Service de pédiatrie générale, hôpital Saint-Vincent-de-Paul, AP–HP, Université Paris-Descartes, 74, avenue Denfert-Rochereau, 75014 Paris, France Table ronde

SFP-02 – Pathologie infectieuse – Utilisation de la procalcitonine (PCT) aux urgences pédiatriques ; nécessité d’une prescription ciblée

La procalcitonine est un marqueur d’infection bacterienne maintenant valide chez l’adulte comme chez l’enfant. Son dosage fait depuis l’objet de nombreuses prescriptions puisqu’il est prescrit chez 10 % des enfants consultant dans notre service. Objectif Montrer le manque de performance de ce marqueur lorsqu’il est prescrit sans distinction dans toutes les situations de suspicions d’infections bacteriennes de l’enfant. Patients et Methodes Analyse retrospective d’une cohorte d’enfants ayant fait l’objet d’un dosage de PCT lors d’une consultation aux urgences pediatriques sur une periode de 2 mois. Les patients ont ete classes en 7 categories d’infections bacteriennes selon des definitions validees dans la litterature (Pyelonephrites, meningites,ORL,digestif,respiratoire,fievre isolee, syndrome grippal). Ont ete etablies des courbes ROC puis calcules la sensibilite, specificite et le rapport de vraisemblance (RV) de la PCT. Le seuil pathologique retenu etait 0.5 ng/ml Resultats 273 dossiers ont ete analyses. Toutes indications confondues, l’aire sous la courbe de la courbe ROC de la PCT est inferieure a celle de la CRP (0.75 ± 0.06 vs 0.81 ± 0.05 respectivement). L’association des 2 marqueurs par une analyse discriminante n’est pas plus performante que la CRP seule (0.82 ± 0.05 vs 0.81 ± 0.05). On retrouve pourtant de bonnes sensibilite, specificite et rapport de vraisemblance + en cas de fievre isolee : 100 ± 40%, 65.7 ± 14 % et 4.85 (IC 95 % : 3.04-7.7) respectivement, et de meningite : 100 ± 33 % et 100 ± 40 % respectivement. Ces parametres sont tres peu performants par contre en cas d’infections ORL ou digestives avec une sensibilite de 36 ± 22 et 40 ± 32%, une specificite de 73 ± 20 et 68 ± 14 % et un RV + de1.33 (IC95 % : 0.44-4) et 1.26 (IC95 % : 0.39-4.08) respectivement. A posteriori,42 % des prescriptions de PCT pour cette cohorte n’etaient pas justifiees. Conclusion La realisation d’un dosage de PCT doit etre reservee aux situations ou ce marqueur est connu comme discriminant. La prescription doit en etre ciblee et seniorisee afin d’eviter des derives d’utilisation deleteres pour tous.

A prospective observational study of medication errors in a pediatric emergency department

We present a prospective, observational study evaluating the incidence of medication errors (ME) in a university hospital pediatric emergency department and describe their characteristics and determinants. A systematic analysis of the handwritten prescriptions was conducted by a clinician and pharmacist. Of 11,573 consecutively studied prescriptions in children under 15 years of age, the ME incidence was 0.9% (n=102). The incidence of errors found was statistically significantly higher in children older than 5 years (OR=2.05; P=0.026). There was no significant difference regarding the time of admission (P=0.544), the day of the week (P=0.940), or the affluence of people in attendance at the emergency department. The errors observed were all prescription errors. Most errors were related to analgesic (51%) and antibiotic (30%) treatments. No serious errors were reported. CONCLUSION We found a low incidence of medication errors in this study. The validation of prescriptions by a senior multidisciplinary staff could contribute to limited medication errors. Measures should be continued to further reduce the incidence of drug errors by calling the attention of prescribers to the most common situations at risk of ME.

Surgical and medical antibiotic prophylaxis

Surgical site infections are the leading cause of perioperative morbidity and mortality as well as increased costs following surgery. Among preventive measures, antibiotic prophylaxis, when indicated, significantly decreases these risks. Adult and pediatric guidelines have recently been published (1,2). Specific pediatric data are scarce, but adult recommendations can be used by extrapolation except for neonates. For procedures that may warrant antimicrobial prophylaxis, agents of choice are frequently first-generation cephalosporins such as cefazolin, that are not currently used in curative treatment, with an appropriate dosage. Administration of an antimicrobial agent within 1 hour before surgery is often sufficient. Continuation for more than 24 hours is exceptionally advised.

Dix pièges à éviter lors de la soumission d’un projet au programme hospitalier de recherche clinique (PHRC) national

La recherche clinique apparaı̂t aujourd’hui comme un moyen d’améliorer les connaissances et les soins proposés aux enfants et à leurs familles au quotidien, tout en fédérant les équipes soignantes de différents hôpitaux autour des multiples étapes d’un projet de recherche. Parmi les difficultés rencontrées par les équipes qui s’investissent dans ce domaine, la question du financement constitue un des premiers défis. Depuis 1992, le Programme hospitalier de recherche clinique (PHRC) national, administré par le Ministère des solidarités et de la santé, est une source importante de financement. Depuis 2013, le processus de sélection des projets financés se fait en deux étapes : la première sélection est réalisée par les membres du jury du PHRC sur la base de lettres d’intentions ; les projets ainsi sélectionnés sont ensuite revus sur dossier complet par des experts extérieurs. À partir de ces expertises, le jury sélectionne les projets définitivement retenus en prenant en compte de l’originalité, de l’impact clinique attendu et de la faisabilité. En tant que pédiatres membres du jury du PHRC national, nous avons souhaité faire un état des lieux de la part pédiatrique des projets soumis au PHRC national depuis 2013. Nous présentons également ici les raisons les plus fréquemment à l’origine du rejet (que les projets soient pédiatriques ou non). L’objectif de cet article était d’apporter un éclairage sur le fonctionnement interne de

Agitation des adolescents dans les services d’accueil des urgences pédiatriques : problématique des cas dits « complexes »

INTRODUCTION Teenagers admitted to the emergency room for a violent attacks episode are increasingly numerous. The source of agitation is multifactorial for these teenagers, often with a complex course. They jeopardize hospital wards, which are often ill-suited for and overwhelmed during these outbursts. This study aims to identify and describe all the teenagers admitted to the hospital over 1 year for a violent outburst and discuss their management. METHODS AND EQUIPMENT Retrospective and descriptive study of teenagers admitted to the pediatric emergency department of the Nantes University Hospital for a violent outburst in 2015. RESULTS During this 1-year study, 99 teenagers out of a total of 182 consultations were admitted for a violent outburst. We noted that 85% of them had a previous history of a violent outburst, 70% of them were seeing a psychologist, and 56% were followed by the child welfare services. Most of the outbursts took place at home and were hetero-aggressive. Upon arrival at the pediatric emergency ward, 90% of the teenagers had calmed down. The mean time spent in the emergency ward was 3h42min. Finally, 31% of the teenagers were hospitalized in the general pediatric unit, 14% in the childrens psychiatric department, and 8% in the adult psychiatry ward. CONCLUSION We observed a high proportion of complex cases in the teenagers admitted to our emergency department for a violent outburst. These teenagers in distress, with a complex previous history, illustrated the relation between violence against themselves and their own violent behavior toward others. Developing short-stay units for a temporary isolation could be an advantageous multidisciplinary approach to allow somatic, psychological, and social evaluation of these vulnerable patients.