E. Launay

Early Impact of 13-Valent Pneumococcal Conjugate Vaccine on Community-Acquired Pneumonia in Children

BACKGROUND Pneumococcal serotypes 1, 3, 5, 7F, and 19A were the most implicated in community-acquired pneumonia (CAP) after implementation of 7-valent pneumococcal conjugate vaccine (PCV7). In France, the switch from PCV7 to 13-valent pneumococcal conjugate vaccine (PCV13) occurred in June 2010. An active surveillance network was set up to analyze the impact of PCV13 on CAP. METHODS An observational prospective study performed in 8 pediatric emergency departments from June 2009 to May 2012 included all children between 1 month and 15 years of age with chest radiography-confirmed pneumonia. Three 1-year periods were defined: pre-PCV13, transitional, and post-PCV13. RESULTS During the 3-year study period, among the 953 274 pediatric emergency visits, 5645 children with CAP were included. CAP with pleural effusion and documented pneumococcal CAP were diagnosed in 365 and 136 patients, respectively. Despite an increase (4.5%) in number of pediatric emergency visits, cases of CAP decreased by 16% (2060 to 1725) between pre- and post-PCV13 periods. The decrease reached 32% in infants in the same periods (757 to 516; P < .001). Between pre- and post-PCV13 periods, the proportion of CAP patients with a C-reactive protein level >120 mg/dL decreased from 41.3% to 29.7% (P < .001), the number of pleural effusion cases decreased by 53% (167 to 79; P < .001) and the number of pneumococcal CAP cases decreased by 63% (64 to 24; P = .002). The number of additional PCV13 serotypes identified decreased by 74% (27 to 7). CONCLUSIONS Our data suggest a strong impact of PCV13 on CAP, pleural effusion, and documented pneumococcal pneumonia, particularly cases due to PCV13 serotypes.

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.

Variability in the diagnostic performance of a bedside rapid diagnostic influenza test over four epidemic seasons in a pediatric emergency department

We wanted to determine the diagnostic performance of a rapid influenza diagnostic test (RIDT) used bedside in a pediatric emergency department (PED). This was a prospective study over four consecutive winters (2009-2013), comparing the results of a RIDT (QuickVue®) with RT-PCR in children admitted to a PED. Among the 764 children included, we did not observe any significant differences in the diagnostic performance of RIDT except during the H1N1 pandemic. The overall sensitivity of the test was 0.82; the specificity 0.98; the positive and negative likelihood ratios 37.8 and 0.19. The positive and negative post-test probabilities of infection were 98% and 17%. The diagnostic performance was increased for influenza B cases (P = 0.03). RIDTs are suitable for use every winter with few differences in its diagnostic value, except during specific pandemic periods. This test could limit unnecessary complementary exams and guide the prescription of antivirals during influenza epidemic periods in PEDs.

Dry Care Versus Antiseptics for Umbilical Cord Care: A Cluster Randomized Trial

BACKGROUND AND OBJECTIVES: In developed countries, where omphalitis has become rare and related mortality nil, benefits of antiseptic use in umbilical cord care have not been demonstrated. We aimed to assess the noninferiority of dry care compared with antiseptics in France where antiseptic use is widespread. METHODS: We conducted a noninferiority, cluster-randomized, 2-period crossover trial, in 6 French university maternity units including all infants born after 36 weeks’ gestation. Maternity units were randomly assigned to provide either their usual antiseptic care or a dry care umbilical cord method for a 4-month period, and then units switched to the alternate cord cleansing method for a 4-month period. The primary outcome was neonatal omphalitis, adjudicated by an independent blinded committee based on all available photographs, clinical, and bacteriological data. We used a noninferiority margin of 0.4%. Analysis was performed per protocol and by intention to treat. RESULTS: Among 8698 participants, omphalitis occurred in 3 of 4293 (0.07%) newborns in the dry care group and in none of the 4404 newborns in the antiseptic care group (crude difference: 0.07; 95% confidence interval: –0.03 to 0.21). Late neonatal infection, parental appreciation of difficulty in care, and time to separation of the cord were not significantly different between the 2 groups. CONCLUSIONS: Dry cord was noninferior to the use of antiseptics in preventing omphalitis in full-term newborns in a developed country. Antiseptic use in umbilical cord care is therefore unnecessary, constraining, and expensive in high-income countries and may be replaced by dry care.

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.

Chronically ill adolescents are also incompletely vaccinated: A cross-sectional study in France

BACKGROUND Adolescent vaccination coverage tends to be suboptimal, leading to resurgent infectious pathologies and vulnerability to various pathogens. The low frequency of medical consultations and missed opportunities for vaccination are often used to explain the low rate of vaccination. The aim of this study was to assess if the vaccination coverage rate is higher in chronically ill adolescents (CIA) who require a close pediatric specialized follow-up versus the rate in healthy adolescents (HA). METHODS A monocentric cross-sectional study was conducted in the Nantes University Hospital. We included 114 CIA and 266 HA. The vaccination coverage rate and the up-to-date immunization status were compared between ill versus healthy adolescents for each of the following vaccines: diphtheria, tetanus, acellular pertussis, inactivated poliovirus (DTaP/IPV), measles-mumps-rubella (MMR), hepatitis B (HepB), meningococcal C conjugate (MnC), human papillomavirus (HPV) and composite combinations (e.g. DTaP/IPV-MMR-HepB-MnC). RESULTS The overall immunization rate for DTaP/IPV-MMR-HepB-MnC was very low, with no significant difference between CIA and HA (9.6% versus 13.5%; p=0.28). Most of the investigated vaccines exhibited similar immunization patterns for the two groups: DTaP/IPV (77.2vs. 76.7%; p=0.97), MMR (92.1vs. 95.9%; p=0.14), HepB (51.8vs. 48.5%; p=0.51) with the exception of the MnC (18.4vs. 27.8%; p=0.05) and HPV (28.6vs. 16.1%; p=0.04). CONCLUSION Despite undergoing specialized and close medical follow-up, we found that the vaccination coverage rate for the CIA remained suboptimal. This indicates that pediatricians need to check the vaccination status and, when required, ensure that the vaccination schedules for these fragile patients are up-to-date.