Francois Angoulvant

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). 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. 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). 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.

To evaluate therapeutic education delivered in a pediatric emergency department to improve parents’ satisfaction and attitudes about judicious antibiotic use. In an emergency department of a tertiary pediatric hospital, children aged 1 month to 6 years and discharged with an oral antibiotic prescription for an acute respiratory or urinary tract infection were randomized to a patient therapeutic education on antibiotic use (intervention group) or fever control (control group) delivered to the parents (in the presence of the children) by a pharmacist trained in therapeutic education. Education consisted in a 30-minute face-to-face session with four components: educational diagnosis, educational contract, education, and evaluation. The main outcome measure was parent satisfaction about information on antibiotics received at the hospital, as assessed by a telephone interview on day 14. The secondary outcome was attitudes about antibiotic use evaluated on day 14 and at month 6. Of the 300 randomized children, 150 per arm, 259 were evaluated on day 14. Parent satisfaction with information on antibiotics was higher in the intervention group (125/129, 96.9%, versus 108/130, 83.0%; P=0.002, exact Fisher test). Group parents had higher proportions of correct answers on day 14 to questions on attitudes about judicious antibiotic use than did control-group parents (P=0.017, Mann-Whitney U test). Therapeutic education delivered by a clinical pharmacist in the pediatric emergency department holds promise for improving the use of antibiotics prescribed to pediatric outpatients. ClinicalTrials.gov NCT00948779 http://clinicaltrials.gov/show/NCT00948779

We aim to describe the number of health care visits before and after pediatric emergency department (PED) visits for common illnesses in a French tertiary pediatric hospital. This was a prospective cohort study with 501 children under 6 years of age who were evaluated and discharged from a tertiary care PED. Enrollment occurred on eight randomly selected study days between November 2010 and June 2011. The caregivers were then contacted via telephone 8 days later to obtain follow-up data, including information about return visits to health care facilities. Multiple visits were made by 206 (41 %) children, previous visits had occurred for 139 (28 %) children, and return visits had occurred for 94 (19 %) children. Previous and return visits were made at the PED as well as in general practitioners’ offices and private pediatric offices. The median age of the subjects was 18 months. Fever was the most common complaint and was associated with more frequent multiple heath care visits. Conclusion: Multiple heath care visits for the same illness are frequent, especially for febrile children. Interestingly, this phenomenon concerns every type of health care facility, including the PED, general practitioners’ offices, and private pediatric offices. Further studies should be performed to achieve a better understanding of this phenomenon and to test specific interventions, such as parental education and improvement of the information system.

Acute respiratory tract infections (ARTIs) are the main reason for antibiotic prescription in children. In 2005, the French Drug Agency published guidelines to minimise inappropriate use of antibiotics for ARTI. The purpose of this study was to assess the impact of implementing these guidelines in a paediatric emergency department. We retrospectively analysed data collected prospectively in a French paediatric emergency department from November 2005 (date of guideline implementation) to October 2009. For each child diagnosed with ARTI, we collected age, diagnosis, and prescribed antibiotics. We computed antibiotic prescription rates in the study population. During the study period, 53,055 children were diagnosed with ARTI and 59% of the 22,198 antibiotic prescriptions given at discharge were related to ARTI. The proportion of ARTI patients given antibiotic prescriptions fell from 32.1% during the first year to 21% in year 4 (p < 10⁻⁴, Cochran-Armitage test). Amoxicillin-clavulanic acid and amoxicillin accounted for 50% and 34% of antibiotic prescriptions for ARTI, respectively. French antibiotic guidelines led to significant decreases in antibiotic prescription for ARTI in our paediatric emergency department.

La drépanocytose est une pathologie fréquente en France, et les douleurs survenant lors des crises vaso-occlusives (CVO) sont un des principaux motifs de consultation aux services d’accueil et de traitement des urgences (SAU), notamment en pédiatrie. La prise en charge de la douleur chez l’enfant drépanocytaire au SAU doit suivre les recommandations nationales mises à jour en janvier 2010 par la Haute Autorité de santé. L’identification rapide de ces patients et l’évaluation de la douleur par des échelles adaptées sont des étapes indispensables à cette prise en charge. Le traitement médicamenteux fait appel aux antalgiques de paliers 1 (paracétamol, ibuprofène) et 2 (codéine, nalbuphine) et rapidement si les douleurs sont sévères à de la morphine notamment en autoadministration continue au pousse-seringue (PCA), en assurant une hydratation suffisante et une prise en charge des effets secondaires des morphiniques. Un bilan biologique comprenant hémogramme et réticulocytes est souvent nécessaire. La drépanocytose est une pathologie caractérisée par la survenue de complications sévères telles que: accident vasculaire cérébral, syndrome thoracique aigu, infection bactérienne sévère et anémie aiguë; aussi, une surveillance attentive de ces patients est indispensable. Les patients drépanocytaires doivent être suivis en collaboration avec des centres de références spécialisés. Une étude internationale des pratiques réalisée au sein du Réseau Mère-Enfant de la francophonie (RMEF) révèle une large utilisation des échelles d’évaluation de la douleur et de la morphine en cas de CVO avec douleurs sévères chez l’enfant. En revanche, le mode d’administration de la morphine par PCA n’est pas encore employé dans tous les centres. Sickle cell disease is common in France, and painful episodes related to it are one of the main causes of emergency department visits. Management of acute painful episodes in children with sickle cell disease should follow the French National guidelines published by the High Authority of Health and updated in January 2010. For optimal pain management, it is important to quickly identify patients with sickle cell disease and assess their pain using validated scales. Pain can be treated using level 1 (paracetamol, ibuprofen) or level 2 analgesics (codeine, nalbuphine), and morphine in case of severe pain. Morphine can be administered using a patient-controlled analgesia (PCA) pump. Laboratory tests including complete blood count and reticulocyte count are often necessary. Adequate hydration and prevention of side-effects of opioids is also necessary. Sickle cell disease is a condition characterized by the occurrence of severe complications such as stroke, acute chest syndrome, severe bacterial infection and acute anaemia, thus requiring careful patient monitoring. Patients with sickle cell disease should be referred to specialized centres. A survey of practices conducted in the Réseau Mère-Enfant de la francophonie (RMEF) shows that pain assessment scales are widely used in patients with sickle cell disease and that morphine is the treatment of choice in cases of severe pain; however, the use of the PCA pumps for morphine administration is still not a common practice in the RMEF centres

Introduction The influenza A (H1N1) 2009 outbreak caused death and a disruption of public health services. Rapid influenza diagnostic tests (RIDT) could be helpful to ease the triage of patients and prevent an overload of emergency and laboratory facilities. Objectives To compare the sensitivity and specificity of the Clearview Exact Influenza A&B test and real-time reverse transcription(RT)–PCR to detect influenza A (H1N1) 2009 in a paediatric emergency department of a paediatric teaching hospital in Paris, France. Methods 76 children with an influenza-like illness and either severe symptoms or an underlying medical condition were prospectively recruited between July 2009 and October 2009. RIDT and RT–PCR were simultaneously performed and compared. Results Among 39 influenza A (H1N1) 2009 RT–PCR-positive children (median age 5 years), 23 Clearview Exact Influenza A&B tests were positive. Sensitivity was 59% (95% CI 42.2 to 74) and specificity was 94.6% (95% CI 80.5 to 99.1). Conclusions This study shows a sensitivity of RIDT of 59%, in agreement with other prospective studies, which could be useful in clinical practice for diagnosis influenza A (H1N1) 2009 in children. In outbreaks of a high prevalence, such as the 2009 outbreak, this test can help to prevent an overload of public health services.

To determine whether the youngest age groups are less likely to be included in paediatric randomised controlled trials (PRCTs) than older children, we conducted a PubMed search using the keyword “randomised controlled trial” and the limit “all child: 0–18 years”. We retrieved 417 articles published in 2006 in 34 leading journals classified as general medical journals, paediatric medical journals, or specialist medical journals. We arbitrarily selected 144 articles, at random. For each study, we evaluated population age characteristics (central tendency, range, and dispersion), study design, sample size and topic. Of the 144 studies, only 82 were first reports of paediatric randomised controlled trials (PRCTs). Among the other studies, many were done in adults. Of the 82 PRCTs, only 11% included newborns and 26% infants; 59% included children and 39% adolescents. Using the same search strategy to retrieve PRCTs in the same journals in the last 4 months of 2009 retrieved 66 PRCTs, of which 17% included newborns, 24% infants, 61% children and 55% adolescents. The three health conditions most often reported were respiratory diseases, infectious diseases, and mental and behavioural disorders. In 34 leading journals, PRCTs were significantly less likely to include newborns and infants than older paediatric patients. Given the huge impact of PRCTs on paediatric health, additional efforts are needed to promote studies in newborns and infants, as well as studies of the impact of recent European and American regulations designed to encourage paediatric drug trials.

We report the first case of cutaneous mucormycosis after a scorpion sting in Tunisia. Histopathology showed broad aseptate hyphae suggestive of a Zygomycete. Saksenaea vasiformis was identified by PCR amplification and sequencing of the fungal DNA on a cutaneous biopsy. Successful treatment was obtained by surgery and liposomal amphotericin B.