Comorbidities directly extracted from the hospital database for adjusting SSI risk in the new national semiautomated surveillance system in France: The SPICMI network

OBJECTIVE

To evaluate the performance of a comorbidity-based risk-adjustment model for surgical-site infection (SSI) reporting and benchmarking using a panel of variables extracted from the hospital discharge database (HDD), including comorbidities, compared to other models that use variables from different data sources.

METHODS

The French national surveillance program for SSI (SPICMI) has collected data from voluntary hospitals in the first 6 months of 2020 and 2021, for 16 selected surgery procedures, using a semiautomated algorithm for detection. Four risk-adjustment models were selected with logistic regression analysis, combining the different patterns of variables: National Nosocomial Infections Surveillance System (NNIS) risk-index components, individual operative data, and 6 individual comorbidities according to International Classification of Disease, Tenth Revision (ICD-10) diagnosis: obesity, diabetes, malnutrition, hypertension, cancer, or immunosuppression. Areas under the curve (AUCs) were calculated and compared.

RESULTS

Overall, 294 SSI were detected among 11,975 procedures included. All 6 comorbidities were related to SSI in the univariate analysis. The AUC of the selected model including comorbidities (0.675; 95% confidence interval [CI], 0.642-0.707), was significantly higher than the AUC of the model without comorbidities (0.641; 95% CI, 0.609-0.672; P = .016) or the AUC using the NNIS-index components (0.598; 95% CI, 0.564-0.630; P < .001). The HDD-based model AUC (0.659; 95% CI, 0.625-0.692) did not differ significantly from the selected model without comorbidities (P = .23).

CONCLUSION

Including HDD-based comorbidities as patient case-mix variables instead of NNIS risk index factors could be an effective approach for risk-adjustment of automated SSI surveillance more widely accessible to hospitals.

Deployment of the French Civil Protection Field Hospital (ESCRIM) in Gölbaşi, Turkey after the February 2023 Earthquake: Lessons Learned

Following the two earthquakes that occurred in Turkey on February 6, 2023 with magnitudes of 7.8 and 7.5, causing over 50,000 deaths and 100,000 injuries, France proposed to deploy, via the European Union Civil Protection Mechanism (EUCPM), the French Civil Protection Field Hospital (ESCRIM [Élément de Sécurité Civile Rapide d'Intervention Médicale]): the French World Health Organization (WHO)-classified Emergency Medical Team (EMT) Level 2 (EMT2).After the acceptance from Turkey on February 8, a disaster assessment team (DAT) was sent on February 10, 2023. It was decided, with local health authorities (LHA), to set up the field hospital in Gölbaşi, Adiyaman Province where the State Hospital was closed due to a structural risk.Arriving in Gölbaşi on February 13 at 2:00am in -12°C (10°F) temperatures, the detachment had no choice but to begin setting up the base of operation (BoO). At dawn, the cold was so intense that one doctor suffered from frostbite. Once the BoO was installed, the team set up the hospital tents. From 11:00am, the sun melted the snow and the ground became very muddy. The objective being to open the hospital as soon as possible, installation of the hospital continued, and it opened on February 14 at 12:00pm/noon, less than 36 hours after on-site arrival.This article describes the mechanics of setting up an EMT-2 in a cold climate, the many problems encountered, and the solutions imagined and proposed.

Good Manufacturing Practice (GMP) Compliance for Phage Therapy Medicinal Products

Facing the emergence of difficult-to-treat bacterial infections, the perspective of using bacteriophages has re-gained interest in many countries. In terms of pharmaceutical classification in EU and United States, phages are considered as anti-infectious medicinal products and biological products, given the intended use and their live nature. During the production steps, the compliance with the Good Manufacturing Practice (GMP) represents the gold-standard to ensure the quality, safety and efficacy of medicinal products, either investigational or approved. In practice, the implementation of GMP rules for phage therapy medicinal products benefits from the long history of vaccine development. Accordingly, a well-structured strategy can be defined for each medicinal product, taking into account the specified indication (i.e., the target bacteria species, the infected site, the route of administration, the product composition). Based on the experience of different phage therapy medicinal products from the recent years, the most important requirements to achieve and claim GMP grade are reviewed here, including for genetically modified phages. Like all new medicinal products, the manufacturing of investigational phages incorporates significant challenges. However, the use of GMP-certified phages provides the best guarantee for the rigorous assessment of quality, safety and efficacy during the clinical development of phage medicinal products, thus appears as a key component for the successful development of phage therapy approaches.

Angioedema associated with thrombolysis for ischemic stroke: analysis of a case-control study

BACKGROUND

Bradykinin-mediated angioedema (AE) is a complication associated with thrombolysis for acute ischemic stroke. Risk factors are unknown and management is discussed.

OBJECTIVES

To clarify risk factors associated with bradykinin-mediated AE after thrombolysis for acute ischemic stroke.

METHODS

In a case-control study conducted at a French reference centre for bradykinin angiœdema, patients with thrombolysis for acute ischemic stroke and a diagnosis of bradykinin-mediated angiœdema, were compared to controls treated with thrombolysis treatment without angiœdema.

RESULTS

Fifty-three thrombolysis-related AE were matched to 106 control subjects. The sites of attacks following thrombolysis for ischemic stroke mainly included tongue (34/53, 64%) and lips (26/53, 49%). The upper airways were involved in 37 (70%) cases. Three patients required mechanical ventilation. Patients with bradykinin-mediated angiœdema were more frequently women [33 (62%) vs. 44 (42%); P = 0.01], had higher frequency of prior ischemic stroke [12 (23%) vs. 9 (8%); P = 0.01], hypertension [46 (87%) vs. 70 (66%); P = 0.005], were more frequently treated with angiotensin-converting enzyme inhibitor [37 (70%) vs. 28 (26%); P < 0.001] and were more frequently hospitalized in intensive care medicine [ICU; 11 (21%) vs. 5 (5%); P = 0.004]. In multivariate analysis, factors associated with thrombolysis-related AE were female sex [odds ratio (OR), 3.04; 95% confident interval (CI), 1.32-7.01; P = 0.009] and treatment with angiotensin-converting enzyme inhibitors [(OR), 6.08; 95% (CI), 2.17-17.07; P < 0.001].

CONCLUSIONS

This case-control study points out angiotensin-converting enzyme inhibitors and female sex as risk factors of bradykinin AE associated with thrombolysis for ischemic stroke.

Epidemiology of Clostridioides difficile infections, France, 2010 to 2017

BackgroundClostridioides difficile is a leading cause of healthcare-associated diarrhoea in middle and high-income countries. Up to 2018, there has been no systematic, annual surveillance for C. difficile infections (CDI) in France.AimsTo provide an updated overview of the epidemiology of CDI in France between 2010 and 2017 based on five different data sources.MethodsThis is a descriptive study of retrospective surveillance and alerts data. Incidence of CDI cases was estimated through the CDI incidence survey (2016) and data from the French National Uniform Hospital Discharge Database (PMSI; 2010-16). Testing frequency for CDI was estimated through the CDI incidence survey and point prevalence studies on healthcare-associated infections (HAI; 2012 and 2017). The national early warning response system for HAI (HAI-EWRS, 2012-17) and National Reference Laboratory data (2012-17) were used to follow the number of severe CDI cases and/or outbreaks.ResultsIn 2016, CDI incidence in acute care was 3.6 cases per 10,000 patient days (PD). There was a statistically significant increase in CDI incidence between 2010 and 2016 (+ 14% annually) and testing frequency was 47.4 per 10,000 PD. The number of CDI HAI-EWRS notifications decreased between 2015 and 2017 with only a few large outbreaks reported.ConclusionThe CDI incidence estimate increased from 2010, but remained below the European average of 7 per 10,000 PD in 2014; there were fewer severe cases or clusters reported in France. The consistency between PMSI and laboratory-based estimated CDI incidence could allow for more routine monitoring of CDI incidence.

Efficacy and tolerability of a cocktail of bacteriophages to treat burn wounds infected by Pseudomonas aeruginosa (PhagoBurn): a randomised, controlled, double-blind phase 1/2 trial

BACKGROUND

Wound infections are the main cause of sepsis in patients with burns and increase burn-related morbidity and mortality. Bacteriophages, natural bacterial viruses, are being considered as an alternative therapy to treat infections caused by multidrug-resistant bacteria. We aimed to compare the efficacy and tolerability of a cocktail of lytic anti-Pseudomonas aeruginosa bacteriophages with standard of care for patients with burns.

METHODS

In this randomised phase 1/2 trial, patients with a confirmed burn wound infection were recruited from nine burn centres in hospitals in France and Belgium. Patients were eligible if they were aged 18 years or older and had a burn wound clinically infected with P aeruginosa. Eligible participants were randomly assigned (1:1) by use of an interactive web response system to a cocktail of 12 natural lytic anti-P aeruginosa bacteriophages (PP1131; 1 × 10⁶ plaque-forming units [PFU] per mL) or standard of care (1% sulfadiazine silver emulsion cream), both given as a daily topical treatment for 7 days, with 14 days of follow-up. Masking of treatment from clinicians was not possible because of the appearance of the two treatments (standard of care a thick cream, PP1131 a clear liquid applied via a dressing), but assignments were masked from microbiologists who analysed the samples and patients (treatment applied while patients were under general anaesthetic). The primary endpoint was median time to sustained reduction in bacterial burden by at least two quadrants via a four-quadrant method, assessed by use of daily swabs in all participants with a microbiologically documented infection at day 0 who were given at least one sulfadiazine silver or phage dressing (modified intention-to-treat population). Safety was assessed in all participants who received at least one dressing according to protocol. Ancillary studies were done in the per-protocol population (all PP1131 participants who completed 7 days of treatment) to assess the reasons for success or failure of phage therapy. This trial is registered with the European Clinical Trials database, number 2014-000714-65, and ClinicalTrials.gov, number NCT02116010, and is now closed.

FINDINGS

Between July 22, 2015, and Jan 2, 2017, across two recruitment periods spanning 13 months, 27 patients were recruited and randomly assigned to receive phage therapy (n=13) or standard of care (n=14). One patient in the standard of care group was not exposed to treatment, giving a safety population of 26 patients (PP1131 n=13, standard of care n=13), and one patient in the PP1131 group did not have an infection at day 0, giving an efficacy population of 25 patients (PP1131 n=12, standard of care n=13). The trial was stopped on Jan 2, 2017, because of the insufficient efficacy of PP1131. The primary endpoint was reached in a median of 144 h (95% CI 48-not reached) in the PP1131 group versus a median of 47 h (23-122) in the standard of care group (hazard ratio 0·29, 95% CI 0·10-0·79; p=0·018). In the PP1131 group, six (50%) of 12 analysable participants had a maximal bacterial burden versus two (15%) of 13 in the standard of care group. PP1131 titre decreased after manufacturing and participants were given a lower concentration of phages than expected (1 × 10² PFU/mL per daily dose). In the PP1131 group, three (23%) of 13 analysable participants had adverse events versus seven (54%) of 13 in the standard of care group. One participant in each group died after follow-up and the deaths were determined to not be related to treatment. The ancillary study showed that the bacteria isolated from patients with failed PP1131 treatment were resistant to low phage doses.

INTERPRETATION

At very low concentrations, PP1131 decreased bacterial burden in burn wounds at a slower pace than standard of care. Further studies using increased phage concentrations and phagograms in a larger sample of participants are warranted.

FUNDING

European Commission: Framework Programme 7.

Ongoing increasing temporal and geographical trends of the incidence of extended-spectrum beta-lactamase-producing Enterobacteriaceae infections in France, 2009 to 2013

Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) are a major focus of multidrug-resistant organisms (MRO) surveillance programmes in France. To describe the temporal and geographical trends of these pathogens, we conducted an epidemiological study based on data extracted from the nationwide MRO surveillance network from 2009 to 2013. During this time, the incidence of ESBL-E infections in French hospitals increased by 73%, from 0.35 to 0.60 per 1,000 patient days (PD) (p < 0.001) and ESBL-E bacteraemia by 77%, from 0.03 to 0.05 per 1,000 PD (p < 0.001). The incidence of ESBL-E infections was higher in intensive-care units (1.62 to 2.44 per 1,000 PD (p < 0.001)) than in recovery and long-term care facilities (0.20 to 0.31 per 1,000 PD (p < 0.001)). Escherichia coli was the most frequent extended-spectrum beta-lactamase-producing (ESBL) pathogen, representing 59% (26,238/44,425) of all ESBL isolates, followed by Klebsiella pneumoniae (20%; 8,856/44,425) in 2013. The most frequent infection was urinary tract infection, for all species. The incidence of ESBL-E varied by region but showed an upward trend overall. Reinforcement of control measures for halting the spread of such MRO is crucial.

National multidrug-resistant bacteria (MDRB) surveillance in France through the RAISIN network: a 9 year experience

BACKGROUND

In the mid-1990s, the prevalence rate of multidrug-resistant bacteria (MDRB) in French hospitals was high and control of MDRB spread then became a major priority in the national infection control programme (ICP).

METHODS

To evaluate the impact of the ICP, a national coordination of MDRB surveillance was set up in 2002. Data were collected 3 months a year in healthcare facilities (HCFs) on a voluntary basis. All clinical specimens of methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBLE) were prospectively included. Incidences per 1000 patient days (PDs) were calculated and trends in incidence from 2003 to 2010 were assessed.

RESULTS

Participation in the surveillance increased from 478 HCFs in 2002 to 933 in 2010. In 2010, MRSA incidence was 0.40/1000 PDs: 1.14 in intensive care units (ICUs), 0.48 in acute care facilities (ACFs) and 0.27 in rehabilitation and long-term care facilities (RLTCFs). ESBLE incidence was 0.39/1000 PDs: 1.63 in ICUs, 0.46 in ACFs and 0.23 in RLTCFs. MRSA incidence significantly decreased from 0.72/1000 PDs in 2003 to 0.41/1000 PDs in 2010 (P<10(-3)); in contrast, ESBLE incidence significantly increased from 0.17/1000 PDs to 0.48/1000 PDs (P<10(-3)). The most prevalent ESBLE were Enterobacter aerogenes (34%) and Escherichia coli (25%) in 2003 and E. coli (60%) and Klebsiella pneumoniae (18%) in 2010.

CONCLUSION

These results demonstrate the positive impact of the national ICP on MRSA rates. In contrast, ESBLE incidence, especially ESBL-producing E. coli, is increasing dramatically and represents a serious threat for hospitals and for the community that deserves specific control actions.

Glycol ethers and semen quality: a cross-sectional study among male workers in the Paris Municipality

OBJECTIVES

Apparent increases in human male reproductive disorders, including low sperm production, may have occurred because of increased chemical exposure. Various glycol ether-based solvents have pronounced adverse effects on sperm production and male fertility in laboratory animals. The authors investigated the effects of past and current exposure to glycol ether-containing products on semen quality and reproductive hormones among men employed by the Paris Municipality.

METHODS

Between 2000 and 2001 the authors recruited 109 men who gave semen, blood and urine samples and underwent an andrological examination. Information on lifestyle, occupation, exposure and medical history was obtained by interview. According to their job and chemical products used during the period 1990-2000, men were classified as either occupationally exposed or non-exposed. Current exposure levels to glycol ethers at the time of the study were evaluated by biological monitoring of six urinary metabolites.

RESULTS

Previous exposure to glycol ethers was associated with an increased risk for sperm concentration, for rapid progressive motility and for morphologically normal sperm below the World Health Organization semen reference values. No effect of previous glycol ether exposure on hormones levels was observed. By contrast, current glycol ether exposure levels were low and not correlated with either seminal quality or hormone levels.

CONCLUSIONS

This study suggests that most glycol ethers currently used do not impact on human semen characteristics. Those that were more prevalent from the 1960s until recently may have long lasting negative effects on human semen quality.

[Local guidelines and quality of antibiotic treatment in urinary tract infections: a clinical audit in two departments of a university hospital]

AIM

To assess the effect of local guidelines implemented at the Nantes University Hospital regarding antibiotic therapy for urinary tract infections.

DESIGN

Before/after study of one medical ward and one urologic surgery ward. Quality was measured by two principal criteria: compliance with guidelines and medical justification in the specific clinical situation. Both criteria considered simultaneously the choice of drug, dose and duration of treatment. Deviations from the guidelines were described.

RESULTS

1086 UTI cases were identified over two 12-month periods, before and after the dissemination of guidelines (for prostatitis, pyelonephritis, indwelling catheter-associated UTIs, and other undefined UTIs). The guidelines were applicable in 313 (30%) cases. Overall, after implementation of the guidelines, the percentage of justified prescriptions did not change significantly (41.8% compared with 38.7%, p=0.299), but the percentage of correct (conforming) prescriptions fell (from 30.4% to 15.7%, p=0.0022). The percentages of correct and justified prescriptions differed in the medical (respectively 45.0% and 46.6%,) and surgical units (13.1% and 36.5%).

CONCLUSIONS

Issuing guidelines does not necessarily improve the quality of antibiotic therapy for UTIs in hospitals.

Preoperative Chemotherapy Does Not Increase Complications After Nonsmall Cell Lung Cancer Resection

BACKGROUND

Neoadjuvant chemotherapy before resection of nonsmall cell lung cancer seems to increase survival, mainly in the early stage. Risks of postoperative complications after chemotherapy and surgery remain controversial. Here we review our experience with patients treated in one thoracic surgery center.

METHODS

Patients undergoing resection for nonsmall cell lung cancer after induction chemotherapy between January 1993 and March 2002 were reviewed. Data collected included age, sex, preoperative forced expiratory volume in 1 second (FEV1), hemoglobin, and arterial oxygen pressure tension (PaO2), postoperative complications, and global survival. The main objectives were postoperative mortality and morbidity. Postoperative mortality and morbidity were defined as complications or deaths occurring within 30 days after surgery. Predictive morbidity factors were identified by univariate and multivariate analysis and overall survival by the Kaplan-Meier method.

RESULTS

In all, 114 patients were reviewed. Different induction chemotherapies were used, mainly cisplatin with vinorelbine or gemicitabine. Postoperative mortality was 2 of 114, 1 of 27 after pneumonectomy, and there were no deaths after lobectomy. Complications occurred in 29% of patients (33 of 114), usually infectious pneumonia and anemia requiring transfusion. Preoperative FEV1, hemoglobin, and PaO2 are not associated with morbidity in univariate or multivariate analysis.

CONCLUSIONS

Preoperative chemotherapy does not increase postoperative mortality and morbidity after nonsmall cell lung cancer surgery, performed exclusively by thoracic surgeons.

Bonnes pratiques de prescription des antibiotiques pour la prise en charge des infections urinaires en milieu hospitalier : identification des écarts aux recommandations et actions correctrices

OBJECTIVE

We analyzed the adequacy of antibiotic therapy prescribed for urinary tract infections (UTI): prostatitis, pyelonephritis, indwelling catheter-associated UTIs, or other undefined UTIs.

DESIGN

The adequacy of prescriptions to local guidelines was assessed retrospectively in two wards (Internal Medicine and Surgical Urology) of the Nantes University Hospital. The principal criteria involved simultaneously: choice of the molecule, dose, and treatment duration. Non-observances of guidelines were major (non-adequacy of the molecule, prescription of a non-active molecule according to in vitro susceptibility tests, non-appropriate treatment abstention), or minor (non-justified treatment, non-justified bitherapy, no prescription of bitherapy when requested, no treatment adaptation when requested, too short or too long treatment length, dosage mistakes).

RESULTS

One thousand eighty-six infections were collected over a 24-month period. The overall rate of adequate prescriptions was 40.1% (46.6% in Internal Medicine and 36.5% in Surgical Urology). In Internal Medicine (226 non observance among 389 prescriptions), the ratio of major non-observance of guidelines was 9.8%. Among them, 44.7% were non-appropriate treatment abstentions. In Surgical Urology (539 non observance out of 695 prescriptions), non-observance related to treatment length were the most frequent. The ratio of major non-observance was 19.9%. Among them, non-adequacy of the molecule reached 60.7%. Non-justified treatment and non-appropriate bitherapies were frequent.

CONCLUSIONS

For both units, indwelling catheter-related UTIs and other UTIs accounted for more than 50% of the infections although not detailed in the local guidelines. Identifying and analyzing Non observance may lead to targeted correcting actions to improve prescription quality.

Size-selective separation of gold nanoparticles using isoelectric focusing electrophoresis (IEF)

Isoelectric focusing in a polyacrylamide pH gradient gel is used to analyze the size distribution of gold nanoparticles synthesized by a chemical route with mercaptosuccinic acid as a ligand. The isoelectric point of the nanoparticles is shown to be size dependent, allowing fractionation by electrophoresis. Each fraction has a narrow size distribution with a standard deviation lower than 0.4 nm.

Exposure to glycol ethers in a population of French men evaluated by measurement of urinary alkoxycarboxylic acids

OBJECTIVES

Glycol ethers are solvents that are present in a large number of products used commercially and domestically. During recent years, ethylene glycol ether derivatives, in particular ethylene glycol methyl ether and ethylene glycol ethyl ether, have been progressively replaced by propylene glycol ether derivatives, which are less toxic. The aim of this study was to estimate the level of exposure to glycol ethers in a sample population of French men employed by the Paris Municipality by measuring the amount of alkoxycarboxylic acid metabolites in their urine.

METHODS

Urine samples were collected at the end of two different working weeks from 109 men, 54 of whom were judged to be occupationally exposed to glycol ether-containing products. Five alkoxyacetic acids (methoxyacetic, ethoxyacetic, n-propoxyacetic, phenoxyacetic, butoxyacetic acids) from ethylene glycol derivatives, and one alkoxypropionic acid (2-methoxypropionic) from a propylene glycol derivative, were simultaneously analysed by gas chromatography coupled to electron-capture detection.

RESULTS

2-Methoxypropionic was the most frequently found alkoxycarboxylic acid. The concentration of this metabolite reached 5.6 mmol/mol creatinine. The second most common alkoxycarboxylic acid was phenoxyacetic (up to 2.3 mmol/mol creatinine). The concentrations of the other alkoxycarboxylic acids were less than 1 mmol/mol creatinine. Although the concentration of alkoxycarboxylic acids was higher among men occupationally exposed to glycol ether-containing products than among unexposed men, the difference was significant only for butoxyacetic acid.

CONCLUSIONS

Our data suggest that the use and exposure levels of glycol ethers have qualitatively and quantitatively changed dramatically over recent years. Particular attention should be paid in the future to alkoxypropionic acids derived from minor isomers of propylene glycol ether derivatives.

[Isolated pleurisy revealing ovarian hyperstimulation syndrome]

Ovarian hyperstimulation is a rare but serious iatrogenic complication following induction of ovulation cycles. Release of vasoactive substances by the stimulated ovaries leads to leakage of intravascular fluid into the extracellular and serous spaces due to enhanced capillary permeability. Pleural effusion is a classical finding in the most severe forms, often associated with ascitis and signs of hemoconcentration. We report the case of a women who presented pleural effusion as the sole inaugural sign of ovarian hyperstimulation.

Chromosome 17q22-q24 and multiple sclerosis genetic susceptibility. American-French Multiple Sclerosis Genetic Group

Recently, genome-wide searches for multiple sclerosis (MS) susceptibility genes have suggested that the chromosome 17q22-q24 region might contain susceptibility genes in two sets of families of different ethnic backgrounds (Finnish and British). Therefore, we decided to test this region in two sets of families of different ethnic backgrounds (American and French), but collected according to the same diagnostic criteria. All lod-score values were non-significant. Moreover, we could exclude that the 17q22-24 region might contain a gene increasing the sibling recurrence risk of MS over 1.4, rendering the existence of such a gene very unlikely, at least in the group of tested families.