La Revue du praticien最新文献

DIAGNOSIS OF INVASIVE NEISSERIA MENINGITIDIS INFECTIONS. Invasive meningococcal infections are unpredictable, difficult to diagnose and extremely serious, with a high risk of death and sequelae in survivors. They primarily affect subjects with no underlying pathology, but risk factors have been identified. The most frequent clinical forms are meningitis, septicemia and meningococcal septic shock, including purpura fulminans. Atypical presentations, such as pneumonia, epiglottitis and digestive tract infections, are increasingly common, especially since the incidence of serogroups W and Y has risen. They can lead to misdiagnosis and are associated with higher case-fatality rates.

Phage therapy: WHERE DO WE STAND? Bacteriophages, discovered at the beginning of the 20th century by Félix d'Hérelle, are viruses that infect and destroy bacteria. Unlike antibiotics, phages are specific to a given bacterial species. After initial successes (shigellosis, cholera), the arrival of antibiotics overshadowed phage therapy. It was not until 2000, with the emergence of antibiotic resistance, that phages and phage therapy made a comeback. They have the status of medicines, but production remains limited. In France, treatments are carried out on a compassionate basis, with a number of isolated successes that need to be confirmed by clinical trials. Some trials are currently underway in France to assess the efficacy of phage therapy in combination with antibiotics. France, a pioneer in phage therapy in its early days and at the time of its comeback, seems to be slowing down in 2024 compared with its European neighbors. The adoption of phage therapy on a routine basis in France will still require time and significant progress.

ANTIBIOTIC TREATMENT OF INVASIVE MENINGOCOCCAL INFECTION. Invasive meningococcal infections (IMI) are extremely severe pathologies that justify very early antibiotic therapy to limit complications and death. Three different situations may arise: 1) clinical suspicion of purpura fulminans in the pre-hospital setting, 2 confirmed or strongly suspected IMI, 3) post-exposure chemoprophylaxis of a patient's contacts. In the first two situations, 3rd generation cephalosporins (C3G), cefotaxime or ceftriaxone are the reference antibiotics, and have the advantage of having an impact on nasopharyngeal carriage of meningococcus. Chemoprophylaxis of contact subjects is based on rifampicin, but ciprofloxacin (subject to retained sensitivity) and C3Gs are possible alternatives.

RISK OF ACQUIRING ANTIBIOTIC-RESISTAN. BACTERIA AND TRAVEL. The continuing expansion of international tourism increases the opportunities of contact with diverse epidemiological environments, leading to both a risk of bacterial acquisition or infection for the traveler and the circulation of the micro-organisms around the world. With the disparate increase in antibiotic resistance worldwide, the traveler becomes a microbiological sentinel for resistance surveillance. Travel has been associated with the acquisition of digestive carriage of multidrug-resistant Enterobacterales, most frequently associated with travel to South Asia, enhanced by diarrhea and/or antibiotic use. But travel has also been the cause of authentic infections caused by multi- or extensively resistant bacteria, such as shigellosis, typhoid fever caused by Salmonella typhi, sexually transmitted infections caused by gonococci, or skin infections caused by methicillin-resistant Staphylococcus aureus (MRSA), for which worry is the low number of antibiotics remaining effective. It is therefore necessary to advise travelers during pre-travel consultations on how to reduce the risk of acquisition.

SHORTENED ANTIMICROBIAL THERAPY DURATION. Antibiotic treatment durations represent an important field of current clinical research. Indeed, shortening antibiotic duration during bacterial pathologies has several advantages: reducing the emergence of resistance on an individual and collective scale, reducing costs, adverse effects and the environmental impact. However, a rigorous investigation is necessary to properly assess the absence of impact on the individual prognosis. In recent years, several randomized trials have made it possible to validate short durations of antibiotic therapy for frequent bacterial pathologies: 5 days during simple acute pyelonephritis, 7 days for non-febrile urinary tract infections in men, 3 to 5 days during acute bacterial pneumonia, 6 weeks for pyogenic spondylodiscitis. However, some durations seem incompressible and/or require individualization: 14 days for febrile male urinary tract infections, 12 weeks for infections on osteoarticular prostheses. It is necessary to reduce the duration of antibiotic treatment to the minimum necessary and to evaluate personalized durations taking into account, in particular, immunocompromised patients who are often excluded from trials.

HOSPITAL ANTIMICROBIAL STEWARDSHIP. Hospital antimicrobial stewardship programs have been thought to preserve the efficacy of antimicrobials for the treatment of human and animal bacterial infections. They must apply for every patient regardless of the type of healthcare facility- large or small, urban or rural, academic or community. Better and less prescribing antimicrobials is mandatory and must follow well established rules including a right diagnosis, effort to document infection, appropriate choice of the drug and shorter duration of therapy. In France, hospital programs have been in place for more than 20 years and met some success, but they remain insufficient regarding some other European countries. Notably, educative strategies including better diagnosis and improvement of antimicrobial use has been facilitated by the implementation of multidisciplinary teams. However, the success of these programs needs more involvement of other hospital practictioners, who must understand and adhere to these principles.