Diagnostic des pneumonies aiguës communautaires aux urgences et distinction entre étiologie virale ou bactérienne

La pandémie actuelle liée à l'émergence du SARSCoV-2 en 2019 a considérablement modifié la perception des médecins de l'impact des virus respiratoires et de leur rôle dans les pneumonies aiguës communautaires (PAC). Alors que plus de 25 % des tableaux de PAC chez l'adulte étaient d'origine virale, les virus respiratoires étaient souvent perçus comme des agents pathogènes peu graves. Devant le défi que représente encore à nos jours la documentation microbiologique d'une PAC, l'instauration d'un traitement empirique par antibiotiques est souvent réalisée aux urgences. La pandémie de COVID-19 a surtout mis en exergue le rôle déterminant de la biologie moléculaire et du scanner thoracique dans l'algorithme diagnostique de la PAC. En effet, un diagnostic rapide et fiable est la clé pour améliorer les mesures de précaution et réduire la prescription inutile d'antibiotiques. Du fait de prises en charges très différentes, il est nécessaire de distinguer l'étiologie virale de la bactérienne d'une PAC.Alternate : The current pandemic linked to the emergence of SARS-CoV-2 in 2019 has considerably changed the perception of doctors of the impact of respiratory viruses and their role in community-acquired acute pneumonia (CAP). While more than 25% of CAP in adults were of viral origin, respiratory viruses were often perceived as harmless pathogens. Faced with the challenge that the microbiological documentation of a CAP still represents today, the establishment of empirical antibiotic treatment is often carried out in the emergency room. The COVID-19 pandemic has primarily highlighted the decisive role of molecular biology and chest CT in the diagnostic algorithm of CAP. Indeed, a rapid and reliable diagnosis is the key to improve isolation decisions and reducing the unnecessary prescription of antibiotics. Due to significantly different treatments, it is necessary to distinguish the viral etiology from the bacterial of a CAP.

Diagnosis of community-acquired acute pneumonia in the emergency room and distinction between viral or bacterial etiology.

The current pandemic linked to the emergence of SARS-CoV-2 in 2019 has considerably changed the perception of doctors of the impact of respiratory viruses and their role in community-acquired acute pneumonia (CAP). While more than 25% of CAP in adults were of viral origin, respiratory viruses were often perceived as harmless pathogens. Faced with the challenge that the microbiological documentation of a CAP still represents today, the establishment of empirical antibiotic treatment is often carried out in the emergency room. The COVID-19 pandemic has primarily highlighted the decisive role of molecular biology and chest CT in the diagnostic algorithm of CAP. Indeed, a rapid and reliable diagnosis is the key to improve isolation decisions and reducing the unnecessary prescription of antibiotics. Due to significantly different treatments, it is necessary to distinguish the viral etiology from the bacterial of a CAP. Copyright © 2022 Lavoisier. All rights reserved.

DUAL MONOCLONAL ANTIBODIES in COVID-19 PATIENTS: CLINICAL and VIROLOGICAL EFFICACY

Background: An emergency use authorization was issued in March 2021 for two combinations of monoclonal antibodies (MAbs) for SARS-CoV-2 infected patients at high risk of severe COVID-19. We performed a cohort study of patients receiving early treatment with Bamlanivimab/Etesevimab (B/E) or Casirivimab/Imdevimab (C/I) in a Paris university hospital. Methods: All patients receiving a MAbs therapy from March to July 2021 were included. Prescriptions were systematically advised by a multidisciplinary team. Both MAbs dual therapies were used up to May 12th, then only C/I due to local emergence of Delta variant. Nasopharyngeal swabs (NPS) were performed at diagnosis and 7 days after infusion. Additional NPS were collected for hospitalized patients at day 3 and during follow-up until negative RT-PCR or patients discharge. Viral sequencing was carried out and viral mutations were retained if present at more than 20% of viral subpopulations. Results: Overall, 66 patients (19 ambulatory) received a MAbs dual therapy for a documented SARS-CoV-2 asymptomatic infection or within 5 days after symptoms onset. Patients had a median age of 67 years [IQR=41-75], 53% were male, 30 (45%) were receiving immunosuppressive treatment (17 being solid organ recipients), 8 (12%) had chronic respiratory insufficiency, and 6 (9%) were receiving chemotherapy. Regarding variants, 82% were Alpha, 5% Delta and 13% other variants. 8 patients (12%) died (6 treated with B/E and two with C/I). Five deaths were related to COVID-19 worsening and three were unrelated. Among the surviving patients, 42 (64%) did not require any oxygen and 16 (24%) required low-flow oxygen. No severe adverse event related to MAbs occurred. A slower viral decay was observed among patients receiving B/E than C/I, with 17/29 and 5/13 having <30 Ct at day 7 post-infusion (p=0.3), respectively, and 9/14 and 1/8 at day 14 (p=0.03). Different Spike mutations emergence were observed including Q493R in 7 patients and E484K in 2 patients, all infected with an Alpha variant, and detected from 6 to 18 days after MAbs infusion. Among the 9 mutations, 8 occurred after B/E infusion and one Q493R occurred after C/I infusions. Conclusion: We described safety and efficacy of early MAbs therapies administration in a cohort of 66 patients at risk of severe COVID-19. Emergence of mutations were observed under both therapies, with increased frequency under B/E. Further studies including patients infected by Delta variant and receiving C/I infusion are ongoing.

Concordance de la détection des virus respiratoires sur écouvillonnage nasopharyngé et lavage broncho-alvéolaire chez l'adulte admis pour une suspicion de pneumonie

Introduction A ce jour, peu de données sont disponibles sur la concordance de la détection des virus respiratoires (en dehors du SARS-CoV2) entre le prélèvement nasopharyngé (NP) et le lavage broncho-alvéolaire (LBA) chez l'adulte. L'objectif de cette étude était de décrire la concordance de leurs résultats. Matériels et méthodes Une analyse rétrospective monocentrique a été réalisée à l'aide des données de 276 adultes suspects de pneumonie et testés par PCR multiplex dans le NP et le LBA à 24 heures d'intervalle. Résultats Les patients étaient majoritairement des hommes (65 %), avec un âge médian de 60 ans[IQR : 50,9-67,8]. 169 patients (61 %) ont été admis en réanimation Nous avons détecté au moins un virus respiratoire dans 95 NP (34 %) et dans 80 BAL (29 %). Comparé au LBA, le NP avait une sensibilité de 71,6 % et une spécificité de 93,4 % et un coefficient Kappa de 0,67. Le même agent pathogène ou combinaison d'agents pathogènes a été observé chez 84 % des patients positifs à la fois sur le NP et le LBA. La grippe B, le parainfluenza, les coronavirus HKU1, NL63, 229E présentaient la concordance la plus élevée (100 %) entre le NP et la LBA, tandis que le coronavirus OC43 et le rhinovirus présentaient la concordance la plus faible (33 % et 67 %, respectivement).Nous avons observé que les patients atteints d'une maladie respiratoire chronique ont une plus faible concordance entre le NP et LBA avec un OR ajusté à 0,5, IC 95 % (0,25-0,97), p = 0,043. Conclusion Dans ce travai, Il y a une bonne concordance entre le NP et le LBA dans la détection des virus respiratoires chez les patients consultant avec une suspicion de pneumonie. Néanmoins, ces données encouragent toujours à réaliser un LBA lorsque cela est possible afin d'obtenir un diagnostic étiologique plus précis. Aucun lien d'intérêt

Analysis of the Feasibility of a Vaccination Campaign against Influenza Epidemic and COVID-19 Pandemic in French Emergency Departments: A National Survey

BACKGROUND: Vaccination is one of the most effective ways to fight the influenza epidemic and the coronavirus disease 2019 (COVID-19) pandemic, which represent a major public issue. The objective was to investigate the adherence of heads of French emergency departments (ED) and nursing departments on a potential vaccination campaign of healthcare workers (HCW) and patients in ED. METHOD: In February 2021, ED and nursing department heads were asked to answer a national survey. It included 24 questions designed to cover some dimensions, including characteristics of the hospital and emergency departments (ED) and questions on vaccination. RESULTS: 414 responses out of 800 questionnaires (51.8%) were collected. Scores out of 10 were, respectively, 7 (6-8) and 8 (6-9) for vaccination against influenza and COVID-19 for HCW and 2 (2-3) and 2 (2-4) for ED patients (H = 989.3;p < 0.0001). Multivariate logistic regression found that the existence of a vaccine program in the hospital and the use of point of care influenza PCR in ED were positively associated with the acceptance of influenza vaccination campaign for HCW (p = 0.003) and patients (p = 0.015). Factors limiting adherence to a vaccination program of HCW and patients were lack of medical staff (p = 0.041 for HCW and p < 0.0001 for patients), overcrowded ED (p < 0.001), and the inability to follow up with patients after the ED visit (p < 0.0001). CONCLUSIONS: There have been many missed opportunities for influenza vaccination, and there is pressure to vaccinate against COVID-19 as soon as possible. Vaccination campaigns in ED could help to improve vaccination coverage. ED staff are more likely to vaccinate HCW than patients. There are factors that support the implementation of such programs, which can be grouped into a culture of diagnosis, control, and prevention of viral infectious diseases within the hospital and ED. On the other hand, there are limiting factors, such as overcrowding and lack of personnel.