Extremely premature infants: How does death in the delivery room influence mortality rates in two level 3 centers in France?

OBJECTIVES: Mortality rates of very preterm infants may vary considerably between healthcare facilities depending on the neonates' place of inclusion in the cohort study. The objective of this study was to compare the mortality rates of live-born extremely preterm neonates observed in two French tertiary referral hospitals, taking into account the occurrence of neonatal death both in the delivery room and in the neonatal intensive care unit (NICU). METHODS: Retrospective observational study including all pregnancy terminations, stillbirths and live-born infants within a 22- to 26-week 0/6 gestational age range was registered by two French level 3 university centers between 2009 and 2013. The mortality rates were compared between the two centers according to two places of inclusion: either the delivery room or the NICU. RESULTS: A total of 344 infants were born at center A and 160 infants were born at center B. Among the live-born neonates, the rates of neonatal death were similar in center A (54/125, 43.2%) and center B (33/69, 47.8%; P=0.54). However, neonatal death occurred significantly more often in the delivery room at center A (31/54, 57.4%) than at center B (6/33, 18.2%; P<0.001). Finally, the neonatal death rate of live-born very preterm neonates admitted to the NICU was significantly lower in center A (25/94, 26.6%) than in center B (27/63, 42.9%; P=0.03). CONCLUSIONS: This study points out how the inclusion of deaths in the delivery room when comparing neonatal death rates can lead to a substantial bias in benchmarking studies. Center A and center B each endorsed one of the two models of preferential place of neonatal death (delivery room or NICU) detailed in European studies. The reasons behind the two different models and their impact on how parents perceive supporting their neonate need further investigation.

[Umbilical cord prolapse: a case study over 23 years]. / La procidence du cordon : à propos d'une série sur 23 années d'activité

AIM: To determine the incidence of umbilical cord prolapse, the characteristics of the population, and to evaluate its management and the neonatal prognosis. MATERIAL AND METHODS: Ninety-three cases of cord prolapse that occurred between January 1986 and December 2009 at our level III labour ward were studied retrospectively. RESULTS: The incidence of cord prolapse was 0.18%. It occurred in 66.7% of cases in multiparous patients, in 19.4% of cases in twin pregnancies, and in 41.9% of cases in breech presentations. In 34.4% of cases, the gestational age was less than 37 weeks. Birth occurred vaginally in 33.3% of cases with a delivery time interval significantly less than for caesarean sections (P<0.001). At complete cervical dilation, more than three quarter of patients delivered vaginally. Vaginal birth was significantly more frequent in case of breech (P=0.009) and second twin (P=0.03). Parity did not influence birth route. Neonates with a birth weight less than 2500 g (30.1%) had significantly more frequently an Apgar score less than 7 at 5 min (P=0.02), a higher rate of transfer to intensive care (P<0.001) and a longer hospital stay (P=0.002). We report six neonatal deaths (6.5%). Neonatal status was not influenced by the time interval for delivery. CONCLUSION: Umbilical cord prolapse is still nowadays a serious complication of pregnancy, responsible for a significant rate of neonatal mortality. The aim in case of cord prolapse is to obtain fetal delivery the quickest way possible so as to improve the neonatal outcome. In some particular obstetrical situations such as breech presentations and second twin deliveries, birth occurs faster if performed vaginally as shown by our case study.

[Twin delivery with the first twin in breech position. A study of 137 continuous cases]. / L'accouchement gémellaire en cas de premier jumeau en présentation podalique. Étude d'une série continue de 137 cas.

AIM: The first twin (T1) in breech position is at risk of complications during vaginal delivery, making the choice of the appropriate delivery route highly important. Although British and American practice guidelines recommend the cesarean section, the French National College of Obstetricians and Gynecologists concluded that there was not enough data to choose one delivery route or the other. In this context, we set out to describe practices in our centre. MATERIAL AND METHODS: Our retrospective study was conducted at a level III labor ward between January 1st, 1995 and December 31st, 2006. One hundred and thirty-seven twin pregnancies at more than 26 gestational weeks (GW), with T1 in breech and T2 in any position, were included. RESULTS: A cesarean section was performed before labor in 60.6 % cases. Among the 54 (39.4 %) cases where a trial of labor was accepted, 29 patients (53.7 % success rate) delivered vaginally and 25 (46.3 %) had a cesarean section during labor. No statistical difference was observed between the neonatal outcomes after cesarean section as compared to vaginal birth. However, a significant relationship was found between delivery route and parity. Less than one-third of nulliparas versus two-third of patients with a history of at least one delivery, having trials of labor, ultimately gave birth vaginally. Thus, we observed a high rate of cesarean section during labor in nulliparas (68 % of the initially accepted trials of labor). CONCLUSION: Our study is the first one that clearly shows that the success rate of the trial of labor is closely related to a history of vaginal birth. Following these results and because of more than two-third of cesarean section during labor in nulliparas, we subsequently plan an elective cesarean section at the 38th GW for nulliparas with twin pregnancies and T1 in breech position. Nevertheless, if any of these patients go in labor before the cesearean section, a careful trial of labor is offered.

[Comparing fetal and maternal morbidities between operative deliveries by Teissier's spatulas and Minicup vacuum extractor]. / Morbidité materno-foetale liée à l'extraction instrumentale par spatules de Teissier. Etude comparative à la ventouse obstétricale de type Minicup.

OBJECTIVE: To compare fetal and maternal morbidities between operative deliveries by long Teissier's spatulas and Minicup vacuum extractor. MATERIAL AND METHODS: A retrospective study was conducted from January 2003 to July 2008 at the maternity ward, Besançon teaching hospital. Operative deliveries in term cephalic singleton pregnancies performed by Teissier's spatulas (case group) were compared to previous deliveries by vacuum extractor Minicup (control group). RESULTS: During the study period, 69 operative deliveries by Teissier's spatulas have been performed. No significant difference was found between the two groups in terms of maternal characteristics. Two third-degree perineal tears occurred following delivery by Teissier's spatulas with no third-degree tear in the vacuum extractor group (p = ns). The episiotomy rate in the Teissier's spatulas group was 15,9% compared to 11.6% in the vacuum extractor group (p = ns). Duration of operative delivery was significantly shorter in the Teissier's spatulas group (3.4 min vs 4.95 min; p = 0.007). Fetal morbidity was identical in the two groups. CONCLUSION: This study found no significant difference in terms of fetal and maternal morbidities between operative deliveries by Teissier's spatulas and vacuum extractor. Moreover, as opposed to Thierry's spatulas, the long Tessier spatulas can be adequately used in accordance with patient's wish and practice guidelines recommending a policy of restrictive episiotomy. However, a larger study is needed to confirm these preliminary results.

[Very preterm birth: is maternal anesthesia a risk factor for neonatal intubation in the delivery room?]. / Le risque d'intubation des grands prématurés en salle de naissance est-il lié au type d'anesthésie maternelle ? Expérience des réseaux périnatals Poitou-Charentes et Franche-Comté

OBJECTIVE: To assess the risk of tracheal intubation at birth in very premature neonates related to the type of maternal anesthesia in case of elective cesarean. POPULATION AND METHODS: All 219 live-born very premature neonates (28-32 weeks of gestation), delivered after an elective cesarean in the 27 maternity wards of 2 French semi-rural neonatal networks. Eighty-three percent (182/219) were delivered in level III maternity wards in university hospitals. RESULTS: Of the very preterm neonates, 33.3% (73/219) were intubated in the delivery room, either for respiratory distress syndrome or a low APGAR score. Very preterm neonates delivered after maternal general anesthesia were more often intubated than those delivered after spinal anesthesia (48.7% vs 25.2%; OR: 2.8; 95% CI: 1.8-5.1). The risk of intubation related to maternal general anesthesia remained statistically significant after an adjustment for gestational age, fetal growth retardation, respiratory distress syndrome, type of maternity ward, and a propensity score that took into account maternal sociodemographic characteristics and the causes of very preterm birth (aOR: 3.4; 95% CI: 1.4-8.2). The risk of intubation related to general anesthesia was lower after adjusting for the 5-min APGAR score (aOR: 2.8; 95% CI: 1.0-7.3). CONCLUSION: Very preterm neonates delivered after cesarean with general anesthesia require tracheal intubation in the delivery room more often than those delivered with spinal anesthesia. This study cannot assess a causal link between anesthesia and the need for neonatal intubation. However, neonatologists have to be aware of the type of maternal anesthesia because it may interfere with the non-invasive ventilation support policy of the very preterm neonate.

[Very preterm birth: should we be interested in maternal pre-pregnancy body mass index?]. / Grande prématurité : faut-il s'intéresser à la corpulence maternelle ?

UNLABELLED: Link between maternal body mass index (BMI) and pregnancy outcome is not clear. OBJECTIVE: To appreciate the impact of prepregnancy maternal BMI on very preterm birth (22-32 gestation's weeks). SECONDARY OBJECTIVE: To assess how maternal BMI does explain the mechanism of very preterm birth among live births. METHODS: Population-based study, including each mother with a live or stillborn baby was included in a geographically defined (Poitou-Charentes and Franche-comté, France) case-control study in 2004 to 2006. Leanness (BMI<18.5kg/m(2)) and overweight and obesity (BMI> or =25kg/m(2)) were defined according to World Health Organization's standards. Statistical analysis consisted in a polynomial regression on 832 mothers of very preterm babies and 431 mothers of full-term babies, taking account for confounders as maternal age, birth country, educational level, maternal work and smoking during the pregnancy. RESULTS: Leanness is a risk factor for very preterm live birth (aOR=1.73 [1.12-2.68]), overweight is a risk factor for stillbirth. (aOR=1.71 [1.03-2.84]). Among mothers of live born babies, leanness is a risk factor for spontaneous preterm birth (aOR=2.12 [1.20-3.74]), whereas overweight is a risk factor for very preterm birth on medical decision due to gestational hypertension (aOR=2.85 [1.80-4.52]). CONCLUSION: Morbid maternal stoutness before pregnancy is a complex risk factor for very preterm delivery. Women and couples should be informed and practitioners should be aware in order to prevent and manage this pathological status.

[Correct and incorrect usage of antibiotics. Prevalence study in Franche-Comté]. / Bon et mauvais usage des antibiotiques. Enquête de prévalence en Franche-Comté.

OBJECTIVE: To report the results observed regarding the prescription of antibiotics according to various indications in the Franche-Comté area: curative for a community infection, curative for a nosocomial infection and prophylactic. METHOD: A total of 6,038 patients hospitalized in 32 hospital centers of the Franche-comté area were surveyed. RESULTS: Among the 1,016 (16.8% of the total) patients receiving anti-infection products, 47.7% received anti-infection agents for the treatment of a community infection, 25.9% for a nosocomial infection and 26.4% for prophylaxis. Multiple antibiotherapy was more frequent for the treatment of community infections than for nosocomial infections [p = 0.067, Relative Risk = 1.11, (confidence interval: 95%: 1.00-1.24)]. Sixty percent of the prescriptions of 3rd generation cephalosporines were within the community framework. This class of antibiotics was widely prescribed for the treatment of E. coli infections, multi-sensitive to antibiotics, not only before but after bacteriological documentation. Among the 83 patients treated with fluoroquinolone for a nosocomial infection, 47 (56.6%) were treated with monotherapy. Regarding prophylaxis, 3rd generation cephalosporine and fluoroquinolone, which are not indicated for this, were widely used, in contradiction with the recommendations of the Société Française d'Anesthésie et de Réanimation (French Society of Anesthesia and Reanimation). CONCLUSION: This survey, despite the limits related to the prevalence method, shows the high frequency of antibiotic prescriptions that do not conform to the recommendations of the ANDEM (French agency for the assessment of medical practice) and the scientific societies.

Clinical and molecular epidemiology of chromosome-mediated resistance to third-generation cephalosporins in Enterobacter isolates in eastern France.

OBJECTIVE: To determine both the prevalence of group I beta-lactamase-related resistance and the clinical setting in which resistance to expanded-spectrum cephalosporins occurs. METHODS: Isolates of Enterobacter spp. were sensitivity tested to a range of antibiotics, and selected isolates were DNA fingerprinted by pulsed-field gel electrophoresis. The medical records of all patients with positive cultures for Enterobacter spp. were reviewed to determine the effect of previous antibiotic treatment on the susceptibility profile of these organisms. RESULTS: The crude incidence of colonization/infection (n = 315) was 0.51 per 100 patients and 0.73 per 1000 days of hospitalization. The 4-day and 7-day Kaplan-Meier rates of colonization/infection with Enterobacter were estimated to be 7.57% (standard deviation (SD = 3.26%) and 4.16% (SD = 2.88%)), respectively. The time lag to colonization/infection with isolates producing large amounts of Bush group 1 beta-lactamase (HLBL) (27.35 +/- 27.30 days) was significantly different from that to colonization/infection with wild-type isolates (13.59 +/- 17.93 days) (P = 0.036). Ninety-six isolates (30.5%) demonstrated acquired resistance to expanded-spectrum cephalosporins: 34 isolates (10.8%) produced extended-spectrum beta-lactamase, and 62 isolates (19.7%) produced HLBL. The 89 Enterobacter isolates susceptible to third-generation cephalosporins yielded 84 major DNA patterns, and the 45 HLBL isolates yielded 38 major DNA patterns. The risk of colonization/infection with HLBL-producing Enterobacter was higher in cases of antimicrobial treatment with third-generation cephalosporins or a fluoroquinolone, and in cases of urinary tract colonization/infection. CONCLUSIONS: The judicious use in hospitals of both expanded-spectrum cephalosporins and other antibiotics such as fluoroquinolones is necessary to curtail the emergence of resistance in Enterobacter spp.

[Epidemiology of hospital bacteremias in eastern France. Eastern CCLIN Network]. / Epidémiologie des bactériémies nosocomiales dans l'Est de la France. Reseau CCLIN Est.

Bacteremia occurs frequently among critically ill patients. The aim of this study carried out in Eastern France was to describe the epidemiology of nosocomial bacteremia and to assess the methicillin-resistance of Staphylococcus aureus (SA). Data were collected during a 4 months prospective survey (09/96-12/96) carried out among 44 hospitals. We counted 2633 episodes of bacteremia classified as contamination (684), nosocomial bacteremia (970) and community bacteremia (979). Incidence rate of nosocomial bacteremia was 30.7 per 100 beds in the intensive care units. When documented, the origin of the nosocomial bacteremia was the most often catheter blood related infection or urinary tract infection. Gram positif cocci were predominant among nosocomial bacteremia (53.8%). Among Gram negative bacteria (enterobacteria) (31.6%), Escherichia coli was the most frequently isolated. SA was methicillin-resistant in 18.3% of community bacteremia and in 26.5% of nosocomial bacteremia. Coagulase negative Staphylococcus were methicillin-resistant in 25.4% of community bacteremia and in 60.1% of nosocomial bacteremia. Measures to prevent catheter blood related infections and urinary tract infections may be started.

Clonal identification of Aeromonas hydrophila strains using randomly amplified polymorphic DNA analysis.

The suitability of arbitrary primer polymerase chain reaction (RAPD) as a typing technique was evaluated by comparing it with pulsed-field gel electrophoresis (PFGE) to characterize Aeromonas hydrophila strains isolated from a cluster of hospital-acquired infections. Five isolates from patients and 10 isolates from the water supply were compared to 10 epidemiologically unrelated strains isolated from patients and rivers. Two methods were used to prepare DNA and two primers (AP3 and AP5) were selected. The discriminatory power was better with the extractive DNA preparation than the boiling method. The discrimination of closely related from less related strains by PCR using AP3 was consistent with that by PFGE: water supply of Cholet hospital contaminated with Aeromonas species was not the source of the cluster of hospital infections and only two patients were infected with clonally-related strains. RAPD using primer AP3 was simpler, cheaper, and quicker to perform than pulsed-field gel electrophoresis and is well suited for the epidemiological study of A. hydrophila isolates.

Risks and routes for ventilator-associated pneumonia with Pseudomonas aeruginosa.

In a prospective study, we screened specimens from 190 mechanically ventilated patients hospitalized in a surgical intensive care unit, and from the environment to assess risks and routes of colonization/infection. Specimens from various sites were collected on admission and once a week throughout each patient's stay. All P. aeruginosa isolates were typed by determination of DNA patterns. Data were collected from patients to identify risk factors. In vitro production of exoenzymes of different strains were compared. Forty-four patients were colonized with P. aeruginosa on the bronchopulmonary tract and 13 suffered from pneumonia. The 7-d and 14-d Kaplan-Meier rates of colonization were 2.21 and 7.03%. Twenty-one patterns of bronchopulmonary tract isolates were isolated from single patients and 10 from several patients. The lower airway was often the first site of colonization. The contribution of environment to patient colonization appeared to be small. The length of hospitalization, the previous use of third-generation cephalosporins less effective against P. aeruginosa, and chronic obstructive pulmonary disease were the most significant predictors of colonization/infection. The in vitro exoprotein production was not correlated with the presence of pneumonia. Our study may be useful in identifying which patients in the mechanically ventilated population are at greater risk of P. aeruginosa pneumonia.

Association of private isolation rooms with ventilator-associated Acinetobacter baumanii pneumonia in a surgical intensive-care unit.

OBJECTIVE: To determine the rates and routes of Acinetobacter baumanii colonization and pneumonia among ventilated patients in a surgical intensive-care unit (SICU) before and after architectural modifications. DESIGN: A nonsequential study comparing two groups of patients. All isolates from systematic and clinical samples were genotyped by pulsed-field gel electrophoresis (PFGE). Records of patients hospitalized during the first and second periods were reviewed and findings were compared. Between the two periods, the SICU was remodeled from enclosed isolation rooms and open rooms to only enclosed isolation rooms with handwashing facilities in each room. SETTING AND PATIENTS: All patients hospitalized and mechanically ventilated for more than 48 hours in the 15-bed SICU of the University Hospital of Besançon (France). RESULTS: For the first and second periods, the rates of colonization were, respectively, 28.1% and 5.0% of patients (P < 10(-7); relative risk [RR], 2.23; 95% confidence interval [CI95], 1.8-2.75) and the specific rates of bronchopulmonary (BP) colonization were, respectively, 9.1 and 0.5 per 1,000 days of mechanical ventilation (P < 10(-5). Seven major PFGE isolate types were identified, 4 of which were isolated from 44 of the 47 colonized or infected patients. Logistic regression analysis showed that colonization was not associated with patient characteristics. CONCLUSION: Conversion from open rooms to isolation rooms may help control nosocomial BP tract acquisition of A baumanii in mechanically ventilated patients hospitalized in an SICU.

Epidemiological study of variations in beta-lactam antibiotic susceptibility of Pseudomonas aeruginosa in two intensive care units.

A six-month prospective study was carried out in the medical and surgical intensive care units (ICUs) at Besançon University Hospital to assess the frequency and risk factors for beta-lactam-resistant isolates of Pseudomonas aeruginosa. Clinical samples were screened for P. aeruginosa, and four antibiograms were distinguished using imipenem and ceftazidime, namely: fully susceptible (SS), imipenem-resistant (RS), ceftazidime-resistant (SR), and resistant to both (RR). DraI restriction fragment length polymorphism of isolates from different patients or with different resistance patterns but the same serotype was assessed by pulsed-field gel electrophoresis. One hundred and twenty-one isolates were obtained from 50 of 281 patients, 60.3% were fully susceptible. 19.8% imipenem-resistant, 13.2% ceftazidime-resistant, and 6.6% resistant to both. Antibiotic-resistance was independent of serotype. Twenty-two of 32 imipenem-resistant isolates from six patients were of the same DNA type, and six other isolates from four patients were of a second DNA type. On only one occasion did a clonally defined strain develop imipenem resistance. By contrast ceftazidime-resistant strains had differing DNA types, but had been originally ceftazidime-susceptible in seven of 12 patients. Reversion of imipenem resistant strains to susceptibility occurred in one patient, and of ceftazidime-resistant strains in five patients. Case-control studies identified prior antibiotic therapy as a risk factor in colonization with resistant strains. Resistance to imipenem followed imipenem therapy, and resistance to ceftazidime followed use of weakly anti-pseudomonal beta-lactam antibiotics. The major route of spread of imipenem-resistant strains was cross-colonization. Thus, assuming appropriate isolation, a carbapenem should be preferred to an extended-spectrum cephalosporin to treat pseudomonas infections in ICU patients.

Use of pulsed-field gel electrophoresis for investigation of an outbreak of Clostridium difficile infection among geriatric patients.

A six-month outbreak of Clostridium difficile infection among elderly residents of a middle-term-care facility was investigated. Pulsed-field gel electrophoresis was used to genotype 22 outbreak strains and 30 epidemiologically unrelated strains. A prospective case-control study was conducted to identify risk factors for epidemic Clostridium difficile-associated diarrhea. All epidemiologically unrelated Clostridium difficile strains of the same serogroup could be differentiated by their DNA patterns with two restriction enzymes (SmaI and KspI). Among clustered strains, two epidemic serogroups (C and K) were identified. Two different DNA patterns were identified among serogroup C strains and three among serogroup K strains. Multivariate analysis showed that the risk of Clostridium difficile infection increased with antimicrobial chemotherapy (beta-lactam agents and pristinamycin) and the presence of a feeding tube. This study confirms the high discriminative power of restriction fragment length polymorphism analysis by pulsed-field gel electrophoresis to describe Clostridium difficile epidemiology. The typing results confirm that infection was principally exogenous in this outbreak. Furthermore, they indicate the need to improve all measures limiting transmission of infection.

Risk factors for nosocomial colonization with multiresistant Acinetobacter baumannii.

A six-month prospective survey was carried out in a university hospital to assess the incidence of Acinetobacter baumannii cross-contamination and to identify risk factors for colonization. Clinical isolates obtained during the study period were biotyped and genotyped by pulsed-field gel electrophoresis after ApaI macrorestriction of total DNA. Case-control univariate and multivariate analyses were performed to identify risk factors for Acinetobacter baumannii colonization. One hundred forty-seven patients hospitalized in 36 units were colonized or infected, of whom 52 were in three intensive care units. The urinary (29%) and bronchopulmonary tracts (26%) were the most frequently colonized sites. Nine major restriction patterns were identified: two were exhibited by epidemic multi-resistant strains of biotype 9 which were isolated from 65 patients hospitalized in ten units. Multivariate analysis showed that case-patients were (a) more likely than non-infected controls to be male, to have been previously hospitalized in another unit and to have had longer stays in the unit before colonization and hyperalimentation; and (b) more likely than controls colonized with other gram-negative bacilli to be male, to have had longer hospitalization, to have received treatment with third-generation cephalosporins and to have had a urinary catheter. The high incidence of colonization with Acinetobacter baumannii can thus be attributed to frequent cross-contamination and the use of broad-spectrum antibiotics. Colonized patients appear to be the major source of cross-contamination as epidemic strains spread throughout the hospital.

[The framework Prospective Payment Information Systems: bias, sources of errors and consequences]. / L'outil PMSI: biais, sources d'erreurs et conséquences.

This paper reviews: 1) the biases linked to the definition method of the Diagnosis Related Groups (DRG), and the biases due to the implicit hospital model of the French programme medicalizing hospital information system (PMSI) which limit its use in hospital management; 2) the sources of errors met in use in the different kinds of data networks when collecting administrative data from medical discharge abstracts, which can induce mistakes in patient hospitalization counts and in the representation of medical units contribution to patients care; 3) the sources of errors in collecting medical informations from medical discharge abstracts can make the patient hospitalizations classified in DRG unrepresentative or uninterpretable; 4) the problems linked to the interpretation of the indicators estimated from the DRGs in hospital management and financial allocation.