Identification and prioritization of bioaccumulable pharmaceutical substances discharged in hospital effluents.

The consumption of pharmaceuticals and their excretion in wastewater is a continuous source of pollution for aquatic ecosystems. In certain cases these compounds are found in the environment at concentrations high enough to cause disturbance in aquatic organisms. Aware of this problem hospitals are giving increasing attention to the nature of their effluents and their impact on the environment, by implementing more efficient effluent management policies. This concern is justified in view of the large volumes of toxic products consumed (detergents, disinfectants, pharmaceuticals, chemical reagents, radioactive elements, etc.). Moreover, these effluents usually do not undergo any specific treatment before being discharged into urban sewage networks. In this article, we present a method for selecting the pharmaceuticals discharged in hospital effluents that have the worst impact on the aquatic ecosystem, primarily based on their bioaccumulation potential. This study focused on the pharmaceuticals consumed at the Hospices Civils de Lyon (HCL), the second largest hospital structure in France (5200 hospital beds). Of the 960 substances consumed in HCL hospitals, a shortlist of 70 substances considered as being potentially bioaccumulable was established. The use of aggravating factors of risk has then led to the final selection of 14 priority compounds. They include 4 compounds consumed in large quantities in HCL hospitals, 6 endocrine disruptors and 4 potentially ecotoxic compounds. For all these compounds, it is now advisable to verify their bioaccumulation potential experimentally and confirm their presence in the environment. In addition, in order to monitor the risk relating to possible contamination of the food chain, it will be necessary to measure accumulated dose levels in species of different trophic levels. Lastly, chronic ecotoxicity tests will permit evaluating the danger and risk that some of these substances may represent for aquatic ecosystems.

Daily physicochemical, microbiological and ecotoxicological fluctuations of a hospital effluent according to technical and care activities.

The problem of hospital effluents falls into the framework of hazardous substances due to the specific substances used and discharged for the most part into urban drainage networks without prior treatment. This in-depth study has led to greater understanding of the effluents discharged by hospitals. The experimental program implemented consisted in carrying out parallel sampling of the effluents of one hospital: a 24 h-average sample and 5 periodic samples corresponding to fractions of times and hospital activities. The samples were characterized by physicochemical, microbiological and ecotoxicological analyses. The results highlight that the effluents contained very little bacterial flora and a moderate organic pollution. However, a numerous of specific pollutants were detected: AOX, glutaraldehyde, free chlorine, detergents, Freon 113 as well as alcohols, acetone, formaldehyde, acetaldehyde, ammonium, phenols and several metals. The battery of bioassays showed that the effluents had a high level of ecotoxicity partly linked to particles in suspension and, that pollution fluctuated greatly during the day in connection with hospital activities. Finally, the PNEC values compared to the concentrations of pollutants dosed in the effluents highlighted that their toxicity was mainly due to several major pollutants, in particular free chlorine. Some hypotheses require additional experiments to be carried out. They concern: reactions of fermentations likely to occur in the drainage network and to form secondary toxic compounds, retention of chlorine by particles and physicochemical characterization of suspended solids.

[Changing medical practices and nosocomial infection rates in French maternity units from 1997 to 2000]. / Surveillance des infections nosocomiales dans les maternités du sud-est de la France entre 1997 et 2000.

OBJECTIVES: In this study we describe the changes in medical practices and nosocomial infection rates in obstetrics observed through a surveillance network in the South East of France. MATERIAL AND METHOD: The maternity units which belong to this network participated in voluntary surveillance using the network's methodology. The criteria for the diagnosis of nosocomial infections were in accordance with the methods described by the Centers for Disease Control and Prevention. RESULTS: 101240 pregnancies including 18503 caesareans (18.3%) were included in the network from 1997 to 2000. During the study period, nosocomial infection rates following caesarean section and vaginal delivery decreased respectively from 7.8% to 4.3% (p < 0.001) and from 2.2% to 0.9% (p < 0.001). This evolution was compared with the evolution of collected risk factors. CONCLUSION: In spite of the methodology limits, general value of surveillance and infection control programs in maternity units has been confirmed by the results of this surveillance network. During the study period, both obstetrics-related risk factors for nosocomial infection and observed hospital-acquired infection rates were dramatically reduced, what prove an improvement of quality of care in maternity units.

[Nosocomial infections due to adenovirus in a paediatric unit]. / Infections nosocomiales à adénovirus dans un service de pédiatrie.

OBJECTIVE: We carried out a retrospective analysis of an outbreak of adenovirus (AdV) infections in a paediatric unit. The aim of the study was to analyse cases, determine the route of transmission and to evaluate the efficacy of the prevention measures. PATIENTS AND METHODS: The study was performed by recollection of AdV infection cases during a period of 1 year and the results were compared with the list of clinical cases recorded during the epidemic. The clinical files of children with a positive specimen were retrospectively analysed. During that period, five members of the medical staff showed clinical signs and symptoms of AdV infection. A throat swab was collected from a subset of the staff. RESULTS: Among nine patients with positive AdV detection, six were infected with an Adv type 2. Six were nosocomially-acquired, the other two were only probable nosocomial infections. The index case was a child presenting a febrile diarrhoea 48 h prior to being admitted to the hospital. Nosocomial transmission was associated with the prolonged shedding of the virus with faeces of the infected cases. The specimens collected from the staff remained negative. The outcome was favourable for all children. CONCLUSIONS: Prevention measures, implemented when the epidemic was characterised, allowed the control of the nosocomial outbreak.

[Epidemic of Staphylococcus aureus nosocomial infections resistant to methicillin in a maternity ward]. / Epidémie d'infections nosocomiales à Staphylococcus aureus résistant à la méticilline dans une maternité.

Methicillin-resistant Staphylococcus aureus (MRSA) nosocomial infections frequently occur in the hospital environment, but their incidence is less often observed in neonates. In the present investigation, seventeen cases were recorded over a nine-week period (two cases per week). Pulsed field gradient gel electrophoresis confirmed the clonal character of the strain. The hypothesis of manually-transmitted infection due to contamination from multiple sources was reinforced by the fact the epidemic persisted in spite of the elimination of the main human infectious source and an absence of risk factors determined by the case-control study. The role of environmental factors in the persistence of this outbreak of MRSA infection has been considered.

[Indicators of quality for hospital antisepsis]. / Indicateurs de qualité pour l'antisepsie à l'hôpital.

In any health care institution, the most important quality indicator for antisepsis is the existence of systems of reference of use, secondly the knowledge of those systems and then the compliance by the different classes of professionals. These refrentials must be regularly evaluated and updated according to general consensus.

[Hospital infection in maternity homes]. / Gospital'naia infektsiia v rodil'nykh domakh.

The results of the prospective survey of hospital infections in mothers and newborns at the obstetrical clinic of the Edouard Herriot Hospital in Lyon are presented. Surveillance lasting six successive years covered 18,026 deliveries with or without the use of cesarean section. The incidence of hospital infections (not taking into account cases of bacteriuria) was 1.6% in parturient women not subjected to cesarean section and 11.7% in those having had this operation. Urinary tract and parietal infections, endometritis were in leading cases. The average incidence of hospital infection in newborns was 2.68%, the leading clinical manifestations being peripheral staphylococcal lesions in the form of pustules.

Air filtration and prevention of aspergillary pneumopathies. Preliminary comparative study of two mobile units for bacteriological air purification with recycling.

Two mobile units for air filtration with recycling designed to reduce the aerobiocontamination of hospital rooms were tested. Their efficacity was evaluated by measurement of particle retention and by quantitative determination of the reduction of aerobiocontamination in rooms occupied by patients. Results show a significant improvement in the aerobiocontamination of test rooms as compared to control rooms. It is thus reasonable to suppose that these systems may provide a practical solution to the problems posed by hospitalization in ordinary rooms of patients subjected to aplasive chemotherapy. A randomized clinical trial is in progress.

[Hospital infection in the maternity department. 3 years of surveillance in 9,204 deliveries of which 1,333 were cesarean sections]. / Infection hospitalière en maternité. Trois années de surveillance portant sur 9 204 accouchements dont 1 333 césariennes.

Hospital or nosocomial infection, or infection acquired in hospitals, is a health problem in all hospital departments and particularly in the maternity department. We report on a prospective survey of surveillance of hospital-acquired infections both from the mother and the baby's point of view after delivery vaginally or with caesarean carried out at the obstetrical clinic of the Edouard Herriot Hospital in Lyon (France) over three successive years with a series of 9,204 deliveries. The incidence of infection in women who were delivered without caesarean section was 1.37% when urinary tract infections had been excluded but 13% in women who had caesarean sections. Endometritis, skin infections and urinary tract infections were the leading causes. As far as the newborn were concerned, hospital infection ran at about 2.60% and this in the main was due to staphylococcal pustules in the skin. These figures are still too high and prevention should be based on more information given and more care taken by the whole staff of such a hospital.

[Prevention methods of nosocomial urinary tract infections]. / Les méthodes de prévention des infections urinaires nosocomiales.

After classifying the nosocomial urinary tract infections, between the hospital acquired infections, this paper review different prevention means proposed to limit their incidence. These consist essentially of recommendations concerning the vesical catheterism. Thus are reviewed catheter indications, the choice of the catheter, its putting conditions, the creation and conservation of a closed system. Besides, patient informations and bacteriological survey of the catheterized patients are also discussed.

[Evaluation of prevention methods of nosocomial urinary tract infections]. / Evaluation des méthodes de prévention des infections urinaires nosocomiales.

Some recommendations for the prevention of nosocomial urinary tract infections are irrefutable, thoroughly admitted. They concern before all the aseptic conditions of setting and care of catheter, to avoid the bacterial penetration in the closed system. They concern the merits of catheter indications, the diminution of catheter conservation period, the applying of a strict asepsis during setting and manipulation of the catheter, the use of a sterile and closed drainage system with a continuous flow. Several improvements concerning the catheter and the drainage system have been proposed. Some of these recommendations have been proved serious and can be applied. On the contrary, the efficiency of others remain to be proved by control assays. Finally, measures with uncertain or unproved values should not be considered.

[Nosocomial septicemia and pseudobacteremia caused by Serratia marcescens]. / Septicémies nosocomiales et pseudo-bactériémies à Serratia marcescens.

An epidemiological survey was carried out which included a dual epidemic of septicaemia and pseudo-bacteremia caused by Serratia marcescens. The survey enabled 15 septicaemias and 43 pseudobacteremias to be detected in a regional hospital between March and August, 1983. Two mishandlings were at the origin of the outbreak: citrated tube normally reserved for coagulation tests were severely contaminated by Serratia marcescens, and inaccurate samplings had been made. Once the mechanisms of contamination were found, specific preventive measures put an end to the epidemic. The authors insist on the need for uncontaminated tubes and citrate solutions and for the development of precise sampling methods which are essential to avoid the occurrence of pseudo-bacteremia or septicaemia. It is important to detect such epidemics at an early stage by an efficient control of nosocomial infections, thus avoiding their extension.