No abstract

BackgroundCongenital bilateral vocal cord paralysis is a rare occurrence. Approximately half the cases are associated with a major comorbidity, usually neurological, neuromuscular or malformative.Case presentationIn a male newborn, respiratory distress syndrome and stridor were observed immediately following birth. The cause was bilateral vocal cord paralysis in the adducted position. Neuroradiological investigation revealed a unilateral discontinuity between the upper pons and the right medulla oblongata. Hypoplasia of the right posterior hemiarches of C1-C2 and the right exo-occipital bone was observed, as was a small clivus. MR angiography showed the absence of the distal right vertebral artery, with hypoplasia and parietal irregularities of the proximal segments. Respiratory autonomy was not obtained despite endoscopic laser cordotomy, corticosteroid therapy and nasal continuous positive airway pressure. The infant died at the age of 4 weeks after treatment was limited to comfort care.ConclusionsA medullary lesion is an exceptional cause of congenital bilateral vocal cord paralysis. The strictly unilateral neurological and vascular defect and the absence of associated intracranial or extracranial malformation make this clinical case unique and suggest a disruptive mechanism. This case also highlights the help provided by advanced neuroimaging techniques, i.e. fibre tracking using diffusion tensor imaging, in the decision-making process.

Background: Bacterial infections (BIs) are widespread in ICU. The aims of this study were to assess the compliance with antibiotic recommendations, and factors associated with non-compliance. Methods: We conducted an observational study in eight French Pediatric and Neonatal ICUs with an antimicrobial stewardship program mostly once a week. All children receiving antibiotics for a suspected or proven BI were evaluated. Newborns <72 hours old, neonates <37 weeks, age ≥18 years, and antibiotic for prophylaxis were excluded. Results: 139 suspected (or proven) BI episodes in 134 children were prospectively included during six separate time-periods over one year. The final diagnosis was 26.6% no bacterial infection, 40.3% presumed bacterial infection, and 35.3% documented bacterial infection. Non-compliance for all parameters occurred in 51.1%, with errors mainly concerning the antimicrobials’ choice (27.3%), duration of each antimicrobial (26.3%), and duration of antibiotic therapy (18.0%). In multivariate analysis, main independent risk factors of non-compliance were prescribing ≥2 antibiotics (OR 4.06, 95% CI 1.69-9.74, p=0.0017), a duration of broad-spectrum antibiotic therapy ≥4 days (OR 2.59, 95% CI 1.16-5.78, p=0.0199), suspecting catheter-related bacteremia (ORs 3.70 and 5.42, 95% CIs 1.32 to 15.07, p<0.02), a BI site with no clear treatment guidelines (ORs 3.29 and 15.88, 95% CIs 1.16 to 104.76, p<0.03), and ≥1 risk factor for ESBL Enterobacteriaceae (OR 2.56, 95% CI 1.07-6.14, p=0.0353). Main independent factors of compliance were having antibiotic therapy protocols (OR 0.42, 95% CI 0.19-0.92, p=0.0313), respiratory failure (OR 0.36, 95% CI 0.14-0.90, p=0.0281), and aspiration pneumonia (OR 0.37, 95% CI 0.14-0.99, p=0.0486). Conclusions: Half of antibiotic prescriptions remain non-compliant with guidelines. Intensivists should daily reassess the benefit of using several or broad-spectrum antimicrobials and stop antibiotics that are no longer indicated. Developing consensus about treating specific illnesses and using service protocols seem necessary to reduce errors. A daily ASP could also improve compliance in these error-prone situations. Trial registration: This trial was approved by Toulouse University Hospital, and is registered in its register of data study, number RnIPH2019-79, and with ClinicalTrials.gov, number NCT04642560. The date of first trial registration in ClinicalTrials.gov was 24/11/2020.

Background Bacterial infections (BIs) are widespread in ICUs. The aims of this study were to assess the compliance with antibiotic recommendations, and factors associated with non-compliance. Methods We conducted an observational study in eight French Paediatric and Neonatal ICUs with an antimicrobial stewardship programme, mostly once a week. All children receiving antibiotics for a suspected or proven BI were evaluated. Newborns < 72 hours old, neonates < 37 weeks, age ≥ 18 years, and children under antimicrobial prophylaxis were excluded. Results 139 suspected (or proven) BI episodes in 134 children were prospectively included during six separate time-periods over one year. The final diagnosis was 26.6% no BI, 40.3% presumed (i.e., not documented) BI, and 35.3% documented BI. Non-compliance for all parameters combined occurred in 51.1%. The main reasons for non-compliance were inappropriate choice of antimicrobials (27.3%), duration of one or more antimicrobials (26.3%), and duration of antibiotic therapy (18.0%). In multivariate analyses, main independent risk factors for non-compliance were prescribing ≥ 2 antibiotics (OR 4.06, 95%CI 1.69–9.74, p = 0.0017), a duration of broad-spectrum antibiotic therapy ≥ 4 days (OR 2.59, 95%CI 1.16–5.78, p = 0.0199), neurologic compromise at ICU admission (OR 3.41, 95%CI 1.04–11.20, p = 0.0431), suspected catheter-related bacteraemia (ORs 3.70 and 5.42, 95%CIs 1.32 to 15.07, p < 0.02), a BI site classified as “other” (ORs 3.29 and 15.88, 95%CIs 1.16 to 104.76, p < 0.03), sepsis with ≥ 2 organ dysfunctions (OR 4.21, 95%CI 1.42–12.55, p = 0.0098), late-onset ventilator-associated pneumonia (OR 6.30, 95%CI 1.15–34.44, p = 0.0338), and ≥ 1 risk factor for ESBL Enterobacteriaceae (OR 2.56, 95%CI 1.07–6.14, p = 0.0353). Main independent factors for compliance were having antibiotic therapy protocols (OR 0.42, 95%CI 0.19–0.92, p = 0.0313), respiratory failure at ICU admission (OR 0.36, 95%CI 0.14–0.90, p = 0.0281), and aspiration pneumonia (OR 0.37, 95%CI 0.14–0.99, p = 0.0486). Conclusions Half of antibiotic prescriptions remain non-compliant with guidelines. Intensivists should reassess on a daily basis the benefit of using several antimicrobials or any broad-spectrum antimicrobials and stop antibiotics that are no longer indicated. Developing consensus about treating specific illnesses and using department protocols seem necessary to reduce non-compliance. A daily ASP could also improve compliance in these situations. Trial registration : ClinicalTrials.gov: number NCT04642560. The date of first trial registration was 24/11/2020.