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BACKGROUND: Public health authorities in Quebec have responded to the progressive emergence of Lyme disease (LD) with surveillance activities and education for family physicians (FPs) who are key actors in both vigilance and case management. OBJECTIVES: To describe FPs’ clinical experience with LD, their degree of knowledge, and their practices in two areas, one with known infected tick populations (Montérégie) and one without (regions nearby Montérégie). METHODS: In the present descriptive cross‐sectional study, FPs were recruited during educational sessions. They were asked to complete a questionnaire assessing their clinical experience with Lyme disease, their knowledge of signs and symptoms of LD, and their familiarity with accepted guidelines for diagnosing and treating LD in two clinical scenarios (tick bite and erythema migrans). RESULTS: A total of 201 FPs participated, mostly from Montérégie (n=151). Overall, results revealed a moderate lack of knowledge and suboptimal practices rather than systematically insufficient knowledge or inadequate practices. A majority of participants agreed to more education on LD. As expected, FPs from Montérégie had a higher clinical experience with tick bites (57% versus 25%), better knowledge of LD endemic areas in Canada and erythema migrans characteristics, and better management of erythema migrans (72% versus 50%). CONCLUSION: The present study documented the inappropriate intention to order serology tests for tick bites and the unjustified intention to use tick analysis for diagnostic purposes. Such practices should be discouraged because they are unnecessary and overuse collective laboratory and medical resources. In addition, public health authorities must pursue their education efforts regarding FPs to optimize case management.

In the first half of 2003, the number of C. difficile infections (22.5 per 1000 admissions) increased in Quebec, Canada. This outbreak was associated with fluoroquinolone and cephalosporin use as well as an increase in C. difficile –associated mortality (to 6.9 percent) and colectomy (to 1.9 percent). The outbreak strain was found to have enhanced virulence, as suggested by the presence of binary toxin genes and the partial deletion of a toxin-repressor gene. In the first half of 2003, the number of C. difficile infections (22.5 per 1000 admissions) increased in Quebec, Canada. This outbreak was associated with fluoroquinolone and cephalosporin use as well as an increase in C. difficile –associated mortality and colectomy. Clostridium difficile is the leading cause of nosocomial infectious diarrhea. 1 The most important risk factor for C. difficile –associated diarrhea is prior antibiotic use. 2 Some patients remain asymptomatic after exposure to C. difficile, whereas illness ranging from mild diarrhea to fulminant colitis develops in others. 2 Only 1 to 5 percent of affected patients have severe disease, leading to colectomy, intensive care, or death. 3 , 4 The best-described C. difficile virulence factors are toxins A and B, encoded by the genes tcdA and tcdB, respectively. 5 Together with two regulatory genes ( tcdC and tcdD ) and a porin gene ( tcdE ), . . .

In the world of infectious diseases, the confidence of the 1960s and 1970s has given way to a stark realization that our mastery of the microbial world is not absolute - as the emergence of SARS and of avian influenza has illustrated. The current outbreak of Clostridium difficile associated diarrhea (CDAD) in Montral and other areas of Quebec is a harsh reminder that even well-known bacteria can change their behaviour and become emerging threats. In this issue, Susan Poutanen and Andrew Simor provide a detailed review of the epidemiology, pathogenesis, clinical presentation, diagnosis, treatment and control of CDAD.1 Despite this knowledge, the incidence of CDAD continues to increase in many hospitals across Canada, the United States and elsewhere. The US Centers for Disease Control and Prevention have analyzed secular trends in the incidence of CDAD and reported a steady increase from 1987 to 2001.2 Of 440 infectious disease physicians in the US who participated in a recent Web-based poll, 30% reported that they are seeing higher rates of CDAD, more severe fulminant CDAD and more relapsing CDAD than in the past. During the past 18 to 24 months, many health care institutions in Montral and other regions of Quebec have experienced a rise in the CDAD incidence (mean 28.2 per 1000 admissions, range 12.8-45.0 per 1000 admissions), which is about 4 to 5 times the rate of 2 years ago and 5 times the national average in 1997.3 There is an overall impression that there has been an increase in the proportion of CDAD cases with severe and fatal complications and an increase in the relapse rate among affected patients. A 1997 Canadian survey4 indicated that the attributable case-fatality rate to be 1.5%, and other authors have reported an attributable mortality of 0.8 to 2% for nosocomial CDAD.5,6 Five months ago, an ad hoc group formed by several Quebec medical microbiologists was established in light of concern about the rising CDAD incidence and its complication rates: this is now called the CDAD Clinical Study Investigators (CDAD-CSI) group. The group has established 4 priorities: (1) to establish the true incidence and serious complication rate of CDAD in affected participating Quebec hospitals by using standardized definitions and methods; (2) to begin in vitro studies of the bacteria in affected hospitals to determine whether increased virulence factors are present; (3) to establish urgent research protocols for therapy; and (4) to devise newer ultra-rapid methods of diagnosis.