En pharmaco-épidémiologie, les études visant à évaluer l’impact des médicaments sur la santé de la population en situation réelle d’utilisation à la demande des Autorités de Santé en France, sont conduites dans un contexte contraint, en l’absence de bases de données médicalisées populationnelle. Le choix des critères d’évaluation des études de terrain à mener est donc crucial. Les critères directs de mesure d’impact (mortalité, morbidité, qualité de vie) sont parfois complexes à obtenir à large échelle, aussi, l’utilisation de critères indirects est souvent nécessaire. La persistance des traitements est un critère combinant de nombreux avantages : reflet de la pratique médicale courante et simplicité de recueil. Dans le cadre de cette thèse, nous avons proposé d’étudier l’intérêt de la persistance des traitements comme critère de mesure d’impact, angle peu exploré jusque là, la persistance étant usuellement considérée comme paramètre d’exposition. Aussi, dans le Chapitre 1, nous avons précisé à quels niveaux la persistance des traitements entre dans le champ de l’évaluation de l’impact. Puis, à partir de trois études de terrain, nous avons évalué l’intérêt de la mesure de la persistance au sein de deux niveaux d’impact. La persistance comme mesure directe de l’utilisation et du respect des recommandations est illustrée dans le Chapitre 2 (prévention secondaire du post-infarctus du myocarde). La persistance comme mesure indirecte de l’efficacité en vie réelle est illustrée : dans le Chapitre 3 où la persistance signe l’échec thérapeutique (traitement curatif de la sinusite aigue) puis dans le Chapitre 4 où la persistance est considérée comme un succès thérapeutique (traitement suspensif de l’épilepsie). Pour finir, nous avons discuté l’intérêt des résultats issus de ces travaux au regard du contexte actuel des demandes d’étude requises par les Autorités de Santé avec la perspective de la mise en place de la nouvelle législation européenne d’évaluation du médicament. / Pharmacoepidemiological studies requested by French Health Authorities to assess impact of treatment in real-life medical practice are performed in a restricted context, in the absence of a national health care databases. The choice of evaluation criteria for field studies is thus crucial. Direct impact measure criteria (mortality, morbidity, quality of life) are sometimes difficult to obtain on a large scale, therefore, the use of indirect criteria is often required. Treatment persistence is a criterion that combines several advantages: reflection of real-life medical practice and ease of collection. In this thesis, we studied persistence of treatment as a measure of impact, an original point of view as persistence is usually considered as a parameter of exposure. In Chapter 1, we have detailed at which level persistence of treatment is part of the field of impact evaluation. Thereafter, using three field studies, we assessed measure of persistence within two aspects of impact. Persistence as a direct measure of use and respect of recommendations is illustrated in Chapter 2 (secondary prevention in post-myocardial infarction). Persistence as an indirect measure of effectiveness is illustrated: in Chapter 3 where persistence is a sign of treatment failure (curative treatment of acute sinusitis) then in Chapter 4 where persistence is considered as treatment success (long-term treatment in epilepsy). In conclusion, we have discussed the results of this work with regards to the current context of studies requested by Health Authorities and with the forthcoming implementation of new European pharmacovigilance legislation.

Staphylococcus aureus is a opportunistic pathogen that can cause severe and chronic infections. The reason of the infections relapse is often the persistence. It is about adapting to stressful conditions by inducing a dormant state, which would allow bacteria to survive exposure to antibiotics and grow again after their elimination. Bacteria that persist in the patient acquire various adaptive mutations, which are transmited creating subpopulations that have a better ability to persist. The aim of this diploma thesis was to compare individual methods of persistent study that could be used in clinical practice in the future, and at the same time to try a closer molecular characterization of the persistent state with using methods for calculating gene expression. I had chronological isolates of Staphylococcus aureus at my disposal, the initial one being the primoisolate, an isolate taken at the diagnostics of cystic fibrosis before the start of antibiotic treatment. Another was taken at a distance of three-quarters of a year and the last with a half-year interval from the previous one. Following whole genome sequencing, genes in which adaptive mutations occurred were identified. The first method determines the degree of persistence by calculating CFU (Colony Forming Units) after antibiotic treatment....

In clinical practice, infections caused by persistent bacteria have become a worldwide problem. We are talking about a subpopulation of cells that are able to withstand lethal doses of antibiotics and after their elimination are capable of resuscitation and re-induction of the disease. The opportunistic pathogen Staphylococcus aureus is one of this bacteria and causes various serious chronic infections. During the long-term persistence in patients, persistent bacteria acquire adaptive mutations. The aim of this diploma thesis was to monitor the degree of persistence in selected clinical isolates, and at the same time to demonstrate the effect of adaptive mutations on the degree of persistence as well as to molecularly characterize the persistent state by gene expression. I had chronological isolates of S. aureus at my disposal, the initial one being the primoisolate, an isolate taken at the diagnostics of cystic fibrosis before the start of antibiotic treatment. Another was taken at a distance of one year and the last with a half-year interval from the previous one. Following whole genome sequencing, genes in which adaptive mutations occurred were identified. The first method determines the degree of persistence by calculating CFU (Colony Forming Units) after antibiotic treatment. I found that this...

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