[Epidemiological aspects of human Q fever in Indre-et-Loire between 2003 and 2005 and comparison with caprine Q fever]. / Aspects épidémiologiques de la fièvre Q humaine en Indre-et-Loire entre 2003 et 2005 et confrontation à la fièvre Q caprine.

OBJECTIVE: Chronic infection is the major risk of Q fever. C. burnetii infections result from the inhalation of contaminated aerosols. Indre-et-Loire is a rural French area with numerous goat farms. We evaluated human Q fever epidemiology and compared it with Q fever in goats. DESIGN: This retrospective study was made between 2003 and 2005. The diagnosis of C. burnetii infection was based on serologic findings from all the subdivision laboratories. Antibodies were detected by using indirect immunofluorescence. Farm animal data was processed by ELISA on blood samples from goats and cattle after Q fever related abortion in 2006 and results of PCR-processed milk samples from 156 goat farms. RESULTS: Forty human cases were studied: 38 acute Q fever (11 pneumonia, 10 hepatitis, 10 pneumonia with hepatitis, two isolated fever) and six chronic Q fever (four endocarditis). Sixteen patients (40%) had been professionally exposed, 10 (25%) of whom were goat farmers. Eight (20%) had been in contact with placenta. All the human cases were located in the south of Indre-et-Loire. Twenty percent of the volunteer goat farms had at least one milk sample positive for Q fever by PCR. Forty-nine of the 75 goat abortion samples were positive in ELISA. Ninety-two of the goat farms with positive samples were located in the south of Indre-et-Loire. CONCLUSION: This study revealed similar location of human and caprine Q fever. Identifying such geographical correlation may lead to improving prevention and detection.

Optimal duration of antibiotic therapy in vertebral osteomyelitis.

OBJECTIVES: To compare the risk of relapse of vertebral osteomyelitis (VO), according to the duration of antibiotic therapy (< or =6 weeks versus >6 weeks). METHODS: We performed a 10-year retrospective study to assess the risk of VO relapse and to verify that this risk was not enhanced in patients who received 6 weeks of antibiotic therapy (Group 1) as compared with those who received a longer treatment (Group 2). VO was diagnosed based on clinical manifestations, magnetic resonance imaging and/or computed tomography findings, and isolation of a pyogenic organism in blood cultures and/or a discovertebral biopsy. Relapse was diagnosed based on isolation of the same organism in blood cultures and/or a discovertebral biopsy. Outcome was evaluated 6 months post-treatment and in December 2004. RESULTS: Group 1 included 36 patients (mean age, 58 +/- 15 years) and Group 2 included 84 patients (mean age, 67 +/- 15 years) (P = 0.003). Clinical data and microorganisms were comparable in the 2 groups. In the first 6 months, 6 (5%) patients died (Group 1, n = 2; Group 2, n = 4), and 5 (4%) in Group 2 relapsed, 2 with recurrent VO and 3 with recurrent bacteremia. In 2004, 91 patients were evaluated (mean follow-up, 40.6 +/- 31 months): 77 (85%) were cured, 13 (14%) died (Group 1, n = 3; Group 2, n = 10), 1 had VO due to a different microorganism (Group 2), and no long-term relapses occurred. CONCLUSION: Our results suggest that antibiotic therapy of VO could be safely shortened to 6 weeks without enhancing the risk of relapse.

Health-related quality of life and patient-provider relationships in HIV-infected patients during the first three years after starting PI-containing antiretroviral treatment.

The aim of this study was to investigate factors associated with better health-related quality of life (HRQL) during the first three years after starting PI-containing antiretroviral treatment. Clinical, social and behavioural data from the APROCO cohort enabled us to analyze simultaneously the association between HRQL and patients' relationships with their health care providers. A self-administered questionnaire collected information about HRQL (MOS-SF36) and relationships with medical staff (trust and satisfaction with information). Two aggregate scores, the physical (PCS) and mental (MCS) component summaries (adjusted for baseline HRQL), were used as dependent variables in the linear regressions to identify factors associated with HRQL. We had complete longitudinal data for 360 of the 611 patients followed through M36. Factors independently associated with a high MCS were (male) gender, no more than one change in treatment, (few) self-reported symptoms and trust in the physician. Factors independently associated with high PCS levels were employment, no children, (few) self-reported symptoms and satisfaction with the information and explanations provided by the medical staff. These results underline the need to improve patient-provider relationships to optimize long-term HRQL. Socio-behavioural interventions should focus on this goal.

[Treatment of acute group A beta-hemolytic streptococcal tonsillitis in children with a 5-day course of josamycin]. / Traitement des angines aiguës à streptocoque beta-hémolytique du groupe A chez l'enfant par la josamycine pendant cinq jours.

MATERIAL AND METHODS: In this randomized open study, 325 children aged two to 15 years with acute tonsillitis and a positive test of GA beta H streptococcal antigen were treated with josamycin 50 mg.kg-1.day-1 b.i.d for 5 days, or penicillin 50,000 to 100,000 IU/day t.i.d for 10 days. Clinical assessments and throat cultures for GA beta HS isolation were performed at the inclusion visit (V1), at the end of treatment visit (V2: day 12 for all patients) and at the follow-up visit (V3: day 30). In case of positive GA beta HS culture, the bacterial DNA by RFLP was performed to differentiate between the persistence (presence of original strain at V2), relapse (eradication at V2 and acquisition of same strain at V3) and reinfection (eradication at V2 and acquisition of different strain at V3). RESULTS: Two hundred and twenty-three patients were included in the bacteriological and clinical criteria per protocol analysis. At V2, eradication rates were comparable: 82% in josamycin and 80% in penicillin patients; clinical cure rates were 90% and 89%. At V3, relapse of GAS assessed only on clinically and bacteriologically cured patients at V2 occurred in 12% of josamycin patients and 12.8% of penicillin patients. Tolerance was good; 14% and 10% of josamycin and penicillin patients respectively experienced an adverse event. CONCLUSION: In this non-inferiority study, the efficacy of a 5-day course of josamycin is comparable to reference treatment in GA beta HS tonsillitis in children.

[Impact of Opposable Medical References (RMO) prescription guidelines for antibiotic prescriptions in ambulatory medicine]. / Impact des Références Médicales Opposables (RMO) sur la prescription antibiotique en médecine ambulatoire.

The French RMO (Références Médicales Opposables) are prescription guidelines based on a critical assessment of antibiotic drug prescription. The RMO 2, which concerns the prescription of commonly used antibiotics for otorhinolaryngological/respiratory infections, provides an example of the advantages and drawbacks of such an approach. Its effect on prescription behaviour is probably significant. The economic impact in terms of health cost has remained within acceptable limits.

[Prescription of beta-lactams for community-acquired broncho-pulmonary infections in adults. Observations in the hospital environment]. / Prescription des bêta-lactamines pour infections broncho-pulmonaires communautaires de l'adulte. Observatoire en milieu hospitalier.

OBJECTIVE: Analyze beta-lactam prescription patterns used in hospitals for the treatment of community-acquired lower respiratory tract infections in adults. PATIENTS AND METHODS: A prospective study was carried out over 4 months (October 1997 to January 1998) in 54 medical units caring for lung disease, internal medicine/infectious disease, geriatric and general medicine patients in 27 hospitals representative of the public facilities in France. Data were collected on the medical unit, the patients, and the antibiotic prescriptions, including discharge prescriptions. The cost analysis of antibiotic therapy took into account all antibiotics given to the patients during their hospital stay. RESULTS: One thousand eighteen patients were included in the study: 266 were treated for acute bronchitis, 405 for bronchitis infection with underlying chronic respiratory disease, and 347 for pneumonia. Noteworthy findings included: low percentage of protocols within the medical units (25.3%), an unexpected frequency of hospitalization for acute bronchitis generally among elderly women, and prolonged intravenous antibiotic therapy and hospitalization (5 to 6 days and 9 to 12.5 days respectively). CONCLUSION: This study confirms the need to reinforce measures aimed at optimizing antibiotic prescriptions in hospitals.

[Methods and monitoring of antibiotic therapy of infectious endocarditis]. / Modalités et surveillance de l'antibiothérapie des endocardites infectieuses.

Antibiotic treatment of infective endocarditis has to be discussed when the microorganism has been identified. Antibiotics must be started as soon as possible, just after blood samplings in case of clinical bacteraemia, or as soon as blood cultures are positive. In case of negative blood cultures, diagnosis of endocarditis has to be reconsidered, according to Duke's criteria, and antibiotics must not be started until there is strong evidence in favour of infective endocarditis. Antibiotic treatment must be bactericidal, intravenously administered, for a long time to sterilize vegetations. Duration of antibiotics depends on the microorganism, and whether there is a valvular prosthesis or not. Hospitalization is often mandatory, but there is a trend towards the use of outpatient treatments, only possible in some indications.

Temporal development and prognostic value of antibody response to the major neutralizing epitopes of gp120 during HIV-1 infection.

Our objective was to analyse the humoral response to the major neutralizing epitopes of gp120. The kinetics of the appearance of antibodies directed to the V3 region (V3 Abs) and antibodies directed to the CD4 binding site (CD4BS Abs) were compared in sequential sera from 20 seroconverters. V3 Abs were titrated using 2 different indirect EIAs with synthetic oligopeptides coated on the solid phase. The sequences of the oligopeptides used were those of the MN isolate or a mixture of the consensus sequences of the 5 major HIV-1 subtypes (A-E). CD4BS Abs titers were determined using an EIA in which serum antibodies compete with a labeled human monoclonal antibody, F105, whose corresponding epitope overlaps the conformation-dependent CD4BS, for binding to purified recombinant gp120 coated on a solid phase. The prognostic value of both antibodies was analyzed in a longitudinal study of 60 HIV-1 infected patients (17 nonprogressors and 43 progressors). Eighty-five percent and 70% of HIV sero-converters were positive for V3 Abs and CD4BS Abs, respectively, during the observation period. V3 Abs were detected first in the majority of the patients (mean delay of appearance, 1.22 +/- 0.96 months vs. 4.81 +/- 2.05 months for CD4BS Abs). Both categories of antibodies appeared simultaneously in 4 patients (20%). No prognostic value could be attributed to these antibodies. Our data confirm that V3 Abs and CD4BS Abs appear with some delay after primary infection, suggesting that they do not play a large or early role in the rapid clearance of viremia in primary HIV-1 infection. These antibodies were not associated with progression to symptomatic infection and are thus of no value for surveillance in HIV-1 infected patients.

[Hepatitis B virus reactivation in patients infected with HIV]. / Reactivarea virusului hepatitei B la pacientii infectati cu HIV.

The authors study the reactivation of B hepatitis virus in three HIV infected patients, correlating the moment of reactivation of and the CD4 and CD8 lymphocytes. Prior to the B viral reactivation, the three patients were with Ac HBc IgG (+) in serum, assessing that the presence of AC HBc IgG is insufficient to prevent the reactivation and to consider a B hepatitis cured. In two patients, prior to the B virus reactivation, AgHBs was (-) in the serum. It is considered that the predominant hepatocytolysis mechanism is the viral one, in the stage of B virus reactivation in patients with AIDS, the cell immunity mechanism being depressed.

[Spontaneous reactivation of the hepatitis B virus?]. / Reactivarea spontana a virusului hepatitei B?

The authors present 4 cases of chronic AgHBs positive hepatitis, with reactivations of hepatitis B virus. The reactivations occurred spontaneously, as mentioned in references. The authors appreciate that the cause of B virus reactivation bases upon factors which modify the immune status of the host. Alcohol is one of these factors, not yet mentioned in references as cause of virus B reactivation. Are also presented data about the existence of virus B mutants, in the studied patients, which could play a role in the reactivation of chronic hepatitis B.

Medical treatment of infective endocarditis: general principles.

The main objective of medical treatment of infective endocarditis is to sterilize the vegetative lesions characteristic of the disease. The general principles of treatment are: (1) identification of the causative organism; (2) in vitro determination of its susceptibility, and (3) the choice of a bactericidal treatment. In vitro susceptibility, the minimum inhibitory concentration (MIC)/minimum bactericidal concentration (MBC) rate, the level of aminoglycoside resistance and in vitro synergy testing are determined according to the organism. Bactericidal therapy requires a combination of antimicrobials with synergistic activity, generally a cell-wall-active agent and an aminoglycoside. Treatment must be instituted parenterally, to ensure complete bioavailability, high serum concentrations and good penetration into the vegetations. The mode of administration depends on the organism, the serum-half-life and the mode of antimicrobial effect whether time or concentration-dependent, and the post-antibiotic effect (PAE). Cell-wall-active antibiotics (beta-lactams and glycopeptides) with a time-dependent activity require concentrations above MIC for as long as possible between administrations, mainly if there is no PAE; conversely, aminoglycosides or fluoroquinolones with a concentration-dependent activity must be used to obtain a peak-concentration five to ten times the MIC. Therapy must be monitored rigorously. The clinical relevance of serum bactericidal titre is poor owing to lack of standardization and its poor predictive value of failure. The duration of therapy must be sufficient (4-6 weeks) to prevent failure or relapse.

Isolated motor control dysfunction related to progressive multifocal leukoencephalopathy during AIDS with normal MRI.

We describe the case of a human immunodeficiency virus-infected 34-year-old man with progressive multifocal leukoencephalopathy (PML). His case displayed unusual features, including a bizarre movement disorder, predominant involvement of the subcortical U fibers on neuropathologic examination, and the absence of MRI abnormalities suggestive of PML. Anatomic-clinical correlations are discussed.

[Acute viral meningitis]. / Méningites aiguës virales.

Viral meningitis are the most frequent cause of clear cerebrospinal fluid (CSF) meningitis and are usually benign. The viral nature is suggested by clinical arguments (context, associated manifestations) and particularly the analysis of CSF, typically lymphocytic. However, problems of CSF interpretation may occur during the polymorphonuclear reaction at the beginning of such meningitis and after elevated protein or low glucose concentration. The main differential diagnosis are: partially treated bacterial meningitis, the beginning of meningococcal meningitis, listeriosis or tuberculous meningitis which need and urgent and specific treatment. The most common agents are the enteroviruses. The etiology can only be detected through careful virological investigations. These studies may be useful in outbreaks or in epidemiological studies.

[Pulmonary malacoplakia and Rhodococcus equi pneumonia in a patient infected with the human immunodeficiency virus. A case report with review of the literature]. / Malacoplasie pulmonaire et pneumonie à Rhodococcus equi chez un patient infecté par le virus de l'immunodépression humaine. A propos d'un cas avec revue de la littérature.

We report a case of pulmonary malakoplakia in a patient suffering from AIDS secondary to a Rhodococcus equi pneumonia. The association between these two pathologies only occurring in the immunodepressed does not seen fortuitous. Deficiency in cellular immunity and macrophage cellular activity as well as failure of intracellular bactericidal and phagolysosomal function are very probably the links. The treatment of this opportunistic germ rests on prolonged poly-antibiotic therapy or indeed surgical excision.