The COBATEST network: monitoring and evaluation of HIV community-based practices in Europe, 2014-2016.

OBJECTIVE: The objective of this paper is to describe the data collected by the CBVCT services from the Community-based testing (COBATEST) network, from 2014 to 2016, in order to provide an insight into community-based voluntary counselling and testing (CBVCT) services' testing activity in Europe. METHODS: A descriptive analysis of HIV testing activity in CBVCT services that are using the COBATEST tools was performed for the period 2014-2016. RESULTS: During the study period, a total of 30 329 HIV tests were performed on 27 934 individuals, of which 1.8% were reactive. Of these reactive tests, 75.8% had a confirmatory test, 92.2% of those were confirmed as positive, and 90.38% of the confirmed positives were linked to care. The total number of tests performed over the study period increased 19.31%. The proportion of confirmatory tests increased from 63.0% to 90.0% and proportion linked to care increased from 84.1% to 93.8%. Most of the tested individuals were men (70.6%), aged between 21 and 35 years (58.5%) and non-foreign born (68.1%). A high proportion of individuals tested were men who have sex with men (MSM; 42.2%). The percentage of reactive screening tests was particularly high among transgender people (8.37%) and among male sex workers (6.38%). Repeat testers had a higher percentage of reactive tests (2.02%) than those tested for first time (1.1%). CONCLUSIONS: These results prove the feasibility of collecting standardized data from CBVCT services in different countries across Europe and demonstrate the usefulness of such data.

Knowledge, actual and potential use of HIV self-sampling testing kits among MSM recruited in eight European countries.

AIM: To describe the knowledge as well as current and potential use of self-sampling kits among men who have sex with men (MSM) and to analyse their preferred biological sample and result communication method. METHODS: We analyse data of MSM of HIV negative or unknown serostatus from an online survey conducted in eight countries (Belgium, Denmark, Germany, Greece, Portugal, Romania, Slovenia and Spain) between April and December 2016. It was advertised mainly in gay dating websites. We conduct a descriptive analysis of the main characteristics of the participants, and present data on indicators of knowledge, use and potential use of HIV self-sampling as well as their preferences regarding blood or saliva sample and face or non-face-to-face result communication by country of residence. RESULTS: A total of 8.226 participants of HIV negative or unknown serostatus were included in the analysis. Overall, 25.5% of participants knew about self-sampling (range: 18.8-47.2%) and 1.1% had used it in the past (range: 0.3-8.9%). Potential use was high, with 66.6% of all participants reporting that they would have already used it if available in the past (range: 62.1-82.1%). Most (78.6%) reported that they would prefer using a blood-based kit, and receiving the result of the test through a non-face-to-face-method (70.8%), even in the case of receiving a reactive result. CONCLUSION: The high potential use reported by MSM recruited in eight different European countries suggests that self-sampling kits are a highly acceptable testing methodology that could contribute to the promotion of HIV testing in this population.

Safe Reduction in CD4 Cell Count Monitoring in Stable, Virally Suppressed Patients With HIV Infection or HIV/Hepatitis C Virus Coinfection.

BACKGROUND: It has been suggested that routine CD4 cell count monitoring in human immunodeficiency virus (HIV)-monoinfected patients with suppressed viral loads and CD4 cell counts >300 cell/µL could be reduced to annual. HIV/hepatitis C virus (HCV) coinfection is frequent, but evidence supporting similar reductions in CD4 cell count monitoring is lacking for this population. We determined whether CD4 cell count monitoring could be reduced in monoinfected and coinfected patients by estimating the probability of maintaining CD4 cell counts ≥200 cells/µL during continuous HIV suppression. METHODS: The PISCIS Cohort study included data from 14 539 patients aged ≥16 years from 10 hospitals in Catalonia and 2 in the Balearic Islands (Spain) since January 1998. All patients who had at least one period of 6 months of continuous HIV suppression were included in this analysis. Cumulative probabilities with 95% confidence intervals were calculated using the Kaplan-Meier estimator stratified by the initial CD4 cell count at the period of continuous suppression initiation. RESULTS: A total of 8695 patients were included. CD4 cell counts fell to <200 cells/µL in 7.4% patients, and the proportion was lower in patients with an initial count >350 cells/µL (1.8%) and higher in those with an initial count of 200-249 cells/µL (23.1%). CD4 cell counts fell to <200 cells/µL in 5.7% of monoinfected and 11.1% of coinfected patients. Of monoinfected patients with an initial CD4 cell count of 300-349 cells/µL, 95.6% maintained counts ≥200 cells/µL. In the coinfected group with the same initial count, this rate was lower, but 97.6% of coinfected patients with initial counts >350 cells/µL maintained counts ≥200 cells/µL. CONCLUSIONS: From our data, it can be inferred that CD4 cell count monitoring can be safely performed annually in HIV-monoinfected patients with CD4 cell counts >300 cells/µL and HIV/HCV-coinfected patients with counts >350 cells/µL.

The COBATEST network: a platform to perform monitoring and evaluation of HIV community-based testing practices in Europe and conduct operational research.

The European project "HIV community-based testing practices in Europe" (HIV-COBATEST) has contributed to the establishment of a network of community-based voluntary counselling and testing services (CBVCTs) that monitors and evaluates HIV testing activity in the communities. The objective of this paper is to describe the data that have been collected during 2014 by the COBATEST network in order to provide an insight into testing activity of CBVCTs in Europe. Members of the CBVCT network share common instruments for data collection and data entry. The network has a common database that allows global data analysis and comparison between different centres. In 2014, 40 CBVCTs of 18 European countries were participating in the network, and, from those, 20 CBVCTs were using the common COBATEST data collection tools. In these 20 CBVCTs, a total of 9266 HIV screening tests were performed on 8554 people, of which 1.58% (135/8554) were reactive and 51.1% (69/135) confirmed positive. Five cases were false positives, and 84.1% (58/69) of the confirmed positive cases were linked to care. Most of the tested individuals were men (70.8%), between 21 and 35 years of age (57.6%) and natives (67.1%). A higher proportion of men who had sex with men (MSM) (38.8%; 3267/8554) were tested compared to heterosexual men (27.7%) and women (23.5%). Rapid blood test was used in 78.5% of the cases and mostly performed in CBVCT offices (88.3%). Among sex workers (SWs), the percentage of reactive screening tests was particularly high (4.0%), especially among male SWs (7.7%) as compared to other risk groups, such as MSM (3.1%). The COBATEST network contributes to the availability of standardized information about the activity and impact of CBVCT centres in Europe. This information and standardized tools can help improve these services and inform decision-makers to better contextualize these interventions within their national HIV-prevention programmes.

Attitudes to rapid HIV testing among Spanish General Practitioners.

OBJECTIVES: The objectives of this study were to investigate the acceptability of rapid HIV testing among general practitioners in Spain and to identify perceived barriers and needs in order to implement rapid testing in primary care settings. METHODS: An anonymous questionnaire was distributed online to all members of the two largest Spanish scientific medical societies for family and community medicine. The study took place between 15th June and 31st October 2010. RESULTS: Completed questionnaires were returned by 1308 participants. The majority (90.8%) of respondents were General Practitioners (GP). Among all respondents, 70.4% were aware of the existence of rapid tests for the diagnosis of HIV but they did not know how to use them. Nearly 80% of participants would be willing to offer rapid HIV testing in their practices and 74.7% would be confident of the results obtained by these tests. The barriers most commonly identified by respondents were a lack of time and a need for training, both in the use of rapid tests (44.3% and 56.4%, respectively) and required pre- and post-test counselling (59.2% and 34.5%, respectively). CONCLUSIONS: This study reveals a high level of acceptance and willingness on the part of GPs to offer rapid HIV testing in their practices. Nevertheless, the implementation of rapid HIV testing in primary care will not be possible without moving from comprehensive pre-test counselling towards brief pre-test information and improving training in the use of rapid tests.

Acceptability of rapid HIV diagnosis technology among primary healthcare practitioners in Spain.

This study investigated the acceptability of rapid HIV testing among general practitioners (GP) and aimed to identify perceived barriers and needs in order to implement rapid testing in primary care settings. An anonymous questionnaire was distributed online to all members of the two largest Spanish scientific medical societies for family and community medicine. The study took place between 15 June 2012 and 31 October 2010. Completed questionnaires were returned by 1308 participants. The majority (90.8%) of respondents were GP. Among all respondents, 70.4% were aware of the existence of rapid tests for the diagnosis of HIV but they did not know how to use them. Nearly 80% of participants would be willing to offer rapid HIV testing in their practices and 74.7% would be confident of the result obtained by these tests. The barriers most commonly identified by respondents were a lack of time and a need for training, both in the use of rapid tests (44.3% and 56.4%, respectively) and required pre- and post-test counselling (59.2% and 34.5%, respectively). This study reveals a high level of acceptance and willingness on the part of GPs to offer rapid HIV testing in their practices. Nevertheless, the implementation of rapid HIV testing in primary care will not be possible without moving from comprehensive pre-test counselling towards brief pre-test information and improving training in the use of rapid tests.

[Fiberoptic bronchoscopy in a respiratory intensive care unit]. / Fibrobroncoscopia en una unidad de vigilancia intensiva respiratoria.

OBJECTIVE: To describe the indications, diagnostic performance and safety of fiberoptic bronchoscopy (FOB) performed in a respiratory intensive care unit (RICU). DESIGN: A prospective, observational study was carried out. SETTING: A 6-bed RICU in a tertiary university hospital. PATIENTS: Patients admitted to RICU who required FOB. INTERVENTIONS: None. MAIN MEASUREMENTS: FOB indications and complications, endoscopic procedures, time required to perform FOB. RESULTS: Sixty-nine out (23%) of the 297 patients admitted to the RICU underwent a total of 107 FOB. Sixty-eight percent of FOB were performed in patients on mechanical ventilation. FOB was performed for diagnostic and therapeutic purposes in 88 (82%) and 19 cases (18%), respectively. The study of pulmonary infiltrates was the main indication for diagnostic FOB (44 cases; 50%), particularly in immunocompromised patients (24 cases; 27%). In immunocompromised patients the diagnostic performance of FOB was significantly higher than in immunocompetent subjects (48% vs 30%; p<0.01). No major complications were recorded. Only a significant drop in PaO(2)/FiO(2) ratio was observed (182 ± 74 vs 163 ± 79; p<0.005) in patients undergoing bronchoalveolar lavage. Overall mortality in patients in the RICU was 14%. In patients requiring a single FOB procedure, mortality was 25%, versus 45% among those requiring more than one FOB procedure. CONCLUSIONS: These results show that FOB is used commonly in the RICU. It is a safe and fast procedure that contributes significantly to clinical management. Patients requiring additional FOB during admission to the RICU show high mortality.

An experimental model of pneumonia induced by methicillin-resistant Staphylococcus aureus in ventilated piglets.

The objectives of the study were to validate a model of methicillin-resistant Staphylococcus aureus (MRSA) pneumonia in ventilated piglets and to study the time-course of biological markers and histopathological changes. 12 piglets were intubated and inoculated with 15 mL of a suspension of 10(6) colony forming units of MRSA in every lobe through the bronchoscope channel. The piglets were ventilated for 12 h (n = 6) and 24 h (n = 6). Clinical parameters were assessed every 6 h and pro-inflammatory cytokines were measured in serum and in bronchoalveolar lavage (BAL) at baseline and sacrifice. Histopathology of each lobe and cultures from blood, lungs and BAL were performed. Animals developed histopathological evidence of pneumonia at necropsy. At 12 h, pneumonia was present in all animals and was severe pneumonia at 24 h. Microbiological studies confirmed the presence of MRSA. A significant increase in interleukin (IL)-6, IL-8 and tumour necrosis factor-α values was seen in BAL at 24 h and IL-6 at 12 h. In serum, only IL-6 levels had increased significantly at 24 h. In ventilated piglets, bronchoscopic inoculation of MRSA induces pneumonia at 12 h and severe pneumonia at 24 h. This severity was associated with a corresponding increase in systemic and local inflammatory response.

Animal models of ventilator-associated pneumonia.

Animal models are an essential step between "in vitro" testing and clinical studies. Different animal models have been useful for the study of pathophysiology, diagnosis and therapy in ventilator-associated pneumonia (VAP). Aspiration has been studied in dog and cat models and bacteriological diagnosis has been evaluated in baboons. Pigs have been used for studying either spontaneous or induced VAP. Intubated piglets in prone position were administered analgesia and muscle paralysis was induced, and the intubated piglets underwent mechanical ventilation for several days. In this model, spontaneous VAP due to common bacterial pig colonisation develops within a few days. Pneumonia can also be induced by inoculating high concentrations of microorganisms (Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus). Different clinical, physiological, microbiological and pathological parameters of infection have been studied in this model. In addition, administration of antibiotics and inflammatory modulators and their consequences in microbiological eradication and local and systemic inflammation have been evaluated with interesting translational results. Although bronchial inoculation of healthy subjects does not resemble the common pathophysiological mechanisms, the experimental model of ventilator-associated pneumonia induced by the inoculation of high concentrations of microorganisms in mechanically ventilated piglets is useful for the study of the local and systemic responses of lung infection and for the determination of potential measures of prevention or therapeutic modulation.

Corticosteroids in severe pneumonia.

The mortality rate in severe community- or hospital-acquired pneumonia is very high, ranging 20-50%. Despite advances in antimicrobial therapy and supportive measures, this rate has not changed in recent years, suggesting that other factors are also responsible for the poor outcome. An abnormal increase in the local and systemic inflammatory response is associated with poor outcome, and this occurs despite adequate antibiotic therapy. There is evidence that acute administration of corticosteroids decreases the inflammatory response and might decrease mortality in severe pneumonia. This has been shown in one small randomised controlled study, terminated prematurely due to 0% mortality in the intervention arm. In addition, an experimental study showed that glucocorticosteroids decrease lung inflammatory response and lung bacterial burden, confirming the results obtained through in vitro investigations. Although these results are promising and suggest a novel role of glucocorticosteroids in pneumonia, the inherent risks and potential side-effects of these drugs require further controlled clinical trials in order to better define the target population before their general use in clinical practice. Specifically, dosage, period of administration, titration, tapering and side-effects are some of the key questions that need to be investigated.

Effects of glucocorticoids in ventilated piglets with severe pneumonia.

There is clinical evidence suggesting that glucocorticoids may be useful in severe pneumonia, but the pathogenic mechanisms explaining these beneficial effects are unknown. The aim of the present study was to determine the effects of adding glucocorticoids to antibiotic treatment in an experimental model of severe pneumonia. In total, 15 Lagerwhite-Landrace piglets were ventilated for 96 h. After intubation, a 75 mL solution containing Pseudomonas aeruginosa (10(6) cfu x mL(-1)) was bronchoscopically inoculated. The animals were randomised into three groups 12 h after inoculation: 1) untreated; 2) treated with ciprofloxacin; and 3) treated with ciprofloxacin plus methylprednisolone. Physiological and laboratory parameters were monitored throughout the study. Pro-inflammatory cytokines were measured in serum and bronchoalveolar lavage (BAL). Histopathology of the lungs and cultures from blood, BAL and lungs were performed. At the end of the study, piglets receiving the antibiotic plus glucocorticoids showed: 1) a decrease in the concentration of interleukin-6 in BAL; and 2) a decrease in the global bacterial burden both in BAL and lung tissue. In conclusion, in this experimental model of pneumonia, the association of glucocorticoids with antibiotics attenuates local inflammatory response and decreases bacterial burden in the lung.

[Recommendations of antifungal treatment in patients with low grade immunosuppression]. / Recomendaciones de tratamiento antifúngico en pacientes con bajo grado de inmunodepresión.

Because of the relevance that the systemic mycoses has acquired in non-highly immunocompromised patients, the treatment difficulties they have due to the increase of the non-albicans Candida species and the need to have a better and more rational use of the new antifungal agents (voriconazole, posaconazole, caspofungin, anidulafungin and micafungin), an experts' panel on infectious diseases in representation of the Spanish Society of Chemotherapy, Spanish Society of Internal Medicine, and Spanish Society of Pneumology and Thoracic Surgery has met in order to make a few recommendations based on the scientific evidence in an effort to improve their efficiency.

Insight into the role of cetaceans in the life cycle of the tetraphyllideans (Platyhelminthes: Cestoda).

Four types of tetraphyllidean larvae infect cetaceans worldwide: two plerocercoids differing in size, 'small' (SP) and 'large' (LP), and two merocercoids referred to as Phyllobothrium delphini and Monorygma grimaldii. The latter merocercoid larvae parasitize marine mammals exclusively and exhibit a specialised cystic structure. Adult stages are unknown for any of the larvae and thus the role of cetaceans in the life cycle of these species has been a long-standing problem. The SP and LP forms are thought to be earlier stages of P. delphini and M. grimaldii that are presumed to infect large pelagic sharks that feed on cetaceans. A molecular analysis of the D2 variable region of the large subunit ribosomal DNA gene based on several individuals of each larval type collected from three Mediterranean species of cetaceans showed consistent and unique molecular signatures for each type regardless of host species or site of infection. The degree of divergence suggested that LP, P. delphini and M. grimaldii larvae may represent separate species, whereas SP may be conspecific with M. grimaldii. In all host species, individuals of SP accumulated in the gut areas in which the lymphoid tissue was especially developed. We suggest therefore that these larvae use the lymphatic system to migrate to the abdominal peritoneum and mesenteries where they develop into forms recognizable as M. grimaldii. The plerocercoid stage of P. delphini remains unknown. In a partial phylogenetic tree of the Tetraphyllidea, all larvae formed a clade that included a representative of the genus Clistobothrium, some species of which parasitize sharks such as the great white which is known to feed on cetaceans. A bibliographic examination of tetraphyllidean infections in marine mammals indicated that these larvae are acquired mostly offshore. In summary, the evidence suggests that cetaceans play a significant role in the life cycle of these larvae. In addition, it seems clear that cetaceans act as natural intermediate hosts for P. delphini and M. grimaldii, as within these hosts they undergo development from the plerocercoid stage to the merocercoid stage. Because tetraphyllidean species use fish, cephalopods and other marine invertebrates as intermediate hosts, the inclusion of cetaceans in the life cycle would have facilitated their transmission to apex predators such as the large, lamnid sharks. The biological significance of infections of LP in cetaceans is unclear, but infections do not seem to be accidental as such larvae show high prevalence and abundance as well as a high degree of site specificity, particularly in the anal crypts and bile ducts.

The clinical value of biomarkers in respiratory complications in hematopoietic SCT.

To determine the role of biomarkers in the clinical management of respiratory complications (RC) in hematopoietic stem cell transplantation (HSCT) recipients, we have prospectively evaluated a cohort of 175 patients followed-up for 1 year after HSCT. To avoid misinterpretation, we have excluded both unidentified respiratory infections (RI) and mixed RI. A total of 64 RC were included. Plasma levels of C-reactive protein (CRP), procalcitonin (PCT) and proadrenomedullin (proADM) were measured at diagnosis and on day 3 and 7. Different cytokines were evaluated in serum on the first day. No HSCT recipients without RC were included as a control group. Compared with RI, non-infectious RC showed a significant increase in CRP, proADM and interleukin 6 on day 0 (P=0.005; P=0.03 and P=0.04, respectively). When only RI were considered, we observed that bacterial-fungal PI showed higher levels of CRP (P=0.02), PCT (P=0.04) and proADM (P<0.01). Persistent low levels of proADM biomarkers suggest viral infection (specificity and positive predictive value 100%). Patients dying of RC had PCT and proADM levels higher than survivors (P=0.002 and P=0.03, respectively). In HSCT recipients biomarkers increase in both infectious and non-infectious RC. They may have utility in the assessment of the severity of RC and in suspecting a viral etiology.

Does Helicobacter pylori have a pathogenic role in bronchiectasis?

AIM: To investigate the presence of Helicobacter pylori (H. pylori) in bronchial biopsies of patients with bronchiectasis, by histochemical and immunochemical staining. SETTING: 800-bed tertiary university hospital. METHODS: Observational study. PATIENTS: forty-six patients with bronchiectasis in a stable clinical condition and 8 control patients. INTERVENTIONS: Serum samples determination of IgG levels for H. pylori by ELISA. Immunostaining with an anti-H. pylori antibody (NCL-HPp, Novocastra) of bronchial mucosa obtained by fiberoptic bronchoscopy from both patients with bronchiectasis and controls. RESULTS: Twenty-one out of 46 patients with bronchiectasis (46%) had positive serology for H. pylori. We obtained 40 bronchial biopsies in patients with bronchiectasis and 8 bronchial biopsies in control patients. No evidence of H. pylori was obtained in the bronchial samples of both patients and controls. CONCLUSIONS: The results of our study could not demonstrate the presence of H. pylori in bronchial specimens from patients with bronchiectasis.

Invasive pulmonary aspergillosis in solid organ and bone marrow transplant recipients.

BACKGROUND: Invasive pulmonary aspergillosis (IPA) remains a major cause of mortality in transplant recipients. New strategies in therapy are needed. METHODS: We prospectively followed all solid organ and bone marrow transplant recipients from January 1998 to January 2003 who showed pulmonary infiltrates. We retrospectively analyzed all of the patients diagnosed as having IPA. Clinical and epidemiological data were collected. Influence of new treatment strategies on survival was also analyzed. RESULTS: Thirty-one cases of API were found: 8 definite, 18 probable, 5 possible among recipients of liver (11), bone marrow (9), kidney (7), kidney-pancreas (3), and heart (1) transplants. Five patients (16%) were previously receiving antifungal prophylaxis. The most common symptoms were fever (74%) and dyspnea and dry cough (48%). Six cases (19%) showed dissemination to extrapulmonary sites: central nervous system (CNS) in five and bone in one. The most common radiographic patterns were alveolar infiltrates (58%); the lesions were usually diffuse and bilateral (58%). The most common Aspergillus species identified was A. fumigatus (74%). The test to detect Aspergillus antigen (galactomannan) in serum performed in 13 cases, was positive in eight (61%). The crude mortality rate was 61% (19 of 31), but in patients on mechanical ventilation, it was 94% (OR 88, IC 95%: 7.1-1094), and in patients with CNS involvement, it was 100%. The influence of the different treatment regimens on survival was analyzed in definite and probable cases: Group 1 (12) included patients who received conventional monotherapy and group 2 (12) patients received combination antifungal therapy or liposomal amphotericin B (1-AMB) at high doses. The mortality in group 1 was 83% (10 of 12), and in group 2 it was 42% (5 of 12) (P < 0.05). CONCLUSIONS: The mortality rate of IPA remains high, especially among patients with CNS involvement or those under mechanical ventilation. Combined antifungal therapy or monotherapy with 1-AMB at high doses significantly reduced mortality compared with conventional monotherapy.

Changes in epizoic crustacean infestations during cetacean die-offs: the mass mortality of Mediterranean striped dolphins Stenella coeruleoalba revisited.

In the summer and autumn of 1990, a cetacean morbillivirus caused a massive epizootic mortality of striped dolphins Stenella coeruleoalba in the western Mediterranean. Previous circumstantial evidence suggested that the disease could also have increased host susceptibility to infestations with epizoic crustaceans. In this study we provide strong evidence supporting this hypothesis. We examined striped dolphins stranded along the Mediterranean central coast of Spain from 1981 to 2004 (n = 136), and recorded data on prevalence, intensity of infestation, size and reproductive status of 2 sessile crustacean species specific to cetaceans, the phoront cirriped Xenobalanus globicipitis and the mesoparasitic copepod Pennella balaenopterae. Compared with the pre-epizootic (n = 12) and post-epizootic (n = 62) dolphin samples, the following changes were noted in the dolphins stranded during the epizootic (n = 62): (1) the prevalence of both X. globicipitis and P. balaenopterae increased; (2) the intensity of X. globicipitis and P. balaenopterae infestations did not increase; indeed, it was even slightly lower than in the other periods, as was their degree of aggregation; (3) individuals of both species were smaller, and a higher proportion were non-gravid; (4) the 2 species tended to co-occur in the same dolphins, but their numbers did not co-vary. These patterns strongly suggest that, during the epizootic, there was a short-term increase in the probability of infestation of these 2 species because of the sudden rise in the population of susceptible hosts; the growth of the new recruits was limited by the early death of dolphins. The high susceptibility was likely related to the immunosuppressive effects of viral infection and the abnormally heavy loads of polychlorinated biphenyls found in sick dolphins; the level of inbreeding was also higher in dolphins from the 'epizootic' sample. Epizoic crustaceans could be suitable indicators of health in cetacean populations.

Ototoxic reaction to erythromycin.

We report a case of bilateral hearing loss in a patient treated with intravenous erythromycin lactobionate. The ototoxic reaction occurred despite the patient's having normal renal and hepatic function and the fact that serum erythromycin levels were within the predicted normal range. In addition to hearing loss, a marked labyrinthic hyporreflexia was also observed. Hearing loss improved after the treatment was discontinued, but labyrinthic abnormalities persisted suggesting that erythromycin had caused a permanent vestibular damage.