Prolonged suppressive antibiotic therapy for prosthetic joint infection in the elderly: a national multicentre cohort study.

During prosthetic joint infection (PJI), optimal surgical management with exchange of the device is sometimes impossible, especially in the elderly population. Thus, prolonged suppressive antibiotic therapy (PSAT) is the only option to prevent acute sepsis, but little is known about this strategy. We aimed to describe the characteristics, outcome and tolerance of PSAT in elderly patients with PJI. We performed a national cross-sectional cohort study of patients >75 years old and treated with PSAT for PJI. We evaluated the occurrence of events, which were defined as: (i) local or systemic progression of the infection (failure), (ii) death and (iii) discontinuation or switch of PSAT. A total of 136 patients were included, with a median age of 83 years [interquartile range (IQR) 81-88]. The predominant pathogen involved was Staphylococcus (62.1%) (Staphylococcus aureus in 41.7%). A single antimicrobial drug was prescribed in 96 cases (70.6%). There were 46 (33.8%) patients with an event: 25 (18%) with an adverse drug reaction leading to definitive discontinuation or switch of PSAT, 8 (5.9%) with progression of sepsis and 13 died (9.6%). Among patients under follow-up, the survival rate without an event at 2 years was 61% [95% confidence interval (CI): 51;74]. In the multivariate Cox analysis, patients with higher World Health Organization (WHO) score had an increased risk of an event [hazard ratio (HR) = 1.5, p = 0.014], whereas patients treated with beta-lactams are associated with less risk of events occurring (HR = 0.5, p = 0.048). In our cohort, PSAT could be an effective and safe option for PJI in the elderly.

Drug interactions between voriconazole, darunavir/ritonavir and tenofovir/emtricitabine in an HIV-infected patient treated for Aspergillus candidus lung abscess.

We report an unusual case of pulmonary aspergillosis in a patient with AIDS and we demonstrated the drug-drug interactions between voriconazole, darunavir/ritonavir and tenofovir/emtricitabine. The combination darunavir-ritonavir-voriconazole should be avoided.

[Is there an increased risk for cardiovascular disease in HIV-infected patients on antiretroviral therapy?]. / Les patients infectés par le virus de l'immunodéficience humaine sous traitement antirétroviral ont-ils un risque cardiovasculaire accru?

There is a growing concern about an increased risk for cardiovascular disease in HIV infected patients receiving antiretroviral therapy (ART). This risk could be related to metabolic abnormalities associated with long-term use of antiretroviral drugs. In fact, well recognized cardiovascular risk factors such as hypertension, dyslipidaemia, diabetes mellitus and central fat deposition are increasingly seen in HIV patients on ART. These factors can also be associated with non reversible risk factors, such as male sex, age greater than 40 years and family history of premature coronary artery disease. In addition, cigarette smoking and sedentary lifestyle may predispose these patients to significant cardiovascular disease. A direct atherogenic effect of HIV infection itself or antiretroviral drugs is unlikely. Epidemiological studies have suggested an increased risk for coronary artery disease in HIV infected persons; nevertheless, only long term follow-up could confirm this statement. Despite these uncertainties, it seems reasonable to identify and manage cardiovascular risk factors in HIV infected patients.

[Lung disease due to Mycobacterium xenopi excluding AIDS. Apropos of 8 cases]. / Atteintes pulmonaires à Mycobacterium xenopi en dehors du SIDA. A propos de 8 cas.

Between 1994 and early 1999, Mycobacterium xenopi was isolated in 11 HIV-negative patients seen at the Respiratory Disease Department of the Dijon University Hospital. Eight of these patients met the criteria of lung infection. Clinical and radiological features simulated pulmonary tuberculosis which delayed diagnosis until the germ was identified. Treatment is considered to be mandatory though it is difficult to manage and often disappointing. In spite of long-term medical care, sometimes associated with surgery, outcome is currently determined by the underlying disease rather than by Mycobacterium xenopi infection.

[Fat embolism with lung hemorrhage]. / Embolie graisseuse à forme hémorragique pulmonaire.

Post-traumatic fat embolism was disclosed by a picture of alveolar hemorrhage. Acute hypoxemia associated with dense bilateral pulmonary infiltrates was observed in a 21 year-old woman, 4 days after an accident with closed tibial fracture. Cruoric pulmonary thromboembolism was ruled out, as was an acute pulmonary edema. Neither infectious nor immunologic etiology was found. The diagnosis of alveolar hemorrhage was based on bronchoalveolar lavage. Lipid droplets in macrophages stained by "Oil Red O" established the relationship with fat embolism. The outcome was favorable. The association of fat embolism and alveolar hemorrhage has already been reported, but remains rare.

[Predictive factors of virological response to primary antiretroviral treatment]. / Facteurs prédictifs de la réponse virologique à un premier traitement antirétroviral.

OBJECTIVES: During 1999, first-line antiretroviral combinations for the treatment of HIV infections have diversified. The aim of our study was two-fold: define the factors associated with initial success and define the factors associated with virological rebound in patients in whom a primary antiretroviral therapy (ARV) had been initiated between 1999 and 2000. METHOD: We conducted a retrospective multicenter study regrouping 6 HIV clinics in the North-East of France. Data were Issued from the patients medical files. Primary success was defined as plasma HIV RNA viral load (VL<200 copies/ml within 6 Months of therapy and two consecutive VL<200 copies/ml. Virological rebound was defined as two consecutive VL>1000 copies/ml after primary success. Predictors of success were determined using multivariate logistic regression and SAS 8.2 software. RESULTS: Analysis concerned 123 patients, with 19% stage C when ARV was initiated. Their median CD4 and PVL values at baseline were 233/mm3 and 73,000 copies/ml respectively. The median duration of follow-up was of 20.7 Months [(mean (STD): 20.6 (6.7)]. Initial treatments were distributed as follows: 2 NRTI + 1NNRTI, n=66 (54%); 2 NRTI+1PI, n=44 (36%); 3 NRTI, n=13 (10%). Primary success was obtained in 100 (81,3%) patients. Among these, 6 (6%) developed secondary virologic failure. The absence of change in initial ARV treatment within first 4 Months, and good compliance to treatment were statistically associated with primary success in univariate (p values respectively: 0.004 and 0.04) and in multivariate analysis (p respectively: 0.009 and 0.03). The proportion of failure was higher in the patients with lower baseline CD4 levels lesser than 200/mm3 (p=0.09). CONCLUSION: In this cohort of patients, tolerance and compliance to the first regimen were associated to primary success. These results emphasize the role of compliance in primary success and reinforces need to work on compliance in such patients.