Factors associated with hospital mortality in community-acquired legionellosis in France.

The aims of this study were to describe the clinical, biological and radiological features of community-acquired (CA) Legionnaires' disease (LD) and identify the predictors of mortality in hospitalised patients. Demographic data, risk factors, clinical and biological features, medical management, complications, and outcome from 540 hospitalised patients with confirmed CA LD were prospectively recorded. 8.1% of patients (44 out of 540) died. The predictors of survival after Kaplan-Meier analysis were male sex (p = 0.01), age <60 yrs (p = 0.02), general symptoms (p = 0.006), intensive care unit (ICU) stay (p<0.001), and class II-III Pneumonia Severity Index score (p = 0.004). Six predictors of death were identified by multivariate analysis: age (per 10-yr increment) (relative hazard (RH) 1.50, 95% CI 1.21-1.87), female sex (RH 2.00, 95% CI 1.08-3.69), ICU admission (RH 3.31, 95% CI 1.67-6.56), renal failure (RH 2.73, 95% CI 1.42-5.27), corticosteroid therapy (RH 2.54, 95% CI 1.04-6.20) and C-reactive protein (CRP) >500 mg · L(-1) (RH 2.14, 95% CI 1.02-4.48). Appropriate antibiotic therapy was prescribed for 70.8% (292 out of 412) of patients after admission and for 99.8% (537 out of 538) of patients after diagnosis confirmation. In conclusion, female sex, age, ICU stay, renal failure, corticosteroid treatment and increased level of CRP are significant risk factors for mortality in CA LD.

Antibiotic prescription by general practitioners for urinary tract infections in outpatients.

In July 2008, in France, guidelines for antibiotic prescriptions for urinary tract infections (UTIs) were amended. As general practitioners (GPs) treat numerous UTIs, we wanted to evaluate whether they followed these guidelines. In order to do this, we performed a prospective study. The point of call was urinalyses. Using this selection method together with criteria diagnostic for urinalysis, we confirmed that patients presented a UTI. Each GP was contacted. Prescriptions were analysed and compared to the 2008 French guidelines for UTIs. Our study included 185 urinalyses. UTIs diagnosed by GPs were as follows: acute cystitis: 72.4 %, prostatitis: 13.5 %, nephritis: 8.7 % and asymptomatic bacteriuria: 5.4 %. The principal antibiotics used were: quinolone (59.5 %), furan (17.8 %) and cotrimoxazole (6.5 %). Only 20 % of the prescriptions were compliant with the guidelines. The correct antibiotic but not the dose or the duration of prescription was selected in 8.1 % of the prescriptions. For cystitis, inappropriate prescription was associated with an extra cost of 694 , namely, 7.4 per treatment. GP prescriptions for UTIs do not follow the guidelines. Even if GPs assert that they are aware of the emergence of resistant strains, it seems that they do not take into account the objective of quinolone restriction, which was one of the backbones of these guidelines.

Association between protective efficacy of anti-lipopolysaccharide (LPS) antibodies and suppression of LPS-induced tumor necrosis factor alpha and interleukin 6. Comparison of O side chain-specific antibodies with core LPS antibodies.

Two-core LPS antibodies, the rabbit J5 polyclonal antiserum and the human anti-lipid A IgM mAb HA-1A, did not improve the survival of mice challenged with E. coli O111 or P. aeruginosa 3, or with the LPS extracted from them, and did not decrease the incidence of Shwartzman reactions in rabbits challenged with O111 LPS. In contrast, O side chain-specific rabbit antisera were protective in these models. The protection afforded by O side chain-specific antisera against endotoxin lethality was associated with decreased LPS-induced serum TNF and IL-6 levels, whereas core LPS antibodies had no effect on TNF or IL-6 levels. The absence of reduction of LPS-induced cytokines levels by core LPS antibodies suggests that these antibodies are not able to prevent the interactions between LPS and target cells.

[Molecular strain typing contribution to epidemiology of tuberculosis in Limousin (1998 to 2006)]. / Intérêt du typage moléculaire pour l'épidémiologie de la tuberculose en Limousin (1998-2006).

OBJECTIVES: We conducted a molecular epidemiology of Mycobacterium tuberculosis in Limousin, a French area with a low incidence of tuberculosis (4.8/100,000 inhabitants in 2005) to define the molecular diversity and the pattern of transmission. DESIGN: Two hundred and fifty-nine strains were isolated (each strain corresponds to one patient) from 1998 to 2006. Both spoligotyping and MIRU15 were chosen for our study because of their discriminatory power. RESULTS: Only 165 medical records were available: 99M/66F, mean age 56.4 years (14-94), 32.7% foreign-born patients, 16.9% homeless or living in shelters, 21.8% of immunocompromised patients (three HIV positive), 14.5% of alcohol addicts. Pulmonary manifestations were predominant (81.8%) with 45.1% of positive smears. Two strains among the 259 presented a multidrug resistance. Spoligotyping identified 136/259 spoligotypes (110 unique, 26 clusters composed of two to 36 isolates); within these 26 clusters, ST53 (n=36) and ST50 (n=19) were the most frequent. Three major families were observed as follow: T1 (30%), Haarlem (30%) and LAM (20%). MIRU15 identified 28/36 isolates in the ST53 group and 14/19 in the ST50 group. Eleven clusters (32 strains) with identical ST-MIRU15 were obtained with a proved case of recent transmission. Alcohol dependence, immunosuppression and pulmonary infections seem to be involved in transmission factors. CONCLUSION: M. tuberculosis strains isolated in Limousin are characterized by their high genetic diversity. The rate of recent transmission (8.1%) is low and therefore a reactivation process is predominant in this area.

Infectious sacroiliitis: Retrospective analysis of 18 case patients.

INTRODUCTION: Few infectious sacroiliitis reports are available in the literature. There is no standard clinical presentation, and diagnosis and treatments are therefore usually delayed. We aimed to describe this infection. METHODS: We performed a single-center retrospective study of patients hospitalized in the infectious diseases unit of the Limoges University Hospital from January 1, 2006 to January 31, 2016. We included all patients presenting with infectious monoarthritis of native sacroiliac joint. Clinical, biological, bacteriological, radiological, and therapeutic characteristics were collected. RESULTS: A total of 18 patients were enrolled. The sex ratio was 1.25. Mean age was 39.6years (17-69years). The average progression time at diagnosis was 17.9days (1-110days). The mean hospital stay was 16.2days (3-35days). Temperature at admission was 38.8°C (37-40°C). Identified bacteria were methicillin-susceptible Staphylococcus aureus in 83.3% of cases (n=15), Proteus mirabilis (n=1), and Streptococcus dysgalactiae (n=1). Thirty-two (88.9%) of the 36 imaging examinations were consistent with the diagnosis. The survival rate was 100% at the end of the six-month follow-up. CONCLUSION: Infectious sacroiliitis is a complex pathology requiring precise clinical examination for a rapid diagnosis. The outcome is usually favorable.

[Disseminated aspergillosis after intra-articular corticosteroid infiltrations]. / Aspergillose disséminée à point de départ articulaire après infiltrations.

Bone and joint infections due to Aspergillus are rare and occur more commonly in immunosuppressed patients. We report the case of an 84-year-old woman who developed septic arthritis caused by Aspergillus fumigatus after corticosteroid infiltration. This patient had presented with arthritis of the left knee for several months but no microorganism had been found despite numerous arthrocenteses. This arthritis was resistant to treatment by numerous corticosteroid infiltrations. During an arthroscopy, analysis of the synovial fluid yielded A. fumigatus. Thereafter, other explorations showed disseminated aspergillosis with osteo-articular destruction, blood and urinary dissemination. A systemic treatment by voriconazole associated to intra-articular injections and surgical debridement was initiated but the patient died. Septic arthritis caused by A. fumigatus is very rare but must be considered as a differential diagnosis of septic arthritis after corticosteroid infiltration. Their complications can be very important and destructive.

[Cutaneous drug reactions induced by glycopeptides]. / Toxidermies induites par les glycopeptides.

Glycopeptides are a class of antibiotics used with a rising frequency because of the increasing number of infections due to Methicillin-resistant staphylococci. The dermatological adverse effect of vancomycin are well-known: "red man syndrome", maculopapular exanthema, etc., with some distinctive features such as Ig A linear dermatosis. Drug eruptions are less common but not insignificant when using teicoplanin, a more recent molecule. A given glycopeptide cannot be considered as an alternative for every patient "allergic" to another, because of cases of cross-reaction and the morbi-mortality of some cutaneous drug reactions. This emphasizes the importance to recognize early clinical signs. In this article, we review the various dermatological adverse drug reactions induced by glycopeptides, and suggest a possible management to clinicians who could be confronted with this problem.

[Nocardiosis: A retrospective case series of 19 patients]. / Nocardiose : analyse rétrospective d'une série de 19 cas.

INTRODUCTION: Nocardiosis are uncommon. The diagnosis may be difficult, with significant morbidity and mortality, often occurring on frail patients. Few data are available in France. METHODS: A retrospective single center study was conducted from 2002 to 2014 and included all patients with at least one positive microbiological sample for Nocardia with a follow-up in our hospital. RESULTS: Nineteen patients, including 15 men, were included with a mean age of 58 years (25-85). Seventeen had a risk factor (lung diseases [13], corticosteroids [12], solid neoplasia [2], HIV infection [2], diabetes mellitus [3], kidney transplant [2], lymphopenia [1]). Infections' locations were: pulmonary (12), brain (3), skin (2), lymph node (1) and corneal (1). The slow growth leads to a median of 35 days for a positive result (3-95). Nine species were identified. Fifteen patients (79%) received one or more lines of antibiotics including: cotrimoxazole (9), amoxicillin (7) cefotaxime/ceftriaxone (7) imipenem (3), or amikacin (3). The average duration of antibiotic therapy was 207 days. Four patients did not receive antibiotics due to a late result or a bacterial co-infection masking nocardiosis. Five patients died (26%) including 2 with cerebral nocardiosis. Six patients were cured, 4 suffered a relapse, 4 had an unknown evolution, and 1 was still treated. CONCLUSION: Our study shows that nocardiosis is a disease difficult to treat. A better understanding of this type of infection is necessary.

[Post-menopausal endometrial tuberculosis]. / Tuberculose utérine post-ménopausique.

A 69-year-old menopaused woman, presented a 2-month history of metrorrhagia. We suspected a malignant disease, but, the histopathologic examination of biopsies, found an endometrial inflammation without malignant cells. Culture for mycobacteria showed a Mycobacterium tuberculosis. A course of four-drug antituberculous therapy was started and the patient recovered. Tuberculosis remains a common disease, but genital infection is infrequent. Usually, it concerns young infertile women from non-industrial countries. More attention should be paid to this disease. Women, irrespective of their age, should be investigated for silent or subclinical genital symptoms, with mycobacterial examination.

[Do HIV patients know their treatment?]. / Les patients infectés par le VIH connaissent-ils leurs traitements?

UNLABELLED: Optimal adherence to antiretroviral therapy (ART) in HIV disease is one of the key factors for its efficacy. OBJECTIVE: The authors had for aim to assess HIV infected patients' knowing of their ART and the correlation with a controlled HIV viral load. DESIGN: We conducted a transversal study. Outpatients were asked at the beginning of a consultation to give the name, the dosage, and the color of their medication. RESULTS: 93 patients were included with a mean age of 45.6 years. 25.8% were AIDS patients and 82.8% had an HIV viral load under 50 copies/ml. The mean duration of treatment was 6.23 years and the latest treatment had been given for 2.26 years. They took an average of 2.6 different drugs and 5.4 pills per day. 22.6% used a pillbox. 90.3% of the patients bought their treatment by themselves and 86% prepared it. The name of all the drugs was known in 68.8%, doses in 90.3%, and colors in 83.9%. In univariate as in multivariate analysis, the use of a pillbox improves the knowledge of the dose (P = 0.01). AIDS patients know the names better (P = 0.02). In univariate and multivariate analysis, knowledge of dosage was correlated to a controlled viral load (P = 0.04). CONCLUSIONS: HIV patients know their treatment well and the knowledge of the dose could be a marker of adherence to ART as it is associated with a controlled viral load.

[Reactive arthritis due to Clostridium difficile]. / Arthrite réactionnelle a Clostridium difficile.

Extracolonic manifestations of Clostridium difficile infections have rarely been reported as a cause of reactive arthritis. We report the case of a monoarticular arthritis following pseudomembranous colitis. A 45 year-old man was admitted for fever and monoarthritis of the left knee, 8 days after the onset of a C. difficile enterocolitis associated with urethritis. Samples obtained from the knee, urine, and blood cultures remained sterile. Bone scintigraphy revealed a left knee and forefoot hyperfixations. The association of arthritis and urethritis led us to the diagnosis of Fiessinger-Leroy-Reiter syndrome. Antibiotics for arthritis were ineffective and stopped, but they were continued for colitis. NSAIDs were prescribed and clinical manifestations disappeared within 24 hours, the patient resumed walking after 48 hours. Four months later there was no relapse and no sequela.

[Salmonella of Indian origin: pseudo-susceptibility to fluoroquinolones]. / Salmonelle d'origine indienne: attention à la fausse sensibilité aux fluoroquinolones.

We report the case of a patient presenting with typhoid fever after returning from a stay in India. This infection was not cured with a course of ciprofloxacin, due to a reduced susceptibility of the bacteria to the drug. This decreased susceptibility to fluoroquinolones was not detected by the antibiogram, but the MIC for nalidixic acid was greater than 32 mg/l. This case suggests using a third generation cephalosporin instead of a quinolone, for people coming from a high-risk zone. It also suggests that the MIC for nalidixic acid and for norfloxacin can be used as the first clue for a reduced susceptibility to fluoroquinolones.

Evaluation of BC-3 and BCP-1 cell lines in immunofluorescence assay to detect HHV-8 antibodies in Kaposi's sarcoma, multiple myeloma and other groups.

BACKGROUND: We describe a comparative study of an immunofluorescence assay using inducible BC-3 and BCP-1 cell lines as sources of HHV-8 antigens. STUDY DESIGN: Detection of both antibodies to proteins expressed in lytic cycle and during latency in sera from HIV-infected patients with KS, HIV-positive patients without KS, normal blood donors, HIV-negative pregnant women and HIV-negative patients with multiple myeloma. Where possible, detection of antibody was associated with nested PCR detection of HHV-8 in peripheral mononuclear cell (PBMC) samples collected from AIDS-KS patients. RESULTS: Immunofluorescence was more intense with the BC-3 cell line than with BCP-1, thus facilitating examination under the microscope. HHV-8 antibodies were detected among 82.75% of AIDS-KS patients, in 27.3% of HIV-infected homosexual men, 2% of blood donors and in 2% of pregnant women. No HHV-8 antibodies were detected in serum samples from HIV-negative patients presenting multiple myeloma. HHV-8 DNA sequences were detected and confirmed by southern blot hybridization in five out of 17 (29.4%) PBMC samples from AIDS-KS patients. Titre of antibodies to proteins expressed in lytic cycle was much higher than the titre of antibodies to proteins expressed during latency. CONCLUSIONS: Both immunofluorescence assays were found useful and HHV-8 seroprevalence rates reported in previous studies were confirmed. In addition, results obtained using these assays tend to provide evidence for a lack of epidemiological association between HHV-8 infection and development of multiple myeloma.

Pneumocystis carinii pneumonia in patients with hematologic malignancies: a descriptive study.

Objectives. A retrospective multicentric study was conducted over a five-year period to evaluate the clinical and laboratory characteristics and outcome of patients with proven Pneumocystis carinii pneumonia (PCP) complicating hematologic malignancies.Results. The study included 60 HIV-negative patients with 18 non-Hodgkin's malignant lymphoma (30%), 13 chronic lymphocytic leukaemia (21.7%), 10 acute leukemia (16.6%), 5 multiple myeloma (8.3%), 4 Waldenström's diseases (6.6%), 4 chronic myeloid leukemia (6.6%), 3 myelodysplasia (5%), 2 Hodgkin's diseases (3.3%) and 1 thrombopenia. Bronchoalveolar lavage was diagnostic in all patients. Forty-nine patients received cytotoxic drugs (81.7%), 25 (41.7%) a long-term corticotherapy and 15 (25%) underwent bone marrow transplantation. Twenty-seven patients (45%) required admission in the intensive care unit, 35 (58.3%) received an adjunctive corticotherapy and 18 mechanical ventilation (30%). Twenty patients (33.3%) died of PCP. A previous long-term corticotherapy (p=0.04), high respiratory (p=0.05) and pulse rates (p=0.02), elevated C reactive protein (p=0.01) and mechanical ventilation (OR=13.37; IC: 1.9-50) were associated with a poor prognosis. Adjunctive corticotherapy did not modify the prognosis.Conclusions. These results suggest that PCP can occur during the course of various hematologic malignancies, not only lymphoproliferative disorders. Prognosis remains poor. The diagnosis should be advocated more frequently and earlier to improve the prognosis.

[Mycoplasma pneumoniae infections. A multicenter retrospective study of 182 cases]. / Les aspects des infections à Mycoplasma pneumoniae. Etude multicentrique rétrospective de 182 cas.

The spectrum of 182 hospital Mycoplasma pneumoniae infections, collected over a five-year period, is reviewed. The diagnosis was based on complement fixation test. Mycoplasma infection was encountered mainly in young people, mean age 29 years. Eighty-four per cent presented with an atypical pneumonia, 33 per cent had extrapulmonary manifestations mainly neurological and cutaneous. Acute respiratory failure occurred in 32 cases. Only 5 patients died. Macrolides or tetracyclines remain the most effective antibiotics but spontaneous recovery is usual.

Campylobacter fetus infections.

BACKGROUND: Campylobacter fetus infections usually occur in immunodepressed patients or patients presenting with diabetes mellitus or cancer. They rarely cause diarrhea but frequently cause bacteremia or vascular diseases. The therapeutic management is not well codified and fluoroquinolone resistance is continuously increasing. METHODS: We conducted a retrospective study of C. fetus infections from January 2007 to August 2013 at the Limoges teaching hospital. The infections were defined by at least 1 bacteriological sample positive for C. fetus. RESULTS: Twenty patients were included (15 men), with an average age of 73 years (43-91). Sixteen presented with cancer, 12 with solid cancer including 9 of the urinary tract, and 9 patients with hematologic diseases. Five patients presented with diabetes mellitus, 9 with isolated bacteremia, 3 with cellulitis, and 3 with septic arthritis. The diagnosis was made by blood cultures for 17 patients. Twenty percent of the isolates were resistant to amoxicillin and 30% to fluoroquinolones. The therapeutic regimens and the treatment duration were quite different. The outcome was unfavorable for 3 patients whose implanted port had not been removed and 1 with subdural hematoma infection. 1 patient died. CONCLUSIONS: C. fetus infection occurs in case of underlying diseases, most frequently promoting urinary tract cancer. Fluoroquinolones must not be used without susceptibility testing and catheters should be removed.

Spectrum of advice and curbside consultations of infectious diseases specialists.

OBJECTIVES: Curbside consultation (CC) of infectious diseases specialists for advice is very frequent but the corresponding workload has rarely been assessed. This activity is mostly oral (phone or direct contact) and poorly quantifiable because it is not charged. We had for aim to evaluate this activity in a French teaching hospital. METHODS: We recorded all CCs given during a 2.5-year period, from mid-2011 to the end of 2013. RESULTS: During the study period, 6789 CCs were recorded (2715 per year), or slightly more than 10 per day. These CCs were divided in 676 travel recommendations and 6113 for other reasons. They were mostly given by phone (77.4%). Most demands came from our hospital (61.4%), followed by community family physicians and specialist (27.1%), other local hospitals (6.5%) and clinics (4.3%). All the departments in our hospital consulted us for advice at least once and answers were mainly given by phone (70.1%) and at bedside (30.5%). The answers were principally advice (50.8%), modification of antibiotic prescription (22.9%), initiation of antibiotic course (14.8%), maintaining the same treatment (6.2%), and stopping antibiotics (4.3%). CCs accounted for 20% of clinical work for 1 physician. If the CCs in our hospital had been paid, our department would have received an additional 77,000€ in revenue. CONCLUSION: This curbside activity is very important and time-consuming for infectious diseases specialists, but it is currently not acknowledged or rewarded.

[Community-acquired meningitis due to methicillin susceptible Staphylococcus aureus]. / Méningites communautaires à Staphylococcus aureus méticilline sensible.

UNLABELLED: Meningitis due to Staphylococcus aureus is infrequent. MRSA is mainly found after neurosurgery, but MSSA may be involved in community-acquired meningitis. However, this kind of infection is not widely reported, despite its severity. METHODS: We describe the characteristics of five patients hospitalized in our ward over a period of 18 months who presented with community-acquired meningitis due to MSSA. RESULTS: The patients were three men and two women with a mean age of 62 years. One patient was immunosuppressed. Neurological signs were present at the onset for only two patients. In all cases, there were extraneurological localizations of the infection, mainly in bones (spondylodiscitis, epidural abscess, arthritis) but also lung infection. Three patients with meningeal inflammation also presented with confusion. CSF analysis revealed less than 950 white blood cells, hyper-CSF-proteins, and hypo-CSF-glucose. Bacteraemia was present in all patients. The source of infection was never determined. The evolution was good for all patients with a prolonged antibiotic course. The analysis of genetic determinants for three strains revealed the presence of TSST-1 which could account for the severity of the disease. CONCLUSION: Community-acquired MSSA meningitis is a serious infection, occurring in patients without risk factors. Hematogenous dissemination leads to multiple tissue infection. A long course of antibiotics, with high doses, is needed to treat meningitis but also extraneurological localizations. The role of TSST-1 needs to be confirmed in other patients.