A six-week antibiotic treatment of endocarditis with spondylodiscitis is not associated with increased risk of relapse: A retrospective cohort study.

BACKGROUND: We compared the relapse rate at 1 year in patients with vertebral osteomyelitis with or without associated endocarditis. PATIENTS AND METHODS: We conducted a retrospective cohort study. Inclusion criteria were patients hospitalized in the infectious disease, rheumatology, cardiology, cardiovascular surgery and two internal medicine units for vertebral osteomyelitis (blood culture and/or disco-vertebral biopsy) and compatible imaging, between 2014 and 2017. We compared patients with associated endocarditis (VO-EI group) and without endocarditis (VO group) using logistic regression to determine the factors associated with relapse and EI. The main outcome was the relapse rate at 1 year. RESULTS: Out of the 207 eligible patients, 62 were included (35 in the VO group and 27 in the VO-EI group). Four patients presented with a new VO during follow-up, one (2.86%) patient in VO group and three (11.11%) in VO-EI group (P=0.68). There were more men in the VO-EI group than in the VO group (74.07% vs. 48.57%, P=0.04), valvulopathies (13/27 vs. 8/35, P=0.06), vertebral localization (1.22±0.50 vs. 1.03±0.17, P=0.04) and septic kidney embolism (5/27 vs. 0/35, P=0.01). Control blood cultures were more often positive in the VO-EI group (12/27 vs. 8/35, P=0.04). In 45% of patients, the germ was a staphylococcus, 29% streptococci, 10% enterococci, 10% gram-negative bacillus (GNB). There were more streptococci and enterococci in the VO-EI group than in the VO group (44.44% vs. 17.14% and 18.52% vs. 8.57%, respectively). Antibiotic safety was good and comparable between groups. CONCLUSION: In a relatively small population, we did not find significantly more relapse in the endocarditis group.

Duration of rifampin therapy is a key determinant of improved outcomes in early-onset acute prosthetic joint infection due to Staphylococcus treated with a debridement, antibiotics and implant retention (DAIR): a retrospective multicenter study in France.

Introduction: In patients undergoing a « debridement, antibiotics, and implant retention ¼ (DAIR) procedure for acute staphylococcal prosthetic joint infection (PJI), post-operative treatment with rifampin has been associated with a higher probability of success.(1,2) However, it is not known whether it is the total dose, delay of introduction or length of therapy with rifampin that is most strongly associated with the observed improved outcomes. Methods: A multicentric, retrospective cohort study of patients with acute staphylococcal hip and knee PJI treated with DAIR between January 2011 and December 2016. Failure of the DAIR procedure was defined as persistent infection, need for another surgery or death. We fitted logistic and Cox regression multivariate models to identify predictors of DAIR failure. We compared Kaplan-Meier estimates of failure probability in different levels of the 3 variables of interest - total dose, delay of introduction or length of therapy with rifampin - with the log-rank test. Results: 79 patients included (median age 71 years [63.5-81]; 55 men [70%]), including 54 (68%) DAIR successes and 25 (32%) DAIR failures. Patients observed for a median of 435 days [IQR 107.5-834]. Median ASA score significantly lower in DAIR successes than in DAIR failures (2 vs. 3, respectively p = 0.011). Bacterial cultures revealed 65 (82.3%) S. aureus and 16 (20.3%) coagulase negative staphylococci, with 2 patients being infected simultaneously with S. aureus and CNS. Among S. aureus isolates, 7 (10.8%) resistant to methicillin; 2 (3.1 %) resistant to rifampin. Median duration of antimicrobial therapy was 85 days [IQR 28.5-97.8]. Fifty-eight patients (73.4%) received rifampin at a median dose of 14.6 mg/kg/day |IQR 13-16.7], started at a median delay of 8.5 days [IQR, 4-7.5] after debridement surgery. Twenty-one patients (26.6%) developed a drug-related adverse event, leading to rifampin interruption in 6 of them (7.6% of total cohort). Determinants of DAIR failure were rifampin use (HR 0.17, IC [0.06, 0.45], p-value <0.001), association of rifampin with a fluoroquinolone (HR 0.19, IC [0.07, 0.53], p-value = 0.002) and duration of rifampin therapy (HR 0.97, IC [0.95, 1], p-value = 0.022). We did not observe a significant difference between DAIR successes and failures in rifampin use, dose and delay of introduction. In a multivariate Cox model, only duration of rifampin therapy was significantly associated with DAIR failure. Kaplan Meier estimate of DAIR failure probability was significantly higher in patients receiving less than 14 days of rifampin in comparison with those receiving more than 14 days of rifampin (p = 0.0017). Conclusion: Duration of rifampin therapy is a key determinant of improved outcomes in early-onset acute prosthetic joint infection due to Staphylococcus treated with DAIR.

Should we expand the indications for the DAIR (debridement, antibiotic therapy, and implant retention) procedure for Staphylococcus aureus prosthetic joint infections? A multicenter retrospective study.

To evaluate factors associated with failure in patients treated with DAIR (debridement, antibiotic therapy, and implant retention) for Staphylococcus aureus prosthetic joint infections (PJIs). We retrospectively analyzed consecutive patients with stable PJI due to S. aureus treated with DAIR at six hospitals between 2010 and 2014. Cox proportional hazards regression was used to study factors associated with treatment failure at 2 years. Of 154 eligible patients, 137 were included (mean age 73 ± 13 years; male 56%). The estimated success rate according to the Kaplan-Meier method was 76.2 [95% CI 68-83] at 2 years of follow-up. In multivariate analysis, longer duration of treatment (hazard ratio (HR) 0.78 [0.69-0.88]; p < 0.001) and combination therapy including rifampin (HR 0.08 [0.018-0.36]; p = 0.001) were independently associated with success, whereas active smoking was independently associated with failure (HR 3.6 [1.09-11.84]; p = 0.036). When the analysis was restricted to patients with early infection onset (< 3 months), early acute infection was also predictive of a better prognosis (HR 0.25 [0.09-0.7]; p = 0.009). Failure was not associated with time from prosthesis insertion to debridement, nor with duration of symptoms > 3 weeks and type of prosthesis (hip or knee). These results remained unchanged when the 14 patients under immunosuppressive therapy were removed from analysis. These data suggest that DAIR can be performed even if infection and symptoms are delayed but reserved to patients who are able to follow rifampin-based combination therapy for a prolonged duration that should not be different for hip and knee PJI.

Prevalence of aortic valve dystrophy and insufficiency in a cohort of 255 HIV-positive patients followed-up in a cardiology department between 2012 and 2014.

OBJECTIVES: To study valve appearance and the presence of valve disease in a cohort of people living with HIV (PLHIV). DESIGN: A prospective study of PLHIV examined at the cardiology department of the Clermont Ferrand university hospital group (CHU) between January 1, 2012, and December 31, 2014. Were excluded those with a history of infection associated with a possible endocarditis. METHODS: Demographic, medical characteristics and cardiovascular disease risk factors at time of cardiovascular examination and Doppler-echocardiography were recorded and analyzed. RESULTS: In total, 903 PLHIV were examined in the infectious diseases department, 255 of whom were included. These consisted of 67 women (26.3%) and 188 men, of a mean age of 51.2±9.7years, in whom coronary artery disease was diagnosed in 18 patients (7.0%), two women and 16 men, representing a prevalence of 3.0% in females and 8.5% in males. The appearance of the aortic cusps was considered dystrophic in 14.1% of cases (36/255), dysplastic in two cases (0.8%), exhibiting a bicuspid deformity in one case. The prevalence of aortic valve abnormality was therefore 6.0% in the women (4/67) and 17.0% in the men (32/188). On facing off this data with the Kora Monica study findings, an increase in prevalence appears only to truly manifest after 50years of age. We registered 35 aortic insufficiency cases (13.7%), representing a higher incidence than that of the Framingham cohort, with age and masculine gender being the determining factors. CONCLUSION: Valve disease, along with coronary artery disease, should be closely monitored in PLHIV.

Outcome of totally implantable venous-access port-related infections.

OBJECTIVE: We aimed to study factors associated with the outcome of totally implantable venous-access port (TIVAP)-related infections. PATIENTS AND METHODS: We conducted a prospective and observational cohort study of patients presenting with a solid tumor and TIVAP-related infection. RESULTS: We monitored 97 patients for 12weeks. The case fatality at 12weeks was high (54%). Factors associated with case fatality at week 12 included patients' underlying cancer (metastatic status, parenteral nutrition, home care). Infectious complications (local abscess, hematogenous metastases, infection recurrence, septic shock) were frequently observed (48%). The delay in TIVAP removal was the only variable significantly associated with complications (TIVAP removed more than a week after removal decision, P=0.001, or more than a week after onset of clinical symptoms, P=0.002). On the basis of IDSA guidelines, we also observed that 25% of patients whose TIVAP had been removed could have benefited from a conservative treatment. Infections occurring within a month of TIVAP implantation were significantly associated with a Staphylococcus aureus infection (P=0.008). CONCLUSION: Case fatality is high in this population of patients due to the poor status of patients. TIVAP should be promptly removed when appropriate but the patient's poor status might delay or even prevent its removal. Some patients could instead benefit from a conservative treatment. There is currently no recommendation for this therapeutic option and studies are needed to clarify its efficacy. Additionally, infection occurring within a month of TIVAP insertion could be a supplementary criterion for removal as S. aureus is associated with early infection.

Culture of per-wound bone specimens: a simplified approach for the medical management of diabetic foot osteomyelitis.

Surgical percutaneous bone biopsy specimen after a 14-day antibiotic-free period represents the gold standard of care for diabetic foot osteomyelitis but may be difficult to implement in many institutions. We evaluate a simplified strategy based on the results of per-wound bone specimen culture. For that purpose, we retrospectively reviewed the charts of 80 consecutive patients with diabetic osteomyelitis and bone sample obtained via the wound after a careful debridement. The outcome was defined as favourable if there was a complete healing of the wound with no sign of infection and stable or improved bone X-ray 6 months after antibiotic therapy completion. Culture of bone specimens was positive in 96% of patients, although half of the patients did receive a course of antimicrobials within 14 days of the bone specimen being obtained. A total of 129 bacterial isolates were obtained from bone cultures with a mean of 1.6 ± 1 isolates per patient (Staphylococcus aureus: 33%; central nervous system: 14%; streptococci: 9%; enterococci: 12%; corynebacteria: 4%; Gram-negative bacilli: 20%; anaerobes: 4%). Forty-six percent of cultures were monomicrobial. The mean duration of follow-up from diagnosis was 17 ± 1 months. Six months after discontinuation of antibiotic, six patients (7.5%) had died, nine were considered as therapeutic failures and 65 were considered as cured. Fifty-four of these 65 patients had follow-up data available at 1 year and remained in remission. In conclusion, a simplified procedure based on the culture of bone sample obtained via the ulcer after a careful debridement of the wound is effective in the medical management of diabetic foot osteomyelitis.

[Prognostic value of the LRINEC score (Laboratory Risk Indicator for Necrotizing Fasciitis) in soft tissue infections: a prospective study at Clermont-Ferrand University hospital]. / Valeur pronostique du score Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) dans les dermohypodermites infectieuses : étude prospective au CHU de Clermont-Ferrand.

BACKGROUND: The LRINEC score was developed in a retrospective study in order to distinguish necrotizing fasciitis from severe soft tissue infections using laboratory data. AIM: To evaluate the prognostic value of the LRINEC score in infectious cellulitis. PATIENTS AND METHODS: A prospective study was performed at the departments of infectious diseases and dermatology of the Clermont-Ferrand University Hospital. The three evaluation criteria were: time from initiation of antibiotics to regression of erythema, duration of fever and occurrence of complications (abscess, surgery, septic shock, necrotizing fasciitis, death, transfer to intensive care). Potential predictive variables were: LRINEC score>6 at admission, comorbidities, local appearance, clinical presentation and soft tissue ultrasound results. RESULTS: Fifty patients were included. The rate of complications was higher for patients with a LRINEC score>6 (54%) than for patients with a score<6 (12%, P=0.008). However, a LRINEC score>6 on admission was not significantly associated with increased duration of erythema or of fever. Prior lymphoedema was associated with a better prognosis. DISCUSSION: The LRINEC score may be a useful tool for the detection of complicated forms of soft tissue infections. Patients with a LRINEC score>6 on admission should be carefully evaluated (hospitalization, surgical assessment, close monitoring).

[Role of endovascular treatment of symptomatic splanchnic artery stenoses in HIV patients: report of three cases]. / Place du traitement endovasculaire des sténoses symptomatiques d'artères digestives chez les sujets infectés par le VIH: trois cas.

Patients with HIV or AIDS frequently present with GI symptoms, sometimes due to early and diffuse atherosclerosis. We report 3 cases of HIV patients with abdominal pain due to severe splanchnic arterial stenosis. Only one patient presented typical clinical findings of mesenteric ischemic. Endovascular treatment was performed in all three cases. Good clinical outcome was immediate in 2 cases. In the third case, subsequent bowel resection was required due to irreversible ischemic injury in spite of local thrombolysis and endovascular revascularization in a patient presenting with acute severe mesenteric ischemia. In all three cases, vascular patency was demonstrated at follow-up. Mesenteric ischemia is a severe complication requiring early diagnosis in HIV patients, especially those with vascular risk factors, especially since endovascular treatment is a valid therapeutic option.

[Invasive Streptococcus agalactiae infections in non-pregnant adults]. / Les infections invasives à Streptococcus agalactiae chez l'adulte (femme enceinte exclue).

OBJECTIVES: Streptococcus agalactiae (Group B streptococcus) is a major cause of invasive diseases in non-pregnant adults, particularly in the elderly and those with underlying conditions. We describe these conditions and clinical characteristics of patients followed in our teaching hospital. METHODS: We retrospectively reviewed clinical records of 64 patients with S. agalactiae-related invasive infection, hospitalized between January 1997 and January 2006. RESULTS: The mean age of patients was 59 (+/-17 years). The H:F sex ratio was 1.06. At least one underlying condition was found in 90.6%. Diabetes mellitus (43.7%), peripheral vascular disease (34.4%), myocardial ischemia (20.3%) and malignant neoplasms (20.3%) were among the most frequent conditions. The mean index of comorbidity (Charlson) was 2.5 (+/-2). Common clinical manifestations included infection of the urinary tract (32.8%), skin and soft-tissue (25%), and osteoarthritis (21.9%). Bacteremia occurred in 31.2% with no identified source in 2 patients. During the first month, 2 cases of endocarditis, 1 case of meningitis, and 4 deaths occurred. CONCLUSION: We confirm the importance of underlying diseases in the emergence of S. agalactiae infections.

[Should presumptive meningoencephalitis treatment in adults be active against Mycoplasma pneumoniae?]. / Le traitement de première intention d'une méningoencéphalite de l'adulte doit-il tenir compte de Mycoplasma pneumoniae?

INTRODUCTION: Meningoencephalitis is the most common central nervous system complication caused by Mycoplasma pneumoniae. Its frequency is probably underestimated. OBJECTIVE: The study's aim was to determine the retrospectively incidence of M. pneumoniae meningoencephalitis among other cases of encephalitis diagnosed in infectiology, neurology and ICU at the Clermont-Ferrand University hospital in 2004 and 2005. DESIGN: A case of meningoencephalitis was defined by encephalopathy (altered level of consciousness and/or change in personality), with one or more of the following symptoms: fever, seizure, focal neurological findings, meningitis, electroencephalography or neuroimaging findings consistent with encephalitis. Tumor and hematoma diagnosed by scan were excluded. M. pneumoniae was considered as a possible cause when patients had positive serological test (IgM Elisa) and/or positive PCR results for the CSF. RESULTS: Four (8.3%) patients among 48 cases of encephalitis could have been caused by M. pneumoniae. All except one convulsed initially. Pneumopathy was found in two patients. All received a specific treatment later. Antibiotics seemed to influence evolution in only two patients. These 4 cases appeared during an epidemic between November 2004 and August 2005: 48 hospitalized adults had positive serological test for M. pneumoniae in 2005 and 15 in 2004, whereas the number of tests was the same in 2004 and in 2005. CONCLUSIONS: M. pneumoniae should be investigated as a cause of meningoencephalitis if initial tests are negative, if patients have respiratory symptoms and in case of epidemic. Presumptive treatment of meningoencephalitis should include an antibiotic active against M. pneumoniae.

[Carcinoma cuniculatum: an uneasy diagnosis to suspect in case of chronic osteomyelitis with unsuccessful outcome despite appropriate antibiotic therapy]. / Carcinome cuniculatum: un diagnostic difficile, à évoquer devant une ostéite chronique d'évolution défavorable sous traitement.

INTRODUCTION: The clinical and histological features of cuniculatum carcinoma (CC) are often misleading. CASE REPORT: We report a case of CC of the foot, which was misdiagnosed as osteomyelitis for a two year period and which relapsed 2 months after complete resection. DISCUSSION: The CC has to be evoked in patients with chronic osteomyelitis and torpid wound. The anatomopathologist needs to be aware of the suspected diagnosis.

[Non Hodgkin's and Hodgkin's lymphomas and HIV: frequency, outcome and immune response under HAART; Clermont-Ferrand University Hospital, 1991-2003]. / Lymphomes non hodgkiniens et hodgkiniens et infection VIH: fréquence, pronostic et reconstitution immune sous trithérapie antirétrovirale; CHU de Clermont-Ferrand, 1991-2003.

OBJECTIVES: The authors had for aim to identify cases of non Hodgkin's (NHL) and Hodgkin's (HL) lymphomas in HIV1-infected patients to assess 1) their incidence, before and after 1996, 2) the clinical features and outcome under treatment together with the survival rate of the patients, 3) the immune reconstitution of lymphoma-free patients under HAART. PATIENTS AND METHODS: A retrospective study was made of HIV1-infected patients managed at the Clermont-Ferrand University Hospital from 1991 to 2003 for the diagnosis and treatment of HIV1-related lymphomas. RESULTS: Forty-one patients were included: 35 NHL and 6 HL giving a cumulative incidence rate estimate from 2.4% between 1991 and 1996 to 3.4% between 1997 and 2003 while other opportunistic diseases were decreasing. A high proportion of aggressive and disseminated disease was observed among NHL cases. Complete remission was achieved in 17 (49%) and 5 (83%) NHL and HL cases respectively. The mean survival was 109+/-54 months and was correlated with CD4 cell count at lymphoma diagnosis (univariate analysis). Among responding patients, 5 died: 3 from opportunistic infections, 1 commited suicide, and 1 from hepatic carcinoma. For responding patients, the mean increase of CD4 cell count under HAART was 58/mm3 over a 2 year-period and 192/mm3 over a 5 year-period of follow-up. CONCLUSIONS: The incidence of lymphomas in HIV-infected patients has not decreased since the introduction of HAART. The immune status assessed by CD4 cell count on diagnosis is correlated with survival. Immune restoration in lymphoma-free patients under HAART is poor.

Comparison of microbiological results of needle puncture vs. superficial swab in infected diabetic foot ulcer with osteomyelitis.

AIM: To study prospectively two methods for the bacteriological diagnosis of osteomyelitis related to diabetic foot ulcer: needle puncture performed across normal skin surrounding the foot ulcer and superficial swabbing of the ulcer. PATIENTS AND METHODS: Diabetic patients with a foot ulcer complicated by bone or joint infection, as detected by X-ray imaging, were included in the study. Ulcer swabbing and needle puncture were performed in each patient. To reach the tissue nearest the bone surface, needle puncture was guided by X-ray imaging and the drop of fluid obtained by aspiration was used for both aerobic and anaerobic bacterial culture. RESULTS: Twenty-one diabetic patients were included. The mean number of microorganisms isolated by needle puncture was significantly lower compared with that obtained by superficial swabbing: 1.09 vs. 2.04 (P < 0.02). Three bacterial species were isolated by needle puncture only in one patient while three or more bacterial isolates were obtained by superficial swabbing in six patients. No bacterial isolate was detected in five patients by needle puncture and in two patients by superficial swabbing. Staphylococcus aureus accounted for 70% of cases (seven patients) when a single bacterial species was obtained by needle puncture. After needle puncture, no wound complication or infection was observed. CONCLUSION: Culture of samples obtained by needle puncture revealed one or two bacterial isolates in two-thirds of diabetic patients with osteomyelitis following foot ulcer. Given the lack of complications, this invasive diagnostic technique should be considered for deep direct sampling in diabetic patients with osteomyelitis related to foot ulcer when surgical debridement is contraindicated or delayed.

[Cryptococcal meningitis disclosed by visual loss in HIV negative patient with ventriculo-atrial shunting]. / Cryptococcose neuroméningée révélée par une baisse de l'acuité visuelle chez un patient atteint de neurosarcoïdose et porteur d'une dérivation ventriculoatriale.

INTRODUCTION: HIV infection is the main cause of cryptococcal neuromeningitis but other diseases may be associated with this infection. CASE REPORT: We report a case of cryptococcal neuromeningitis in a patient with sarcoidosis and ventriculoatrial shunting. The patient was successfully treated by effective therapy without device withdrawal. CONCLUSION: The relationship between cryptococcosis and sarcoïdosis has been already described and may be not fortuitous. However it remains a very rare complication of sarcoidosis. Because of its potential severity (mortality rate of 40%), the diagnosis of cryptococcosis should be evoked as a differential diagnosis of neuro-sarcoidosis.

A case of Aspergillus mediastinitis after heart transplantation successfully treated with liposomal amphotericin B, caspofungin and voriconazole.

Reported here is a case of mediastinitis caused by Aspergillus fumigatus and Staphylococcus epidermidis following a heart transplantation that was successfully treated with amphotericin B in combination with new antifungal drugs (caspofungin and voriconazole), antibiotics and superficial wound drainage. A review of the literature revealed that Aspergillus as a cause of mediastinitis has been rarely described. In the few existing reports, evolution was generally fatal, especially in immunocompromised patients, despite treatment with antifungal drugs and surgery.

[Prevention and infection in adults patients with hyposplenism]. / Infections chez l'adulte asplénique et prévention.

People with asplenia are at risk for infections due to many causative agents, mainly Streptococcus pneumoniae. Among adults, splenectomy is the most frequent etiology of hyposplenism followed with chronic hematological and connective diseases. Physiopathology of the immunologic impairment due to hyposplenia is multifactorial. Physicians and even patients must be aware of overwhelming sepsis occurring on these conditions. The prognosis of these life-threatening infections is related to the precocity of the treatment onset. These infections, mainly due to S. pneumoniae (50-90% of cases) could be prevented with appropriate precautions. Patients presenting with asplenia must be largely vaccinated against these infectious agents: S. pneumoniae, Haemophilus influenzae b, and possibly Neisseiria meningitidis. Oral phenoxymethylpenicillin seems to be the simplest chemoprophylaxis (despite the global increase of pneumococcal strains with reduced susceptibility). Duration of treatment following splenectomy is discussed: The French medicine agency (AFSSAPS) recommends a 2-year treatment after surgery and for patients having functional hyposplenism (persistency of Howell-Jolly bodies) and/or associated immunodeficiency. Despite these prevention policies, the patient must be informed of the risk of very severe infection.

[Use in Mozambique of WHO diagnostic strategies in HIV infection]. / Application au Mozambique de stratégies diagnostiques OMS de l'infection par le VIH.

The lack of expensive equipment and well-trained laboratory technicians in developing countries makes it difficult to use standard methods (2 EIA confirmed by western blotting) to diagnose HIV infection. This led the WHO to develop simplified algorithms based on sequential screening tests, with no confirmation by immunoblotting. These algorithms were tested in the normal diagnosis conditions of a medical unit in Maputo, Mozambique. We tested 402 sera, collected with the consent of the patients concerned. The sera were first tested for HIV according to French regulations (2 EIA with western blot if at least one EIA was positive). This strategy identified 53 sera as positive for HIV1 and 1 serum as positive for HIV2. We then tested who algorithms, one for a predicted rate of prevalence < 10% and the other for a predicted rate of prevalence > 10%. Neither algorithm performed adequately for diagnostic purposes. Further evaluation with a panel of local sera is required to select the most suitable algorithm in terms of specificity and sensitivity, and algorithms should be throughly tested before inclusion in national AIDS control strategies.