Impact of Enterococcus faecalis Endocarditis Treatment on Risk of Relapse.

BACKGROUND: Enterococcus faecalis infective endocarditis (EFIE) is characterized by a higher frequency of relapses than other infective endocarditis. The role of the treatment on its occurrence remains poorly understood. The aim of this study was to investigate whether the antibiotic regimen could impact the risk of relapse in EFIE. MATERIALS: This was a multicenter retrospective study of patients diagnosed with definite EFIE between 2015 and 2019 in 14 French hospitals. The primary endpoint was the occurrence of relapses within the year following endocarditis diagnosis. As death was a competing risk for relapse, Fine and Gray models were used for studying risk factors and impact of treatment. RESULTS: Of the 279 patients included, 83 (29.7%) received the amoxicillin-gentamicin (A-G) combination, 114 (40.9%) amoxicillin-ceftriaxone (A-C), 63 (22.6%) A-G and A-C (A-G/A-C) sequentially, 9 (3.2%) amoxicillin (A), and 10 received other treatments. One-year-relapse rate was 9.3% (26 patients). Relapse occurred after a median delay of 107 days from EFIE diagnosis; 6 occurred after 6 months, and 6 were diagnosed by blood cultures in asymptomatic patients. In multivariate analysis, surgery during treatment was a protective factor against one-year relapse and death.The cumulative incidence of relapse 1 year after endocarditis was 46.2% for patients treated with amoxicillin, 13.4% with A-G, 14.7% with A-C, and 4.3% with A-G/A-C (P≥.05 in multivariate analysis). CONCLUSIONS: Relapses after treatment of EFIE are frequent, frequently asymptomatic, and may occur more than 6 months after the initial episode.

Toward an optimization of empirical antibiotic therapy in acute graft pyelonephritis: A retrospective multicenter study.

OBJECTIVE: Acute graft pyelonephritis (AGPN) is the most frequent infectious complication in kidney transplant recipients (KTR). The treatment of acute community-acquired (CA) pyelonephritis is based on third-generation cephalosporins (3GC) and fluoroquinolones. Cefepime or a piperacillin-tazobactam combination are more often used in healthcare-associated (HCA) infections. However, these recommendations do not consider the resistance observed in KTRs. The objective of our study was to define the most appropriate empirical antibiotherapy for AGPN in KTRs according to the CA and HCA settings. To answer this question, we assessed the prevalence of resistance to different antibiotics usually recommended for urinary tract infections (UTIs) in the general population. METHODS: Observational, retrospective, multicenter study covering all episodes of AGPN occurring in hospitalized KTRs in 2019. RESULTS: A total of 210 patients were included in 7 centers and 244 episodes of AGPN were analyzed (158 CA-AGPN and 86 HCA-AGPN). The prevalence of 3GC and fluoroquinolone resistance was 23 % (n = 36) and 30 % (n = 50) in CA infections (n = 158), and 47 % (n = 40) and 31 % (n = 27) in HCA infections (n = 86), respectively. Cefepime resistance rate was 19 % (n = 30) in CA-AGPN and 29 % (n = 25) in HCA-AGPN. Piperacillin-tazobactam combination had resistance rates > 15 % in both CA and HCA infections. The only antimicrobials with resistance rates < 10 % were aminoglycosides and carbapenems. CONCLUSION: None of the antibiotics recommended in empirical treatment in UTIs has shown a resistance rate of less than 10% with regard to AGPN. Therefore, none of them should be used as monotherapy. A combination therapy including amikacin could be an appropriate strategy in this setting.

Hypermetabolic pulmonary lesions on FDG-PET/CT: Tularemia or neoplasia?

OBJECTIVES: Pulmonary tularemia is a rare and little-known disease, whose clinical and radiological presentation can be confused with those of much more frequent pathologies, such as lung cancer or B-cell lymphoma (46,000 and 5,000 new cases respectively per year in France). Furthermore, PET/CT is a powerful tool for the diagnosis of malignancies or the exploration of fever of unknown origin. The objective of this study was to describe the characteristics of pulmonary tularemia and to determine whether its PET/CT aspect could help distinguish it from neoplasia. METHODS: Retrospective observational study collecting all pulmonary tularemia cases for which a PET/CT was performed between 2016 and 2020. RESULTS: Twenty-seven cases of pulmonary tularemia were analyzed. The sex ratio was 4.4, and the median age was 60 years. Clinical manifestations were mainly represented by fever (n=23), arthralgia (n=7) and cough (n=6). PET/CT revealed intensely hypermetabolic mediastinal adenopathies in all cases, associated with parenchymal (n=20) or pleural (n=6) lesions, suggesting neoplastic pathology in 15 patients. Cytopuncture or lymph node biopsy was performed in 16 patients, revealing non-specific adenitis (n=8), necrotic epithelio-gigantocellular granuloma (n=3), or were non-contributory (n=5). All patients reported significant environmental exposure. The outcome was favorable for all patients, spontaneously for 8 of them and after antibiotic therapy with either doxycycline or ciprofloxacin for the other 19. CONCLUSIONS: Depending on the epidemiological setting, pulmonary tularemia may be considered an alternative diagnosis to lung cancer, lymphoma, or tuberculosis, in the presence of infectious symptoms and hypermetabolic pulmonary lesions and mediastinal lymphadenopathies on PET/CT.