The impact of comorbidities and their stacking on short- and long-term prognosis of patients over 50 with community-acquired pneumonia.

BACKGROUND: The prognosis of patients hospitalized with community-acquired pneumonia (CAP) with regards to intensive care unit (ICU) admission, short- and long-term mortality is correlated with patient's comorbidities. For patients hospitalized for CAP, including P-CAP, we assessed the prognostic impact of comorbidities known as at-risk (AR) or high-risk (HR) of pneumococcal CAP (P-CAP), and of the number of combined comorbidities. METHODS: Data on hospitalizations for CAP among the French 50+ population were extracted from the 2014 French Information Systems Medicalization Program (PMSI), an exhaustive national hospital discharge database maintained by the French Technical Agency of Information on Hospitalization (ATIH). Their admission diagnosis, comorbidities (nature, risk type and number), other characteristics, and their subsequent hospital stays within the year following their hospitalization for CAP were analyzed. Logistic regression models were used to assess the associations between ICU transfer, short- and 1-year in-hospital mortality and all covariates. RESULTS: From 182,858 patients, 149,555 patients aged ≥ 50 years (nonagenarians 17.8%) were hospitalized for CAP in 2014, including 8270 with P-CAP. Overall, 33.8% and 90.5% had ≥ 1 HR and ≥ 1 AR comorbidity, respectively. Cardiac diseases were the most frequent AR comorbidity (all CAP: 77.4%). Transfer in ICU occurred for 5.4% of CAP patients and 19.4% for P-CAP. Short-term and 1-year in-hospital mortality rates were 10.9% and 23% of CAP patients, respectively, significantly lower for P-CAP patients: 9.2% and 19.8% (HR 0.88 [95% CI 0.84-0.93], p < .0001). Both terms of mortality increased mostly with age, and with the number of comorbidities and combination of AR and HR comorbidities, in addition of specific comorbidities. CONCLUSIONS: Not only specific comorbidities, but also the number of combined comorbidities and the combination of AR and HR comorbidities may impact the outcome of hospitalized CAP and P-CAP patients.

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.

Cost-effectiveness and public health impact of using high dose quadrivalent influenza vaccine in the French older adults population.

INTRODUCTION: Seasonal influenza outbreaks in France cause a surge in patients, exacerbating the overburdened healthcare system each winter. Older adults are particularly vulnerable to serious events related to influenza. Quadrivalent influenza high dose (QIV HD) vaccines have been developed to offer better clinical protection in older adults, who often exhibit suboptimal immune response to quadrivalent influenza standard dose vaccines (QIV SD). This study aims to evaluate the public health impact and cost-effectiveness of administering HD versus SD vaccines to individuals aged 65+ in France. METHODOLOGY: Using a static model and decision-tree approach, the study analyzed health outcomes such as influenza cases, GP (general practitioner) visits, hospitalizations, and mortality; relative vaccine efficacy (rVE) estimates were derived from a pivotal randomized-controlled trial and a meta-analysis comparing HD to SD vaccines. Two approaches were implemented to model hospitalizations (conditional on influenza or not), and analyses on bed occupancy were performed. RESULTS: Results showed that using QIV HD instead of QIV SD during an average influenza season in France led to the prevention of 57,209 additional cases of influenza, 13,704 GP visits, and 764 influenza-related deaths. Moreover, switching to QIV HD resulted in additional 1,728 to 15,970 hospitalizations avoided and 15,124 to 138,367 reduced days of hospitalization depending on the hospitalization approach used. The cost-utility analysis showed a cost per quality-adjusted life year (QALY) gained ranging from 24,020 €/QALY to 5,036 €/QALY. CONCLUSIONS: Switching to QIV HD in older adults showed to be cost-effective, with even greater public health benefits at higher coverage rate, regardless the season severity.

Influence of procalcitonin on decision to start antibiotic treatment in patients with a lower respiratory tract infection: insight from the observational multicentric ProREAL surveillance.

Procalcitonin (PCT)-guided antibiotic stewardship is a successful strategy to decrease antibiotic use. We assessed if clinical judgement affected compliance with a PCT-algorithm for antibiotic prescribing in a multicenter surveillance of patients with lower respiratory tract infections (LRTI). Initiation and duration of antibiotic therapy, adherence to a PCT algorithm and outcome were monitored in consecutive adults with LRTI who were enrolled in a prospective observational quality control. We correlated initial clinical judgment of the treating physician with algorithm compliance and assessed the influence of PCT on the final decision to initiate antibiotic therapy. PCT levels correlated with physicians' estimates of the likelihood of bacterial infection (p for trend <0.02). PCT influenced the post-test probability of antibiotic initiation with a greater effect in patients with non-pneumonia LRTI (e.g., for bronchitis: -23 % if PCT ≤ 0.25 µg/L and +31 % if PCT > 0.25 µg/L), in European centers (e.g., in France -22 % if PCT ≤ 0.25 µg/L and +13 % if PCT > 0.25 µg/L) and in centers, which had previous experience with the PCT-algorithm (-16 % if PCT ≤ 0.25 µg/L and +19 % if PCT > 0.25 µg/L). Algorithm non-compliance, i.e. antibiotic prescribing despite low PCT-levels, was independently predicted by the likelihood of a bacterial infection as judged by the treating physician. Compliance was significantly associated with identification of a bacterial etiology (p = 0.01). Compliance with PCT-guided antibiotic stewardship was affected by geographically and culturally-influenced subjective clinical judgment. Initiation of antibiotic therapy was altered by PCT levels. Differential compliance with antibiotic stewardship efforts contributes to geographical differences in antibiotic prescribing habits and potentially influences antibiotic resistance rates.

Morbidity and mortality associated with influenza exposure in long-term care facilities for dependent elderly people.

The purpose of this paper is to describe the impact of exposure to influenza on hospitalizations and deaths in the elderly residents of long-term care facilities (LTCFs). An observational, longitudinal, prospective, multicenter, cohort study collected influenza and influenza-like cases, diseases, hospitalizations, and deaths of dependent elderly residents of French LTCFs during the 2004-2005 seasonal influenza epidemic. A total of 8,041 residents of 98 participating LTCFs were included. The mean age was 85 +/- 9 years; 93% were vaccinated against influenza and 64% of the residents were exposed to influenza during the epidemic. Exposure to influenza increased both the all-cause risk of hospitalization (9.2% of the residents exposed vs. 7.4% of the residents not exposed) (relative risk, RR [95% confidence interval, CI] = 1.24 [1.05; 1.47]) and the all-cause risk of death (5.8% vs. 4.3%) (RR [95% CI] = 1.36 [1.10; 1.70]). Exposure to influenza increased the risks of death and hospitalization. Additional measures should be taken to avoid influenza exposure and apply recommendations more thoroughly in the particularly susceptible population of elderly LTCF residents.

[Swallowing disorders, pneumonia and respiratory tract infectious disease in the elderly]. / Troubles de la déglutition du sujet âgé et pneumopathies en 14 questions/réponses.

Swallowing disorders (or dysphagia) are common in the elderly and their prevalence is often underestimated. They may result in serious complications including dehydration, malnutrition, airway obstruction, aspiration pneumonia (infectious process) or pneumonitis (chemical injury caused by the inhalation of sterile gastric contents). Moreover the repercussions of dysphagia are not only physical but also emotional and social, leading to depression, altered quality of life, and social isolation. While some changes in swallowing may be a natural result of aging, dysphagia in the elderly is mainly due to central nervous system diseases such as stroke, parkinsonism, dementia, medications, local oral and oesophageal factors. To be effective, management requires a multidisciplinary team approach and a careful assessment of the patient's oropharyngeal anatomy and physiology, medical and nutritional status, cognition, language and behaviour. Clinical evaluation can be completed by a videofluoroscopic study which enables observation of bolus movement and movements of the oral cavity, pharynx and larynx throughout the swallow. The treatment depends on the underlying cause, extent of dysphagia and prognosis. Various categories of treatment are available, including compensatory strategies (postural changes and dietary modification), direct or indirect therapy techniques (swallow manoeuvres, medication and surgical procedures).

[Awareness and adherence to Pertussis vaccination guidelines by occupational medicine physicians in Paris healthcare institution]. / Connaissance et application des recommandations vaccinales concernant la coqueluche par la médecine du travail des établissements de santé de Paris.

OBJECTIVE: A questionnaire was used on 44 public and private hospital physicians in Paris to evaluate their knowledge of and adherence to Vaccination Guidelines, three years after their introduction. RESULTS: Eighty per cent of the physicians answered and 92.5% were aware of the vaccination guidelines but only 2 out of 4 respected the targeted vaccination in young adults even when the vaccine was available. A policy of pertussis vaccination was applied only in 12 institutions, but even in these, the rate of vaccinated healthcare workers remained low or was not documented. CONCLUSION: Pertussis is a potential risk to newborns not or partially vaccinated in France. Even if the vaccine is available, adherence to pertussis vaccination guidelines must be improved. Efforts should be made to better publicize and apply pertussis vaccination guidelines.

[Vaccine hesitancy: How to lift the brake?] / Défiance vis-à-vis de la vaccination : comment lever les freins ?

INTRODUCTION: We are at a "post-trust" period, characterised by vaccine hesitancy which is being widely diffused by the media and social networks. The consequences of this include: measles, whooping cough epidemics, vaccine coverage decreasing for the youngest, and remaining at low levels in adults. Mandatory vaccination has been extended for children less than two years in France, with the objective to increase vaccination rates during this period. STATE OF THE ART: The medical literature on this topic is increasing, mainly regarding descriptions of reasons for vaccine hesitancy. These include doubt about vaccine efficacy, safety, and real need as well as with regard to social aspects, cultural, religious beliefs. The literature that explores the best way to address vaccine hesitancy is still scarce. Healthcare workers are a key in promoting vaccine acceptance. There is a need to address the issue of vaccine hesitancy in a multicompartmental way. Health authorities must communicate in a clear and concise style that is trust-based and science-informed, being transparent both on vaccine benefits and on issues around vaccine safety. For caregivers, motivational interviewing can help patients change behaviour. CONCLUSION: Anti-vaccine ideas were born with vaccines; they are abundantly spread through the Internet and social networks and can give a false impression of their basis in reality. It is time for positive action not merely a defensive approach.

Summer influenza outbreak in a home for the elderly: application of preventive measures.

Influenza outbreaks occasionally occur in nursing homes (NHs) despite vaccination, but occurrence during summer is a rare event. We describe an influenza outbreak during a heatwave in 2005, and discuss the usefulness of rapid diagnosis in facilitating early intervention as well as appropriate infection control measures. An outbreak was observed in a single NH with 81 residents (mean age 88 years) and 48 healthcare workers (HCWs) and lasted seven days. Fever, cough and wheezing were reported as the main symptoms in 32 affected residents (39.5%) and 6 (12.5%) HCWs. Influenza was suspected and provisionally confirmed by a rapid diagnostic test performed on specimens from four patients. The outbreak was further confirmed by culture and reverse transcriptase-polymerase chain reaction in seven out of 10 residents. The strain was similar to the winter epidemic strain of the 2004-2005 season: H3N2A/New York/55/2004. As soon as the outbreak was confirmed, a crisis management team was set up with representatives of the local health authority and NH staff. A package of measures was implemented to control the outbreak, including patient isolation and the wearing of surgical masks by all residents and staff. A therapeutic course of oseltamivir was prescibed to 19/32 symptomatic patients and to 5/6 HCWs, and 47 residents and 42 remaining HCWs received a prophylactic post-exposure regimen. The outbreak ended within 48 h. Case fatality rate was 15.6% among residents. Pre-outbreak influenza vaccine coverage among the residents was 93.5% and 41.7% in HCWs. The rapid diagnostic test enabled prompt action to be taken, which facilitated infection control measures.

[Are pertussis vaccination guidelines applied to adults and health care workers?]. / La vaccination anticoquelucheuse de l'adulte et des professionnels de santé est-elle connue et appliquée?

UNLABELLED: The prevalence of pertussis in newborns led French health authorities to recommend using a booster dose at 13 years of age, and adding a booster dose for parents, siblings, and health care workers. OBJECTIVE: The aim of the study was to check if the new recommendations were applied by health care workers and if mothers still in the maternity ward were informed and agreed with these recommendations. METHOD: A questionnaire assessing knowledge, acceptance of the recommendations was sent to different health care workers and given to mothers in two maternity wards. RESULTS: Three hundred and seventy-five questionnaires filled out by health care workers were analyzed (298 general practitioners, 30 pediatricians, 24 obstetricians, 21 midwives) and 100 questionnaires by mothers. Only 1% of mothers and 55% of health care workers knew about the new recommendations, but only 8.3% of obstetricians and 4.8% of midwives. 92.6% of health care workers considered they were justified, but not applicable in 21.3%, 75% declared informing mothers systematically, and 14.5% documenting their pertussis vaccine status. The vaccination status was greater than 80% for diphtérie-tétanos-polio (dTP) in health care workers, 29.5% of these workers and 49% of mothers considered being vaccinated in a near future. CONCLUSION: Information, educational campaigns and specific actions are needed to apply the new recommendations which will warrant the success of targeted vaccination, in order to reduce pertussis in infants of more than six months of age.

Incidence of pertussis in subjects aged 50years and older in France in 2013-2014.

OBJECTIVE: To assess the incidence of pertussis (whooping cough) in subjects aged 50years and older in France. METHODS: Participating family physicians (FPs) using the patient record management software AxiSanté® included patients aged 50years and older, who had signed an informed consent form, presenting with persistent cough for 7 to 21days. Bordetella genetic material was detected by polymerase chain reaction (PCR) on nasopharyngeal samples collected at the FP's discretion. RESULTS: A total of 42 FPs included 129 patients from June 2013 to August 2014 (large cities: 38; medium-sized cities: 57; rural areas: 34); 106 samples were analyzed. Overall, 30 pertussis cases were diagnosed: 10 cases confirmed by PCR, 18 purely clinical cases, and two direct epidemiological cases. The crude incidence rate per 100,000 patients aged≥50years was 103.6 (95% CI: 69.9-47.9): 77.1 in large cities, 103.1 in medium-sized cities, and 143.9 in rural areas. The extrapolated incidence rate per 100,000 persons aged≥50years was 187.1 (95% CI: 126.2-67.1): 131.1 in large cities, 256.1 in medium-sized cities, and 242.2 in rural areas. CONCLUSION: The population aged 50years and older can serve as a reservoir. Its role in Bordetella pertussis circulation should be taken into account for pertussis booster vaccination programs.

[Pertussis: Where do we stand 10years after the introduction of cocooning vaccination strategy in France?] / Coqueluche : où en est-on en France 10ans après la mise en place de la stratégie vaccinale du cocooning ?

The goals of this article are to review the pertussis cocooning strategy, which has been recommended in France since 2004 to protect infants not yet vaccinated from becoming infected by vaccinating their immediate entourage, and to present room for improvement. The analysis of the literature between 2004 and 2015 shows that pertussis vaccine coverage in new parents is lower than 50% and that attempts that have already been implemented to increase it are effective. Pertussis vaccine coverage improvement requires all health actors to collaborate and be trained in informing and motivating parents to get vaccinated before, during and after pregnancy (the parents then will act as relays to their relatives); generalization in maternity wards of systematic checking of the vaccination card; extension to the midwives of the right to prescribe and administer pertussis vaccine to spouses; vaccination facilitation in maternity wards with the support of health organizations. Exchange and sharing of experiences between health care professionals are essential. Pregnancy is the ideal period to promote pertussis vaccination.

Treatment of imported malaria in adults: a multicentre study in France.

BACKGROUND: Data about anti-malarial drugs prescription practices in Europe and the safety of imported malaria treatments are scanty. In 1999, a French consensus development conference published guidelines for the prevention and treatment of imported P. falciparum malaria. The impact of these guidelines has not been evaluated. AIM: To investigate the impact of these guidelines on the prescription of anti-malarials, and to evaluate the incidence of acute drug events (ADEs) leading to discontinuation of treatment. DESIGN: Cross-sectional survey. METHODS: Members of the medical staff in 14 French infectious and tropical disease wards completed a standardized form for each patient treated for imported malaria in 2001. A propensity score matching technique was used to estimate the risk of ADEs leading to discontinuation of the regimen. RESULTS: In the 474 patients studied, quinine was the first-line anti-malarial most often prescribed. Only 3% of patients received halofantrine. Mefloquine was associated with a RR of 4.9 (95%CI 3.2-7.4, p < 0.00001) risk of discontinuation of treatment due to ADEs. DISCUSSION: The very limited use of halofantrine indicates that the main practice recommendations of the guidelines have been taken into account. Mefloquine was associated with a substantial risk of discontinuing the treatment because of ADEs. This is a serious limitation for the use of mefloquine in the treatment of out-patients with imported malaria.

[Neuraminidase inhibitors in the general practice management of influenza: who prescribe them, when and with which results?]. / Les inhibiteurs de la neuraminidase dans la grippe en médecine générale: qui prescrit, quand et avec quels résultats?

OBJECTIVE: To describe in real-life conditions the flu therapeutic management, motivations to prescribe or not NAI (General Practitioners' (GPs) characteristics, decisional factors) and treated patients' course. DESIGN: A prospective, longitudinal, pharmacoepidemiological study involved 305 GPs in France during 2002-2003 winter epidemic peak. All patients>or=1 year old, with a clinical diagnostic of flu were included. RESULTS: One hundred and eighty-five GPs (150 NAI prescribing and 30 non-prescribing physicians) have included at least 1 patient. Prescribing physicians were the best informed on flu and NAI. 660 patients were analysed (250 NAI+ and 410 NAI-). 66% of NAI+ and 40% of NAI- attended to a consultation within 24 h (P<0.001). 31% of NAI+ and 20% of NAI- had a visit at home (P=0.002). Among the patients without complication at inclusion (N=585), 3% of NAI+ received an antibiotherapy vs 13% of NAI- (P<0.001). 43% of the patients had a sick leave, shorter for the NAI+ than NAI- (respectively, 3.7+/-1.7 vs 4.2+/-1.7 days, p=0.017). NAI was taken within 3 hours (median) after prescription by the 78% of the patients who returned their diary cards. The NAI+ patients had a faster improvement of symptoms than NAI- (within 24 h, respectively: 18 vs 5%, P<0.001) and they returned faster to routine activities (within 48 h, respectively: 27 vs 11%, P<0.001). CONCLUSIONS: This study evidenced the good use of NAI by the physicians. It confirms their therapeutic efficacy in real-life conditions and suggests their prescription allows decreasing antibiotic co-prescriptions and sick leaves duration, profits to consider in NAI benefit/risk ratio.

Subcutaneously administered antibiotics: a national survey of current practice from the French Infectious Diseases (SPILF) and Geriatric Medicine (SFGG) society networks.

A national survey was performed to explore antibiotic prescription by the subcutaneous (sc) route among French infectious diseases and geriatric practitioners. Among the participating physicians, 367 (96.1%) declared administering sc antibiotics at some point. Ceftriaxone was prescribed sc by all but one, and ertapenem, teicoplanin, aminoglycosides and amoxicillin by 33.2%, 39.2%, 35.1% and 15.3%, respectively. The sc route was resorted to mainly in case of unavailable oral, intravenous or intramuscular routes, especially during palliative care. Pain, skin necrosis and lack of efficacy were the main adverse effects, reported by 70.8%, 12.8% and 19.9% of practitioners, respectively. Further studies are needed to precise the indications, modalities and tolerance of sc antibiotic use.

Longitudinal DRG-based survey of all-cause and pneumococcal pneumonia and meningitis for inpatients in France (2005-2010).

OBJECTIVE: This population-based retrospective study quantified the burden of all-cause and pneumococcal pneumonia and meningitis in the Rhône-Alpes region of France from 2005 to 2010, when the 7-valent pneumococcal conjugate vaccine uptake increased from 50 to>90% in children. PATIENTS AND METHODS: Hospital admission data was obtained from the French Diagnosis Related Groups program database (French acronym PMSI). Patients were residents of the Rhône-Alpes region hospitalized for the diseases of interest during 2005-2010. Hospitalization and in-hospital mortality rates were calculated by age, sex, and year on the basis of the Rhône-Alpes region population. Hospitalization and in-hospital mortality rates were compared using Chi(2) tests with statistical significance adjusted for multiple comparisons. RESULTS: The highest hospitalization rates by age group were: all-cause pneumonia, oldest group (>65 years); all-cause and pneumococcal meningitis, youngest group (0-4 years), and pneumococcal pneumonia, youngest and oldest groups. Hospitalization rates significantly decreased for all-cause pneumonia (5-19 years: -12.71%) and all-cause meningitis (20-49 years: -29.22%). Pneumococcal disease rates did not significantly change in any age group. Mortality rates from all-cause pneumonia and meningitis were highest in the oldest age groups. CONCLUSIONS: The burden of all-cause and pneumococcal pneumonia and meningitis remains substantial. Significant changes (decreases) between 2005 and 2010 in hospitalization rates were limited and varied among age groups, most likely because this study began 2 years after PCV7 was first introduced in France for children at broadly-defined high risk. Further research is needed on the relationship between serotype epidemiology and clinical patterns of disease.

[Clinical trial of an antipneumococcal vaccine in elderly subjects living in institutions]. / Essai clinique du vaccin antipneumococcique chez des personnes âgées vivant en institution.

Pneumococcal vaccine effectiveness was assessed in a randomized trial among 1,686 old people (mean age: 74, standard deviation: 4 years) living in 24 geriatric hospitals and 26 homes for the aged in our district; 937 were vaccinated with Merck-Sharp and Dohme pneumococcal vaccine (14 serotypes). The 749 others composed the reference group. This study was performed during 2 years, since December 1980. Both groups were randomized after a two-criteria stratification: by clinical risk assessed before the study, and by type of homes for the aged. Forty pneumonias were diagnosed, with 13 proved pneumococcal etiology. The incidence of pneumonia was significantly reduced in the vaccinated group (p less than 10(-4) but the mortality rate was not modified. We concluded in favor of the effectiveness of pneumococcal vaccine: etiological fraction 77.1% (51.2%-89.3% confidence limits, 95% risk) in the population we studied. The incidence of pneumococcal-proved pneumonia was not significantly reduced.

[Clinical manifestations of Chlamydia pneumoniae infections]. / Manifestations cliniques des infections à Chlamydia pneumoniae.

Chlamydia pneumoniae is a newly described and ubiquitous bacterium. Most infections are asymptomatic as shown by a high worldwide seroprevalence (> 50% of cases). It is a common cause of acute respiratory infections, mainly pneumonia (> 50% of cases) and other acute respiratory tract infections (25% of acute bronchitis, < 5% of sinusitis, otitis and pharyngitis). About 10% of the community acquired pneumonia cases have been associated with Chlamydia pneumoniae infection. This incidence depends on a cyclic epidemiology with a high incidence for 2 to 3 years followed by a low prevalence for 3 to 4 years. Most chlamydial infections are mild but occasionally severe with death especially in old people. Mostly acute infections are recurrent infections. The seroprevalence is higher in asthmatic patients, its role in acute exacerbation of chronic bronchitis is not definitely established. Extra-respiratory acute infections are less frequent, either fever alone, or cardiovascular diseases (acute myocarditis, pericarditis and endocarditis) or neurological (encephalitis, meningitis or Guillain-Barré syndrome). In addition, seroepidemiology studies have shown an association with coronary artery disease, Chlamydia pneumoniae was detected in coronary atheroma by immunochemistry, polymerase chain reaction and by electron microscopy. Chlamydia pneumoniae may be involved in the atherosclerotic process. To define the clinical spectrum of infection requires precise laboratory diagnosis, the most efficient tests (PCR, direct immunofluorescence and culture) are done in specialized laboratories, serological tests are less reliable. Macrolides, cyclines and fluoroquinolones are the most potent antibiotics but with differences in vitro within and between these families of antibiotics. Bacteriological failures are described despite the in vitro activity. A lot of questions on clinical aspects, epidemiology and treatment are unanswered, we need more studies.

[What is current opinion of antiviral therapy for the flu in 2001?]. / Que penser du traitement antiviral de la grippe en l'an 2001?

INTRODUCTION: The availability of new neuraminidase inhibitors which interact on the influenza A and B viruses could be the start of a new approach to flu treatment. Until now, vaccination has been the principal medical treatment, except in the case of a pandemic caused by antigenic shifts. In this article the authors will answer the following questions: Potentially, is there room for antiviral drugs and why? Are these drugs efficient and according to which criteria? Who are they for? And what indications must be followed? Are they well tolerated? Do they induce any viral resistance? M2 protein inhibitors (i.e., amantadine and rimantadine) are compared with neuraminidase inhibitors (i.e., zanamivir and oseltamivir). CURRENT KNOWLEDGE AND KEY POINTS: Neuraminidase inhibitors prescribed during the first 48 h have a medical curative effectiveness on non-complicated forms carried by healthy patients--symptoms last no longer than 1 to 3 days and their severity is reduced. This efficiency could potentially concern unexpected complications due to the diminution of antibiotics absorption. The inhibitors seem to induce little resistance and are responsive to influenza B as opposed to the M2 protein inhibitors. They seem to be well-tolerated by patients and they are also efficient when it comes to prophylaxis measures. FUTURE PROSPECTS AND PROJECTS: It is assumed that these treatments are used in a curative and preventive manner in order to give them their full strategic importance (their use is currently forbidden in France). This importance will require that physicians and the population be well aware of the epidemic and that responsive physicians who know the medical indications quickly implement the treatment. It is necessary to carry out surveys with those at risk who are seriously ill with the flu in order to measure ratios such as cost efficiency. The use of these treatments will have to be evaluated, bearing special attention on the risks of the emergence of resistant viruses and on the impact on vaccination.

[Adenocarcinoma of unknown primary site with thoracic localization and HIV: four case reports]. / Adénocarcinomes d'origine inconnue à manifestation thoracique et VIH: à propos de quatre cas.

INTRODUCTION: Non AIDS-defining cancer would have increased in HIV-patients as suggested by numerous studies. Four cases of adenocarcinoma of unknown primary site with thoracic localization that occurred in HIV-infected patients are described. EXEGESIS: To date, there have been no published data about carcinomas of unknown primary site relating to HIV-infected patients; however, immunodepression could promote them. Carcinomas of unknown primary site account for 0.5 to 10% of all cancer in general population. Primary carcinoma is identified in approximately one third of the cases and often corresponds to lung cancer in case of sus-diaphragmatic metastasis, particularly in case of pleural metastasis. Lung cancer in HIV-infected patients affects mostly young men who smoke and are often intravenous drug addicts. Adenocarcinoma is the most common histological type of cancer. CONCLUSION: Further studies of lung cancer in HIV-infected patients will help evaluate their frequency. In case of increasing frequency, lung cancer should then be included in AIDS-defining cancers.