Clinical Evaluation of the Modified Faine Criteria in Patients Admitted with Suspected Leptospirosis to the Territorial Hospital, New Caledonia, 2018 to 2019.

Leptospirosis is endemic in New Caledonia. Clinical diagnosis is often difficult and its evolution can be fatal. Leptospirosis requires specific management before biological confirmation. Modified Faine criteria (Faine Score) have been suggested to diagnose leptospirosis on epidemiological (parts A and B) and biological (part C) criteria. The main objective of our study was to assess the relevance of the epidemiological-clinical modified Faine score, parts A and B (MF A + B), in patients with suspected leptospirosis in New Caledonia. A monocentric case-control study was conducted in suspect patients for whom a Leptospira polymerase chain reaction (PCR) test was done within the first 7 days of signs onset at the tertiary hospital from January 2018 to January 2019. Cases and control subjects were matched 1:2 in the gender and age categories. Bivariate, and then multivariable, analyses studied the association between the MF A + B score and a positive Leptospira PCR test, adjusted on the variables retained. In all, 35 cases and 70 control subjects matched for age and gender were analyzed. Multivariable analysis by logistic regression found a significant association between an MF A + B score taken from the categories "possible leptospirosis" (score, 20-25) and "presumed leptospirosis" (score, > 26), and the case or control subject status (P < 0.0001). Model performance was high, with an area under the curve value of 99.27%, 93.55% sensitivity, and 96.36% specificity, which classified subjects correctly in 95.35% of cases. Our study suggests using the MF A + B score to identify possible cases of leptospirosis and initiate antibiotic therapy before biological confirmation in New Caledonia. This score should be evaluated in areas where more differential diagnoses exist and where PCR is not widely available.

Necrotizing soft-tissue infections in New Caledonia: Epidemiology, clinical presentation, microbiology, and prognostic factors.

BACKGROUND/OBJECTIVES: Necrotizing soft-tissue infections (NSTIs) are severe and rapidly progressive infectious conditions. We herein describe the clinical characteristics, microbiology, and prognosis factors of NSTIs in New Caledonia. METHODS: All patients admitted for confirmed NSTIs at the only surgical facility in New Caledonia from January 2008 to July 2013 were retrospectively included. Factors associated with mortality were analyzed by multivariate risk regression. RESULTS: Over the period under review, 67 patients were studied (annual incidence rate, 6.1/year/100,000 inhabitants). The overall mortality rate was 24%. Melanesian people (n = 47; 70%) were more affected than other ethnic groups (n = 20; 30%; p = 0.001). The mean age was 54 years, and men were predominantly affected (n = 46; 69%). The most common comorbidity reported was diabetes mellitus (n = 24; 36%). Nonsteroidal anti-inflammatory intake prior to admission was reported in 14 cases (21%). Lower limbs were the most commonly affected anatomical sites (n = 36; 54%). At least one pathogen was identified in 31 cases (46%), whereas polymicrobial flora was found in 26 cases (39%). No bacteria were isolated in 10 cases (15%). Streptococcus pyogenes was the most frequently isolated bacterium (n = 21; 32%). Factors associated with mortality were use of norepinephrine [odds ratio (OR) 25.6; 95% confidence interval (CI) 4.8-135.8] and presence of two comorbidities (OR 8.6; 95% CI 1.7-42.3). CONCLUSION: NSTIs are particularly frequent in New Caledonia. Local health care workers should have a high index of suspicion for the disease to initiate surgical and medical treatments early.

Newly diagnosed rheumatic heart disease among indigenous populations in the Pacific.

OBJECTIVES: Rheumatic heart disease (RHD) remains the leading acquired heart disease in the young worldwide. We aimed at assessing outcomes and influencing factors in the contemporary era. METHODS: Hospital-based cohort in a high-income island nation where RHD remains endemic and the population is captive. All patients admitted with newly diagnosed RHD according to World Heart Federation echocardiographic criteria were enrolled (2005-2013). The incidence of major cardiovascular events (MACEs) including heart failure, peripheral embolism, stroke, heart valve intervention and cardiovascular death was calculated, and their determinants identified. RESULTS: Of the 396 patients, 43.9% were male with median age 18 years (IQR 10-40)). 127 (32.1%) patients presented with mild, 131 (33.1%) with moderate and 138 (34.8%) with severe heart valve disease. 205 (51.8%) had features of acute rheumatic fever. 106 (26.8%) presented with at least one MACE. Among the remaining 290 patients, after a median follow-up period of 4.08 (95% CI 1.84 to 6.84) years, 7 patients (2.4%) died and 62 (21.4%) had a first MACE. The annual incidence of first MACE and of heart failure were 59.05‰ (95% CI 44.35 to 73.75) and 29.06‰ (95% CI 19.29 to 38.82), respectively. The severity of RHD at diagnosis (moderate vs mild HR 3.39 (0.95 to 12.12); severe vs mild RHD HR 10.81 (3.11 to 37.62), p<0.001) and ongoing secondary prophylaxis at follow-up (HR 0.27 (0.12 to 0.63), p=0.01) were the two most influential factors associated with MACE. CONCLUSIONS: Newly diagnosed RHD is associated with poor outcomes, mainly in patients with moderate or severe valve disease and no secondary prophylaxis.

Infective endocarditis in the Pacific: clinical characteristics, treatment and long-term outcomes.

INTRODUCTION: Data on clinical characteristics and outcomes of infective endocarditis (IE) in the Pacific are scarce. METHODS: Retrospective hospital-based study in New Caledonia, a high-income country, on patients aged over 18 years with definite IE according to the modified Duke criteria (2005-2010). RESULTS: 51 patients were included: 31 (60.8%) men; median age of 52.4 years (IQR 33.0-70.0). Left-sided IE accounted for 47 (92.2%) patients: native valve IE in 34 (66.7%) and prosthetic valve IE in 13 (25.5%). The main underlying heart disease included: rheumatic valve disease in 19 (37.3%), degenerative heart valve disease in 12 (23.5%) and congenital heart disease in 6 (11.8%). Significant comorbidities (Charlson's score >3) were observed in 20 (38.7%) patients. Infection was community acquired in 43 (84.3%) patients. Leading pathogens included Staphylococcus aureus in 16 (31.4%) and Streptococcus spp in 15 (29.4%) patients. Complications were noted in 33 patients (64.7%) and 24 (47.1%) were admitted to the intensive care unit. Cardiac surgery was eventually performed in 22 of 40 (55.0%) patients with a theoretical indication. None underwent emergent cardiac surgery (ie, first 24 h); 2 (3.9%) were operated within 7 days; and 20 (39.2%) beyond 7 days. 11 (21.6%) patients died in hospital and 21 (42.9%) were dead after a median follow-up of 28.8 months (IQR 4.6-51.2). Two (3.9%) were lost to follow-up. CONCLUSIONS: In New Caledonia, IE afflicts relatively young patients with rheumatic heart disease, and carries high complication and mortality rates. Access to heart surgery remains relatively limited in this remote archipelago.

Severe traumatic brain injuries from motor vehicle-related events in New Caledonia: epidemiology, outcome and public health consequences.

OBJECTIVE: Traumatic brain injuries (TBI), which are mostly due to road traffic crash (RTC), are a major public health concern. This article describes the incidence, severity and outcome of TBI caused by RTC in New Caledonia over a five-year period. METHODS: Data of all individuals admitted in intensive care unit with severe TBI (Glasgow Coma Scale score ≤8 at admission) caused by RTC in New Caledonia from 2008 to 2012 were analysed. Causes and severity of trauma, demographic data, and short-term as well as last available long-term outcome of patients were analysed. Five types of road users were compared (car drivers, car passengers, motorcyclists, bicyclists and pedestrians). Outcome was defined according to the Glasgow Outcome Scale classification. RESULTS: A total of 109 patients were included in the study. The median age of patients was 24 [IQR18-33] years with a sex ratio of 2.8 (80 men/29 women). The rate of 44 among Melanesian males was two times higher that among 16 European males (22/100,000 people vs 11/100,000 people). The total survival at the Intensive Care Unit discharge (short-term outcome) was 84%, being the highest among passengers (88%) and the lowest among motorcyclists (69%). Of the patients tested for psychoactive substances, half tested positive. Lost to follow-up rate was 67%. CONCLUSION: Poor outcome occurs in patients with RTC-related TBI, with young Melanesian men being the most affected. Public health action should focus on this group using culturally appropriate messages.

Incidence of hospital-admitted severe traumatic brain injury and in-hospital fatality rates in a Pacific Island country: a 5-year retrospective study.

BACKGROUND: Epidemiology of severe traumatic brain injury (TBI) is poorly defined in the Pacific region, including in New Caledonia. The aim of this study was to assess the incidence, causes and outcome of hospital-admitted severe TBI in the whole population of New Caledonia. METHODS: A retrospective study on patients with severe TBI admitted to the only trauma centre during the 5-year period (2008-2012) was performed. The electronic patient register was searched for diagnoses of intracranial injuries to identify patients. Severe TBI was defined as a Glasgow Coma Scale Score ≤ 8 during the first 24 hours after injury. RESULTS: The annual incidence ranged from 10/100 000 in 2010 to 15/100 000 in 2011. Road traffic accidents (n = 109; 71%), falls (n = 26; 17%) and assaults (n = 19; 12%) were causes of severe TBI. Young Melanesian adults (median age = 26 [19-36]) were the most affected. In ICU, the overall case-fatality rate was 25%. The mortality rate was the highest among victims of assaults (47%). CONCLUSIONS: The high incidence of hospital-admitted patients with severe TBI in this study combined with high in-ICU mortality rates supports the need for targeted public health action to prevent assaults and traffic road accidents in this vulnerable population.