[Management of lower respiratory tract infections by general practitioners in France]. / Prise en charge des infections respiratoires basses en médecine générale en France.

OBJECTIVE: The purpose of this study was to describe the diagnostic and therapeutic strategies used by general practitioners (GPs) in patients with lower respiratory tract infections (LRTI). METHODS: Four hundred fifty GPs practicing in France participated in the study; they included 804 patients. The GP recorded social and demographic data and their prescription on a data sheet and responded to a phone questionnaire about their strategy. RESULTS: Most of the LRTI were acute bronchitis (72%); pneumonia and acute exacerbations of chronic bronchitis were observed respectively in 11% of the patients recruited. Diagnostic criteria used by the GPs were generally auscultation signs in patients with fever, cough and expectoration. Specialized advice (always a chest physician) and hospitalization were exceptional. Prescription of complementary exams was strongly related to the diagnosis of pneumonia (OR = 33.3; CI0.95: 15.48-70.4). Sick leaves were related to general symptoms (fever, asthenia). Antibiotics were prescribed in 95.7% of the patients, mainly aminopenicillin (40.4%) and macrolides (33.2%). Nonsteroidal or steroidal antiinflammatory drugs were prescribed in 72.5% of the patients irrespective of the LRTI diagnosis. DISCUSSION: The fact that GPs do not often refer patients to specialists or order hospitalization confirms their important role in setting up recommendations. It would also be necessary to develop an education program on better use of antibiotics targeted to GPs and patients.

Change in transaminases in hepatitis C virus- and HIV-coinfected patients after highly active antiretroviral therapy: differences between complete and partial virologic responders?

Patients with HIV and hepatitis C virus (HCV) coinfection have more severe hepatitis-related disease than do patients with HCV infection alone. Highly active antiretroviral therapy (HAART) with protease inhibitor appears to restore pathogen-specific immune responses, especially in patients with persistent undetectable HIV viral load. To evaluate the potent impact of immune restoration induced by HAART on the course of HCV-related disease, HCV viremia and levels of transaminases were compared between two groups of patients: 10 HIV/HCV-coinfected patients with persistently undetectable HIV viremia (group A) and 12 HIV/HCV-coinfected patients with persistent detectable HIV viremia. No difference was detected in HCV viral load in either group. An increase in transaminases was found only in patients with persistent undetectable HIV viral load, which was correlated with the increase in CD8+ T cells. This may suggest that the restoration of CD8+ T cell cytotoxicity could lead to an enhancement of hepatitis C-related disease in HCV/HIV-coinfected patients receiving HAART.

[Experience with an "isolation unit" for patients infected with multi-resistant bacteria. Retrospective study of 49 patients]. / Expérience d'une "unité d'isolement" dans la prise en charge de patients porteurs de bactéries multirésistantes. Etude rétrospective sur 49 patients.

OBJECTIVES: Perform a retrospective analysis of care in a hospital "isolation unit" for patients infected with multirestant bacteria (MRB), i.e. meticillin-resistant staphylococcus aureus (SAMR), broad spectrum beta-lactamase secreting enterobacteria. (BLSE). PATIENTS AND METHODS: Forty-nine patients infected with MRB were cared for in our hospital isolation unit between January 1, 1996 and January 1, 1997. Each patient was in a separate room equipped with a sink and soap distributor, single-use towels, and individual material for patient care (stethoscope, mobile equipment, writing material, etc.). The personnel were given special training in the prevention of nosocomial infections. At admission, and in all patients, bacteriological samples to search for SAMR were acquired from nasal discharge, urine, perineal swabs, wounds and bed sores. Wound, urine and fecal samples were also taken to search for BLSE. Search for other sites of infection depended on the clinical situation. The management protocol in the isolation unit included: isolation, daily antiseptic baths, topical application of antibiotics or antiseptics on all bacteriologically proven sites of SAMR infection, selective decontamination of the digestive tract for patients with BLSE positive stools. Systemic antibiotics were given case by case. RESULTS: Mean duration of stay in the isolation unit was 17 days for SAMR infections and 14 days for BLSE infections. Mean delay to sterilization of the infected sites varied depending on the localization: 2.3 days for blood and 19.4 days for stools. Seven patients died. After leaving the isolation unit, the bacteriological course was followed in 23 patients: there were 7 cases of recurrence at least one site within a mean delay of 34.5 days. CONCLUSION: Use of isolation units provides an interesting solution for health care centers to control spread of multiresistant bacteria. Considering the endemic state of multiresistant bacteria infections in French hospitals, each health care unit should have correctly equipped facilities for isolating infected patients.

Association between primary cytomegalovirus infection and severe hemolytic anemia in an immunocompetent adult.

Hemolysis is a rare complication of cytomegalovirus infection in the immunocompetent adult, and the mechanisms responsible for it remain obscure. Guidelines for treatment have yet to be established, and the effectiveness of antiviral therapy has not been proven. In this report, an unusual case of primary cytomegalovirus infection manifested by severe hemolysis in an immunocompetent adult is presented. Treatment with ganciclovir (5 mg/kg b.i.d.) for 10 days and prednisolone (2 mg/kg/day) for more than 3 months suggests that both virological and immunological mechanisms are probably responsible for the hemolysis.

Hepatitis C in France: a national survey in the Departments of Internal Medicine and Infectious Diseases. The GERMIVIC (Joint Study Group on Hepatitis C virus of the French National Society of Internal Medicine and the French Society of Infectious Diseases).

Infection with Hepatitis C virus is a significant public health problem that has important clinical and financial consequences. Understanding of the epidemiology of HCV is needed to help define future therapeutic and preventive strategies. So far, the importance and characteristics of the epidemics have been best appreciated in specialist units dealing with liver disease. The purpose of our study was to survey the number and characteristics of hepatitis C antibody positive patients in Departments of Internal Medicine and Infectious Diseases. We conducted a multicentre national prospective analysis of all positive HCV-antibody patients, either inpatient or outpatient, reported over a period of one month across France. Two thousand and two cases were identified. Epidemiological, clinical and therapeutic characteristics are described. Risk factors were identified in 86%. For 10% of the patients, hepatitis C seropositivity was discovered during the period of survey. At the time of first diagnosis, 47% of patients presented with no clinical or biological abnormality. Coinfection with HIV was frequent (59%). Only 20.3% of the patients had received or were receiving a treatment with interferon. Within the limits of the methodology used, this study shows that Hepatitis C infection is a substantial clinical problem in French Departments of Internal Medicine and Infectious Diseases. Our findings may help the public health authorities in better appreciating the impact of hepatitis C and making policy decisions.

[Effects of double and triple antiretroviral agents on the HCV viral load in patients coinfected with HIV and HCV]. / Effets des bi- et trithérapies antirétrovirales sur les charges virales VHC chez les patients coinfectes par le VIH et le VHC.

HIV infection accelerates natural course of HCV infection, but impact of antiretroviral treatment on HCV infection is not well known. The aim of this study is to compare the change of HCV viral load in patients on combination of 2 nucleoside analogues and in patients on combination of 2 nucleoside analogues and protease inhibitor. HCV and HIV viral load, lymphocyte CD4 counts, alanine aminotransferase (ALT) and aspartate amino transferase (AST) were measured before and 3 months after starting treatment in 2 groups: Group 1 (n = 15) treated with 2 nucleoside analogues and Group 2 (n = 15) treated with 2 nucleoside analogues and a protease inhibitor. Results show a significant increase in lymphocyte and a significant decrease in HIV viral load in the both group but no significant change in HCV viral load and in ALT and AST. In conclusion efficiency of anti-HIV therapy (combination of 2 nucleoside analogues with or without a protease inhibitor) doesn't seem to have any impact on the course of HCV viremia in HIV-coinfected patients.

[Cerebral and pulmonary miliary tuberculosis in an immunocompetent patient: aggravation in an adequately treated patient]. / Miliaire tuberculeuse cérébrale et pulmonaire chez un patient immunocompétent: aggravation sous traitement adapté.

BACKGROUND: Extrapulmonary localizations are observed in 20% of tuberculosis cases, mainly in immunosuppressed patients. Prognosis is poor in case of relatively uncommon cerebral localizations and miliary dissemination, especially if treatment is initiated in late stages. We report a case of disseminated tuberculosis associated with cerebral and pulmonary localizations in an immunocompetent patient. THe disease progressed despite adapted treatment. CASE REPORT: A young immunocompetent man with an uneventful history developed miliary tuberculosis with pulmonary localizations visualized on the computed tomography (CT) of the thorax. Brain CT was normal, but magnetic resonance imaging revealed several intracranial lesions. The disease course was marked by development of neurological symptoms and progression of the cerebral lesions after one month of treatment. No evidence of therapeutic failure (insufficient dosing, non-compliance, primary resistance) could be identified. DISCUSSION: Magnetic resonance imaging provides a more precise evaluation of tuberculosis lesions in the brain. Early antituberculosis therapy associated with corticosteroids can improve prognosis. Clinicians should be aware that cerebral lesions may continue to progress despite appropriate treatment, a course which is not satisfactorily explained by any current pathogenic hypothesis.

[Cytomegalovirus infection in pregnant women. Seroepidemiological prospective study in 1,018 women in Isere]. / Infection à cytomégalovirus chez la femme enceinte. Etude séro(-)épidémiologique prospective chez 1,018 femmes en Isère.

Cytomegalovirus (CMV) is the leading cause of viral congenital infections. In children, the consequences may be severe, especially in case of maternal primary infection during pregnancy. A prospective study was carried out in the department of Isère, in 1,018 pregnant women, in order to establish the seroprevalence of CMV, the frequency of primary infections during pregnancy and the associated risk factors. The overall seroprevalence was 51.5%; it increased significantly with age, parity, and low socioeconomic status. It was higher in women born in the South of France (51.6%) than in those born in the North (37.4%). Among a total of 878 women with serological follow-up, 7 primary infection cases (0.8%) were observed. Seventeen women (1.9%) presented border IgM values in the first serum, and these values were not related to recent infection. Extrapolation of the results to the whole department of Isère, suggests that each year about 100 pregnant women would be concerned by CMV primary infection, with 2 or 3 cases of death or severe sequelae in children. In light of these results, the interest of serological screening is discussed.

Rifabutin versus placebo in combination with three drugs in the treatment of nontuberculous mycobacterial infection in patients with AIDS.

The aim of this double-blind, randomized, placebo-controlled, 12-week study was to assess the efficacy of rifabutin (450 or 600 mg/d) in the treatment of disseminated nontuberculous mycobacterial infection in patients with AIDS. Companion drugs in both arms of the study were ethambutol, clofazimine, and isoniazid. Because of low accrual, the study was prematurely terminated when a total of 382 patients had been enrolled, of which 200 were eligible (i.e., their specimens were culture-positive for Mycobacterium avium complex [MAC] or Mycobacterium xenopi at baseline) and 102 were evaluable (i.e., they were eligible, were treated for a minimum of 6 weeks, and had at least one culture assessment after baseline). The original protocol called for a total of 220 evaluable patients. At week 12, rifabutin treatment was associated with higher, although nonsignificant, rates of bacteriologic conversion than was the placebo arm, with regard to both the eligible patients (25% vs. 18%) and the evaluable patients (45% vs. 38%). Corresponding median times to culture conversion were 42 vs. 63 days (eligible patients) and 43 vs. 69 days (evaluable patients). No significant difference was observed in clinical improvement, mortality, or toxicity between the two treatment arms. The addition of rifabutin to a triple-drug regimen may contribute to the clearance of disseminated MAC infection in patients with AIDS, without causing additional toxicity.

[Hepatitis C virus infection in internal medicine and infectious diseases departments in France. Preliminary results of a national epidemiological survey]. / Infection par le virus de l'hépatite C dans les services de médecine interne et les services de pathologie infectieuse en France. Résultats préliminaires d'une enquête épidémiologique nationale.

OBJECTIVES: In order to know the number and the main clinical features of patients with hepatitis C virus (HCV) infection, we conducted a national epidemiological study of patients followed in Internal Medicine and in Infectious Diseases departments in France. METHODS: For each patient with HCV infection seen between 13/03 and 13/04/1995 (in- or out-patients), a chart was completed. RESULTS: The response rate was about 30% with 2002 charts being analyzed. There were 59% males and 39% females, with a peak of frequency between 25 and 40 years, including 1241/2002 (62%) patients. Most patients were of French origin (85.7%). We found that 1436/2002 (72%) patients came from provinces of southern France and Paris. In 10% of cases the diagnosis was made during the study period. A route of transmission was identified in 86.4%, mainly drug abuse 60.4% and blood product transfusion 19.3%. At the time of diagnosis, main clinical features were: no symptom 47%, liver biological abnormalities 52%, cirrhosis 7.4%, cryoglobulinemia 2.7%, auto-immune disease 3%, hepatocellular carcinoma 0.85%. We frequently found a viral co-infection: HIV 56.1%; HBV 22.2%. A confirmation RIBA test was done in 67.8%, measurement of viremia in 33.4%, genotyping in 6.7% and liver biopsy in 28.7% of cases. Finally, 407 (20.3%) patients received a specific anti-HCV treatment. CONCLUSION: These preliminary results underscore: 1) the large percentage of the population with HCV infection followed outside of hepatogastroenterology departments in France. 2) the high probability that the HCV epidemic is underestimated as we noted 10% of new diagnosis during the study period. 3) the requirement for a multidisciplinary approach for these HCV patients.