[Management of antiretroviral treatment in HIV-infected patients exhibiting virologic failure]. / Gestion du traitement antirétroviral chez les patients infectés par le VIH, en échec thérapeutique.

THE BASES OF THERAPEUTIC FAILURE: In view of its varying clinical, immunological and virological components, therapeutic failure during HIV infection is debatable. It relies on monitoring the patient during treatment, taking into account prior therapy and the initial level of CD4 and HIV viral charge, and their evolution. Immuno-virological failure can be defined as a detectable viral charge and CD4 lymphocytes lesser than 200 elements/mm3. Therapeutic failure can be related to various factors: poor compliance to treatment, insufficient dosing, poor absorption or drug interactions reducing its efficacy and HIV resistance to antiretrovirals. THE MANAGEMENT OF PATIENTS EXHIBITING CONFIRMED THERAPEUTIC FAILURE: Requires assessment of patient's compliance and the search for drug or nutritional interactions. Pharmacological doses of antiretrovirals are useful in explaining the onset of failure or in adapting the dose. A genotype resistance test will orient the choice of new molecules in patients with reduced therapeutic options. THE CHOICE OF A NEW COMBINATION: Relies on knowledge of prior treatments and the reasons for their withdrawal (failure or intolerance) and the profile of in vitro cross-resistance to antiretrovirals. The optimal prescription combines at least two new molecules and/or a new class of antiretrovirals to which the patient has not yet been exposed. IN PATIENTS IN WHOM THERE IS NO THERAPEUTIC RESOURCES: An association of three classes of antiretrovirals with a total of 5 to 8 molecules are proposed in high-dose therapies. The use of suspension of therapy, to permit re-sensitivity, is presently being studied. THE OBJECTIVE OF TREATMENT: In non-responding patients, it is essential to retain an number of CD4 protectors depending on the clinical progression of the disease, while awaiting new therapeutic options, contrary to first or second line treatment, the priority aim of which remains reaching a undetectable viral charge.

[Prosthetic valve endocarditis due to Coxiella burnetii: six cases]. / Endocardites à Coxiella burnetii sur prothèse: six observations.

PURPOSE: Prosthetic valve endocarditis is a dangerous complication of valvular surgery (3-6%). Among involved pathogens, Coxiella burnetii is an occasional agent, though isolated with increasing frequency. We report our experience with this peculiar endocarditis and lay stress on specific diagnostic and therapeutic difficulties. METHODS: Between 1990 and 1995, six patients retrospectively met the diagnosis criteria for definite endocarditis due to Coxiella burnetii. RESULTS: Five Algerian men and one French woman presented with prosthetic valve endocarditis with negative blood cultures (on bioprosthesis: four cases, on mechanical valve: two cases). The main clinical and biological feature was febrile congestive heart failure with hepatomegaly, splenomegaly, hepatic and renal abnormalities, inflammatory syndrome, hypergammaglobulinemia, anemia and lymphopenia. Serological testing for Coxiella burnetii provided diagnosis in all cases. Echocardiography displayed vegetations in all cases. Valvular replacement was performed in four patients. With antibiotic therapy including doxycycline or/and hydroxychloroquine, quinolones or rifampicine, all patients experienced complete clinical, biological and echographic remission. CONCLUSION: Q fever prosthetic valve endocarditis presents as a systemic disorder occurring in patients with valvular heart disease. From now on, early diagnosis and efficient medical treatment may provide permanent prosthetic sterilization.