Impact of the French Infectious Diseases Society's (SPILF) proposals for shorter antibiotic therapies.

OBJECTIVE: To compare the practices of French infection specialists related to antibiotic therapy duration between 2016 and 2018. METHODS: We conducted two identical surveys (in 2016 and 2018) targeting hospital-based infection specialists (medical physicians, pharmacists) who gave at least weekly advice on antibiotic prescriptions. The questionnaire included 15 clinical vignettes. Part A asked about the durations of antibiotic therapies they would usually advise to prescribers, and part B asked about the shortest duration they would be willing to advise for the same clinical situations. RESULTS: We included 325 specialists (165 in 2016 and 160 in 2018), mostly infectious disease specialists (82.4%, 268/325), members of antibiotic stewardship teams in 72% (234/325) of cases. Shorter antibiotic treatments (as compared with the literature) were advised to prescribers in more than half of the vignettes by 71% (105/147) of respondents in 2018, versus 46% (69/150) in 2016 (P<0.001). Guidelines used by participants displayed fixed durations for 77% (123/160) of cases in 2018 versus 21% (35/165) in 2016. Almost all respondents (89%, 131/160) declared they were aware of the 2017 SPILF's proposal. CONCLUSION: The release of guidelines promoting shorter durations of antibiotic therapy seems to have had a favourable impact on practices of specialists giving advice on antibiotic prescriptions.

Perceptions, attitudes, and practices of French junior physicians regarding antibiotic use and resistance.

OBJECTIVES: To assess the perceptions, attitudes, and practices of French junior physicians regarding antibiotic use and resistance, and then to identify the characteristics of junior physicians associated with appropriate practices of antibiotic use. METHOD: European junior physicians received an email invitation to complete a 49 item web questionnaire between September 2015 and January 2016. We present the French data. Multivariate regression models were used to identify the characteristics of junior physicians associated with appropriate prescription practices and with consideration of the antibiotic prescription consequences. RESULTS: The questionnaire was completed by 641 junior physicians: family medicine (37%), other medical specialties (e.g., pediatrics, internal medicine, neurology: 45%), surgical specialties (11%), and anesthesiology-intensive care specialty (7%). Most respondents (93%) declared being aware of the risk of bacterial resistance and 41% acknowledged prescribing antibiotics more often than necessary. Two factors were independently associated with appropriate prescription practices: a high perceived level of education on antibiotic use (OR=1.51; 95% CI [1.01-2.30]) and a medical specialty (OR=1.69; 95% CI [1.16-2.46]). Factors independently associated with taking into account adverse events of antibiotics were a good perceived knowledge of antibiotics (OR=3.71; 95% CI [2.09-6.61]), and a high perceived education level on antibiotics (OR=1.70; 95% CI [1.11-2.58]). CONCLUSION: Our data can help better define interventions targeting junior physicians in antibiotic stewardship programs.

Correction to: Prediction of unfavorable outcomes in cryptococcal meningitis: results of the multicenter infectious Diseases International Research Initiative (ID-IRI) cryptococcal meningitis study.

In the original version of this article, Mustafa Sunbul was not included in the list of authors for this article. The name has been added accordingly.

Prediction of unfavorable outcomes in cryptococcal meningitis: results of the multicenter Infectious Diseases International Research Initiative (ID-IRI) cryptococcal meningitis study.

Cryptococcal meningitis (CM) is mostly seen in immunocompromised patients, particularly human immunodeficiency virus (HIV)-positive patients, but CM may also occur in apparently immunocompetent individuals. Outcome analyses have been performed in such patients but, due to the high prevalence of HIV infection worldwide, CM patients today may be admitted to hospitals with unknown HIV status, particularly in underdeveloped countries. The objective of this multicenter study was to analyze all types of CM cases in an aggregate cohort to disclose unfavorable outcomes. We retrospectively reviewed the hospitalized CM patients from 2000 to 2015 in 26 medical centers from 11 countries. Demographics, clinical, microbiological, radiological, therapeutic data, and outcomes were included. Death, neurological sequelae, or relapse were unfavorable outcomes. Seventy (43.8%) out of 160 study cases were identified as unfavorable and 104 (65%) were HIV infected. On multivariate analysis, the higher Glasgow Coma Scale (GCS) scores (p = 0.021), cerebrospinal fluid (CSF) leukocyte counts > 20 (p = 0.038), and higher CSF glucose levels (p = 0.048) were associated with favorable outcomes. On the other hand, malignancy (p = 0.026) was associated with poor outcomes. Although all CM patients require prompt and rational fungal management, those with significant risks for poor outcomes need to be closely monitored.

Sclerotic scatter.

Sclerotic scatter involves the scattering of incident light by the limbal sclera followed by entry of part of the scattered light into the cornea, where some of the light travels through total internal reflection to the other side, where it scatters a second time in the limbal sclera. It is then visible in the form of a limbal scleral arc of light. Sclerotic scatter has been used for decades to spot and delineate corneal opacities, which disrupt and scatter the light travelling through total internal reflection. To implement the technique, the slit beam and the binoculars of the slit lamp should be dissociated so that the limbal sclera is illuminated, while the binoculars are centered on the cornea. The technique does not provide any information as to the depth of corneal opacities and therefore needs to be complemented by direct illumination. The second sclerotic scatter may also be used clinically, for instance for diode cycloablation, the posterior part of the arc of light projecting 0.5mm behind the scleral spur. This article aims to describe the phenomenon of sclerotic scatter, explaining how the slit-lamp should be set to use this technique, describing its clinical applications (in the opacified cornea and in the normal sclera), showing that the limbal scleral arc of light of sclerotic scatter may be seen under certain circumstances in daily life with the naked eye and, finally, explaining how the arc of light differs from peripheral light focusing ("Coroneo effect").

Managing atypical and typical herpetic central nervous system infections: results of a multinational study.

There have been many studies pertaining to the management of herpetic meningoencephalitis (HME), but the majority of them have focussed on virologically unconfirmed cases or included only small sample sizes. We have conducted a multicentre study aimed at providing management strategies for HME. Overall, 501 adult patients with PCR-proven HME were included retrospectively from 35 referral centres in 10 countries; 496 patients were found to be eligible for the analysis. Cerebrospinal fluid (CSF) analysis using a PCR assay yielded herpes simplex virus (HSV)-1 DNA in 351 patients (70.8%), HSV-2 DNA in 83 patients (16.7%) and undefined HSV DNA type in 62 patients (12.5%). A total of 379 patients (76.4%) had at least one of the specified characteristics of encephalitis, and we placed these patients into the encephalitis presentation group. The remaining 117 patients (23.6%) had none of these findings, and these patients were placed in the nonencephalitis presentation group. Abnormalities suggestive of encephalitis were detected in magnetic resonance imaging (MRI) in 83.9% of the patients and in electroencephalography (EEG) in 91.0% of patients in the encephalitis presentation group. In the nonencephalitis presentation group, MRI and EEG data were suggestive of encephalitis in 33.3 and 61.9% of patients, respectively. However, the concomitant use of MRI and EEG indicated encephalitis in 96.3 and 87.5% of the cases with and without encephalitic clinical presentation, respectively. Considering the subtle nature of HME, CSF HSV PCR, EEG and MRI data should be collected for all patients with a central nervous system infection.

How do physicians cope with controversial topics in existing guidelines for the management of infective endocarditis? Results of an international survey.

International guidelines are available to help physicians prescribe appropriate antibiotic regimens to patients with infective endocarditis (IE). However some topics of these guidelines are controversial. We conducted an international survey to assess physicians' adherence to these guidelines, focusing on these controversial items. An invitation to participate to a 15-question online survey was sent in 2012-2013 to European Society of Clinical Microbiology and Infectious Diseases (ESCMID) members, scientific societies and corresponding authors of publications on IE mentioned in PubMed from 1990 to 2012, inclusive. Eight hundred thirty-seven physicians participated in the survey, and 625 (74.7%) completed it over the first question. The results showed great heterogeneity of practices. Claiming to follow guidelines was marginally associated with more guideline-based strategies. Gentamicin use depended on causative pathogens (p <0.001) and physician specialty (p 0.02). Eighty-six per cent of the physicians favoured vancomycin alone or in combination with gentamicin or rifampicin as a first-line treatment for left-sided native valve methicillin-resistant Staphylococcus aureus IE, 31% considered switching to oral therapy as a therapeutic option and 33% used the ampicillin and ceftriaxone combination for enterococcal IE as a first-line therapy. Physician specialty significantly affected the choice of a therapeutic strategy, while practicing in a university hospital or the number of years of practice had virtually no impact. Our survey, the largest on IE treatment, underscores important heterogeneity in practices for treatment of IE. Nonetheless, physicians who do not follow guidelines can have rational strategies that are based on the literature. These results could inform the revision of future guidelines and identify unmet needs for future studies.

Multicolumn spinal cord stimulation for significant low back pain in failed back surgery syndrome: design of a national, multicentre, randomized, controlled health economics trial (ESTIMET Study).

BACKGROUND: Many studies have demonstrated the efficacy of spinal cord stimulation (SCS) for chronic neuropathic radicular pain over recent decades, but despite global favourable outcomes in failed back surgery syndrome (FBSS) with leg pain, the back pain component remains poorly controlled by neurostimulation. Technological and scientific progress has led to the development of new SCS leads, comprising a multicolumn design and a greater number of contacts. The efficacy of multicolumn SCS lead configurations for the treatment of the back pain component of FBSS has recently been suggested by pilot studies. However, a randomized controlled trial must be conducted to confirm the efficacy of new generation multicolumn SCS. Évaluation médico-économique de la STImulation MEdullaire mulTi-colonnes (ESTIMET) is a multicentre, randomized study designed to compare the clinical efficacy and health economics aspects of mono- vs. multicolumn SCS lead programming in FBSS patients with radicular pain and significant back pain. MATERIALS AND METHODS: FBSS patients with a radicular pain VAS score≥50mm, associated with a significant back pain component were recruited in 14 centres in France and implanted with multicolumn SCS. Before the lead implantation procedure, they were 1:1 randomized to monocolumn SCS (group 1) or multicolumn SCS (group 2). Programming was performed using only one column for group 1 and full use of the 3 columns for group 2. Outcome assessment was performed at baseline (pre-implantation), and 1, 3, 6 and 12months post-implantation. The primary outcome measure was a reduction of the severity of low back pain (bVAS reduction≥50%) at the 6-month visit. Additional outcome measures were changes in global pain, leg pain, paraesthesia coverage mapping, functional capacities, quality of life, neuropsychological aspects, patient satisfaction and healthcare resource consumption. TRIAL STATUS: Trial recruitment started in May 2012. As of September 2013, all 14 study centres have been initiated and 112/115 patients have been enrolled. Preliminary results are expected to be published in 2015. TRIAL REGISTRATION: Clinical trial registration information-URL: www.clinicaltrials.gov. Unique identifier NCT01628237.

[Infectious events during the course of systemic necrotizing vasculitis: a retrospective study of 82 cases]. / Événements infectieux au cours des vascularites nécrosantes systémiques: étude rétrospective de 82 cas.

PURPOSE: The aim of this study was to assess the infections occurring in a series of 82 patients followed for a systemic necrotizing vasculitis and to determine potential risk factors. METHODS: We studied retrospectively the medical files of 23 Churg and Strauss syndrome, 18 periarteritis nodosa, 14 microscopic polyangiitis, and 27 granulomatosis with polyangiitis, over a 15-year period. Infection delay corresponded to the period from treatment to first infection or between two infections. RESULTS: A total of 61 patients developed 147 infections. Causal agent was identified in 70 cases, 42 were bacterial, 20 viral and 8 fungal. Bronchopneumonia was the most frequent infection (43 %). Sixty-two percent of infections occurred within 2 years after vasculitis diagnosis. Seven infections were major, requiring intensive care, with one infection-death related. Pneumocystis prophylaxis concerned 75 % of patients on cyclophosphamide. Significant factors reducing infection delay were initial hypergammaglobulinemia, hypoalbuminemia, lymphopenia, as well as cyclophosphamide and methotrexate treatment. Large quantities of corticosteroids, cyclophosphamide or azathioprine increased infection delay. This result underlines the early occurrence of infectious complications during vasculitis course. CONCLUSION: Infectious events occurring in systemic necrotizing vasculitis are frequent and occurs early in disease course, and could be prevented with simple prophylactic measures. Vasculitis relapse and infection share similarities and this require permanent clinical vigilance.

[Bacterial pneumonia in HIV-infected patients (excluding mycobacterial infection)]. / Pneumonies bactériennes chez les personnes infectées par le VIH (hors mycobactéries).

Respiratory infections are the most common complications in HIV patients, regardless of the degree of immunosuppression. Even though antiretroviral therapy has a protective effect on the risk of bacterial pneumonia, this still remains high (including those with CD(4)>500/mm(3)). The most frequently isolated bacteria are Streptococcus pneumoniae and Haemophilus influenzae. The clinical and radiological presentations of lower respiratory tract infections in HIV patients are quite variable. The clinical presentation is more severe and the radiological presentation is more atypical if the immunosuppression is severe. The first-line antibiotic therapy is an injectable third-generation cephalosporin (ceftriaxone or cefotaxime) or co-amoxiclav. Pneumococcal vaccination (as well as influenza vaccine) is recommended. Although rare, Nocardia spp. and Rhodococcus equi seem more common among AIDS patients.

Factors associated with recurrence of catheter-related bloodstream infections in home parenteral nutrition patients.

Blood cultures from outpatients receiving home parenteral nutrition (HPN) via long-term central venous access (CVA) were retrospectively analyzed from January 2003 to May 2009. When infection of the CVA was not due to Staphylococcus aureus, Pseudomonas aeruginosa, or Candida, catheter salvage was attempted for a maximum of three consecutive infections on the same CVA. Factors influencing the time-to-next-infection were studied, whether the catheter was changed after the last infection or not. Neither the McCabe score, age, history of cancer, diabetes mellitus nor immunosuppression, curative antibiotic lock, type of bacteria, type or duration of treatment had an influence on the time-to-next-infection. The time-to-next-infection was significantly associated with the status of CVA (saved or changed) and its type (tunneled catheter with or without a cuff, or implanted port catheter).

A survey on the use of gentamicin in infective endocarditis.

US and European guidelines recommend a daily divided gentamicin dose (3 mg/kg in two or three equally divided doses) for the treatment of infective endocarditis caused by staphylococci or enterococci, but once-daily dosing (3 mg/kg/day) is recommended for streptococcal endocarditis. However, studies have recommended the use of higher doses of gentamicin (4 or ≥5 mg/kg/day) administered once-daily. A survey was conducted in France by mailing a questionnaire to the 595 members of the French Infectious Disease Society regarding their gentamicin prescription patterns in infective endocarditis, focusing on the dosing regimen. The survey was answered by 137 physicians (23%). The proportions of physicians following guideline-based regimens were similar for each organism (30.9%, 38.8%, and 39.4% for staphylococci, enterococci, and streptococci, respectively [p=0.26]). In contrast, the proportions of physicians following literature-based regimens were significantly different for each organism (59.6%, 42.5%, and 27.7% for staphylococci, enterococci, and streptococci, respectively [p<0.001]). The number of years practicing and the type of practice (university vs. non-university hospital) did not influence the gentamicin dose or regimen. Although adherence to published guidelines for gentamicin administration in patients with infective endocarditis was poor, a large proportion of physicians who did not follow those guidelines used literature-based regimens.

Structural modifications in the arterial wall during physiological aging and as a result of diabetes mellitus in a mouse model: are the changes comparable?

AIM: Vascular accelerated aging represents the major cause of morbidity and mortality in subjects with diabetes mellitus. In the present study, our aim was to compare premature functional and morphological changes in the arterial wall resulting from streptozotocin (STZ)-induced diabetes mellitus in mice over a short-term period with those that develop during physiological aging. The effect of aminoguanidine (AG) on the prevention of these alterations in the diabetic group was also analyzed. METHODS: The vascular relaxation response to acetylcholine (ACh) in the mouse was tested in isolated segments of phenylephrine (Phe)-precontracted aorta at 2, 4 and 8 weeks (wk) of STZ-induced diabetes and compare to 12- and 84-wk-old mice. Aortic structural changes were investigated, and receptor for AGE (RAGE) aortic expression was quantified by western blot. RESULTS: Compared to the 12-wk control group (76 ± 5%), significant endothelium-dependant relaxation (EDR) impairment was found in the group of 12-wk-old mice, which underwent a 4-wk diabetes-inducing STZ treatment (12wk-4WD) (52 ± 4%; P < 0.01) and was yet more apparent in the group of 16-wk-old mice, which underwent an 8-wk diabetes-inducing STZ treatment (16wk-8WD) (34 ± 4%; P < 0.001). The alteration in EDR was relatively comparable between the diabetic 12wk-4WD group and the 84-wk-old group (52.7 ± 4 vs. 48 ± 4%). Intima/media aortic thickening and aortic structural changes were significantly increased in the diabetic 12wk-4WD group and were even more apparent in the 84-wk group compared to the 12-wk controls. AG treatment in the 12wk-4WD+AG diabetic group significantly improved EDR, decreased RAGE expression and showed an aging preventive effect on the structural changes of the arterial wall. CONCLUSION: Our study compared EDR linked to physiological aging with that observed in the case of STZ-induced diabetes over a short-term period, and demonstrated the beneficial effect of AG.

[Association myositis and hepatocellular carcinoma: one case and review of literature]. / Association myopathie inflammatoire et hépatocarcinome : à propos d'une observation et revue de la littérature.

Association inflammatory myopathies and tumors are not fortuitous but association with hepatocellular carcinoma is rarely reported in literature. We described a case of association polymyositis hepatocellular carcinoma in 37-year-old black African patient, with fatal issue.

[Could a resident be a remote infectious disease specialist consultant? The Lille teaching hospital experience]. / Faut-il mettre un interne en infectiologie transversale ? L'expérience au centre hospitalier régional et universitaire de Lille.

Infectious diseases specialist consultants are usually senior physicians. At the Lille University Hospital, it was decided to associate an infectious disease (ID) resident to this remote infectious disease activity to improve his training in this field. He visited the emergency department daily, participated in weekly multidisciplinary meetings with medical staff, and was in first line to answer the phone which is the usual means for hospital doctors to ask specific questions. It was a very instructive experience for an ID resident because of the diversity of clinical cases in other departments and he often had to refer to medical literature. However, being a remote consultant could be difficult for an ID resident. He might be less well considered than a senior physician by the other specialists. To conclude, a remote infectious disease consultant can be an ID resident if he is experienced and supervised by a senior physician.

Recurrent bacteremia, a complication of cyanoacrylate injection for variceal bleeding: report of two cases and review of the literature.

We report the first description of recurrent bacteremia in two patients after cyanoacrylate injection for gastric varices bleeding treated with antibiotics alone. Adapted and prolonged antibiotic treatment allowed a complete resolution of the infection with no relapse after more than 6 months. According to recent data, prophylactic antibiotics should be further investigated for patients with bleeding varices undergoing cyanoacrylate injection.

[Primary Salmonella vascular graft infection and conservative treatment]. / Infection primaire de prothèse vasculaire à salmonelle et traitement conservateur.

The authors report an unusual case of prosthetic vascular graft infection due to Salmonellatyphimurium. The initial treatment combined antibiotherapy and surgical replacement of the arteriovenous graft. The infection relapsed within 6 weeks and was successfully treated with antibiotics only. Five cases of vascular graft infection due to Salmonella have been reported so far, but only one occurred in a previously healthy man and was not related to local infection, but to bacteremic seeding. Specific features of vascular graft infection and importance of prevention are discussed.