Evolving microbiological epidemiology and high fetal mortality in 135 cases of bacteremia during pregnancy and postpartum.

The outcome of bacterial bloodstream infections during pregnancy has greatly improved over the last few decades. However, there are no recent data on the characteristics of bacteremia in pregnant women. The aim of this study was to describe clinical and microbiological features of bacteremia and to assess maternal and fetal outcome. This retrospective study was conducted in the obstetrics departments of five teaching hospitals in Paris, France, from 2005 to 2009. The incidence of bacteremia was 0.3%. The most common sources of bacteremia were chorioamnionitis (47%) and the most common pathogen isolated was Escherichia coli. Empirical antimicrobial therapy was inappropriate in 29% of bacteremia cases, mostly (65%) when secondary to infection with an aminopenicillin-resistant microorganism. Bacteremia during pregnancy was associated with a 10% fetal mortality. Bacteremia during pregnancy is a rare occurrence, but it is associated with an unexpectedly poor fetal outcome and a high mortality rate.

[Early diagnosis and prevention of comorbidities among HIV-infected patients: the Orchestra Saint-Antoine Program]. / Dépistage et prévention des comorbidités chez les patients infectés par le VIH: le programme Orchestra Saint-Antoine.

OBJECTIVES: The Saint-Antoine Orchestra Program aims at improving the clinical management of HIV-infected patients through access to care, prevention and early diagnosis of comorbidities. METHODS: The program was initiated in December 2004 on the whole database. The following topics were concerned: cardiovascular risk factors, gynecological follow-up, anti-HBV vaccinal coverage, sexuality and prevention of STIs, therapeutic adherence and counsels to travelers. The program included several actions: diffusion of information to patients, development of a computerized chart (alert pop-ups), individualized prescription advice and recommendations for specialist referral. RESULTS: The program was applied to 1959 patients whose initial characteristics were: mean age: 43+/-10 years; ratio M/W: 1466/493; European origin: 69%; sub-Saharan: 19%; mean duration of HIV infection: 9.3+/-6 years; naïve of antiretrovirals: 14%; mean CD4+count: 494+/-277/mm(3); HIV viral load inferior to 50 cp/ml: 62%. Among 1347 patients for whom cardiovascular risk factors were completely informed, 42% had two or more factors. In particular, 31% of them were smokers, 7% had an arterial pressure superior to 140/90 mmHg and 11% had LDL-cholesterolemia superior to 4.1 mmol/l. Among 1448 untreated patients, 70% were initially considered as adherent. Half of the concerned women had neither cervical smear nor mammography up to date. Among 67% patients with an informed complete HBV serology, 27% were seronegative among which 310 (86%) were eligible for the vaccine. Problems of sexual difficulties or prevention were initially discussed for 11% of patients. Among them, 14% had a problem of prevention and 148 (66%) recognized sexual difficulties. CONCLUSION: The initiation of the Saint-Antoine Orchestra program has provided a unique opportunity to assess and improve the prevention and management of comorbidities in HIV patients. Also, this program aimed to improve professional practices.

Long-term evolution of CD4 count in patients with a plasma HIV RNA persistently <500 copies/mL during treatment with antiretroviral drugs.

BACKGROUND: The increase in CD4 count may reach a plateau after some duration of virological response to highly active antiretroviral therapy (HAART). METHODS: A total of 1281 HIV-infected patients initiating HAART were enrolled in the AntiPROtease (APROCO) cohort. We investigated determinants of increase in CD4 count using longitudinal mixed models in patients who maintained a plasma HIV RNA <500 HIV-1 RNA copies/mL. RESULTS: A total of 870 patients had a virological response at month 4. The median follow-up time was 57 months. Mean estimated increases in CD4 count in patients with persistent virological response were 29.9 cells/muL/month before month 4, 6.4 cells/microL/month between months 4 and 36, and 0.7 cells/microL/month (not significantly different from 0) after month 36. Three factors were associated with a significantly positive CD4 count slope after month 36: male gender (+0.9), no history of antiretroviral therapy at baseline (+1.7) and baseline CD4 count <100 cells/microL (+2.6). In patients who maintained a virological response after 5 years of HAART, a CD4 count >500 cells/microL was achieved in 83% of those with a baseline CD4 count >or=200 cells/microL and in 45% of those with a baseline CD4 count <200 cells/microL. CONCLUSION: The increase in CD4 count reaches a plateau after 3 years of virological response. Even if patients initiating HAART with low CD4 counts still show a CD4 count increase after 3 years, it remains insufficient to overcome immune deficiency in all patients.

[Resolution of choreic movements associated with HIV encephalitis with anti-retroviral therapy]. / Mouvements choréiques résolutifs sous traitement anti-rétroviral au cours d'une encéphalite à VIH.

INTRODUCTION: Infection of the central nervous system with human immunodeficiency virus (HIV) can be associated with movement disorders. CASE REPORT: A case of chorea during HIV encephalitis which responded well to antiretroviral therapy is reported. Choreic movements disappeared with a decrease of MRI lesions observed in basal ganglia. CONCLUSION: The efficacy of anti-retroviral therapy in choreic movements, a rare syndrome with HIV encephalitis, can be underlined.

[The use of microbiological tools for the diagnosis of nosocomial pulmonary infections]. / Utilisation des outils diagnostiques microbiologiques dans les infections pulmonaires communautaires.

OBJECTIVES: To assess the use of microbiological examinations, notably serology, in the etiological diagnosis of pulmonary diseases in a department of infectious diseases. METHODS: A retrospective study assessing the habits of microbiological examination prescriptions in pulmonary infections was carried out from 1/05/2000 to 31/10/2001. All patients admitted during this period for pulmonary infection diagnosis and treatment in the infectious diseases and tropical Unit of Saint Antoine Hospital (Paris), were included. The relevance of use of the following diagnostic procedures was assessed: cytobacteriological examination of sputum, specimens obtained on bronchoscopy, hemoculture, serology and search for Legionella urinary antigens. Factors having influenced the co-prescription of these microbiologic examinations were analysed. RESULTS: The survey concerned 179 patients: 7 acute bronchitis, 25 acute exacerbations of chronic bronchitis and 147 community-acquired pneumonia. Microbiological diagnosis was obtained for 34 patients (17.4%), primarily on respiratory specimens. Serology was prescribed in 61 cases with a second serology in 23% (14/61). The principal factor predictive of bacterial serology prescription was the existence of interstitial opacity on chest radiography. Likewise, the search for Legionella urinary antigens was associated with the presence of interstitial opacity on the X-ray and of hyponatremia. However, it was only carried out in 37% of pneumonia with serious clinical presentation (25/67) and was followed by the prescription of combined antibiotics in 70% of the cases (40/57). CONCLUSION: Assessment of the microbiology diagnostic methods of pulmonary infections showed the misuse of serology and insufficient prescription of the search for Legionella urinary antigens, recommended in the case of serious clinical signs.

Impact of highly active antiretroviral therapy on the occurrence of bacteraemia in HIV-infected patients and their epidemiologic characteristics.

OBJECTIVE: 1. to assess the impact of highly active antiretroviral therapy (HAART) on the occurrence of bacteraemia in HIV-infected patients and their clinical and microbiological characteristics. 2. to identify risk factors for bacteraemia in this setting. METHODS: The files of all HIV-infected patients hospitalized for an episode of bacteraemia in a 28-bed infectious diseases unit between January 1995 and December 1998 were reviewed. Cases occurring during HAART were compared to cases occurring in patients not receiving HAART. Furthermore, in a case-control study, patients with bacteraemia occurring during HAART were compared with other patients receiving HAART. RESULTS: There were 74 episodes of bacteraemia in patients not receiving HAART and 31 episodes in patients receiving HAART. The occurrence of bacteraemia fell from 10.5/100 hospitalizations in 1995 to 5.5/100 in 1998 (P = 0.02 trend test). The occurence of P. aeruginosa bacteraemia fell sharply (9/398 vs 1/273, P = 0.05). A significant fall in catheter-related infections was observed between 1995 and 1998 (5.5% vs 1.8%). The two-thirds/one-third distribution of hospital-acquired and community-acquired infections remained stable throughout the period study. In patients receiving HAART, the case-control study showed by multivariate analysis, that a CD4 cell count of less than 100/ micro L [OR = 7.3 (1.9-49.7)], and the use of exogenous devices [OR = 13.3 (2.5-71)] were significantly associated with the risk of bacteraemia. CONCLUSION: The introduction of HAART has been associated with a significant fall in the occurrence of bacteraemia. However, patients with a low CD4 cell count remain at risk of bacteraemia with similar microbiological and epidemiological characteristics than in the pre-HAART era.