Prolonged suppressive antibiotic therapy for prosthetic joint infection in the elderly: a national multicentre cohort study.

During prosthetic joint infection (PJI), optimal surgical management with exchange of the device is sometimes impossible, especially in the elderly population. Thus, prolonged suppressive antibiotic therapy (PSAT) is the only option to prevent acute sepsis, but little is known about this strategy. We aimed to describe the characteristics, outcome and tolerance of PSAT in elderly patients with PJI. We performed a national cross-sectional cohort study of patients >75 years old and treated with PSAT for PJI. We evaluated the occurrence of events, which were defined as: (i) local or systemic progression of the infection (failure), (ii) death and (iii) discontinuation or switch of PSAT. A total of 136 patients were included, with a median age of 83 years [interquartile range (IQR) 81-88]. The predominant pathogen involved was Staphylococcus (62.1%) (Staphylococcus aureus in 41.7%). A single antimicrobial drug was prescribed in 96 cases (70.6%). There were 46 (33.8%) patients with an event: 25 (18%) with an adverse drug reaction leading to definitive discontinuation or switch of PSAT, 8 (5.9%) with progression of sepsis and 13 died (9.6%). Among patients under follow-up, the survival rate without an event at 2 years was 61% [95% confidence interval (CI): 51;74]. In the multivariate Cox analysis, patients with higher World Health Organization (WHO) score had an increased risk of an event [hazard ratio (HR) = 1.5, p = 0.014], whereas patients treated with beta-lactams are associated with less risk of events occurring (HR = 0.5, p = 0.048). In our cohort, PSAT could be an effective and safe option for PJI in the elderly.

[Libman-Sachs endocarditis and ischemic stroke: A case report]. / Endocardite de Libman-Sachs et accident vasculaire cérébral ischémique : à propos d'un cas.

Libman-Sacks endocarditis is a rare cardiac manifestation of anti-phospholipid syndromes, in which non-infectious thrombotic vegetations are found on the heart valves. Most patients are asymptomatic whereas the risk of thromboembolism is considerable. Diagnostic work-up is based on questioning and clinical examination data looking for extracardiac signs, biological data and also on imaging, and, above all, echocardiography. We report the case of a 47-year-old female patient with no known history who is admitted to hospital with paresthesia of the right hemi-body associated with dysarthria. Cerebral CT scan confirms a paraventricular ischemic stroke. The etiological work-up for stroke is negative except the transesophageal echocardiogram which reveals mitral valve vegetations. Further investigations lead to the diagnosis of Libman-Sacks endocarditis. Treatment with Coumadin is started, with a target INR of between 2 and 3, as recommended. The clinical course was favourable, with stable lesions on transoesophageal echocardiography carried out later.

[Acute Q fever, antiphopholipid antibodies and renal artery thrombosis: case report and literature review]. / Fièvre Q aiguë, antiphospholipides et thrombose artérielle rénale : à propos d'un cas et revue de la littérature.

INTRODUCTION: Antiphospholipid antibodies (aPL) can be associated with numerous infectious and particularly Q fever. Data on the pathogenicity of aPL in the course of acute Q fever are scarce. CASE REPORT: We report the case an acute Coxiella burnetii infection associated with clinical and biological manifestations of the aPL syndrome, including a renal infarction. Along with antibiotic treatment, anticoagulation and intravenous immunoglobulins, the clinical outcome was favourable. Antiphospholipid antibodies and Q fever antibody titers had a closely related evolution. CONCLUSION: Arterial thrombosis associated with Q fever and aPL is exceptional. The nosology and potential mechanisms are discussed.

[Medical treatment in peripheral arterial disease: a professional practice study in 262 patients]. / Traitement médical de l'artériopathie oblitérante des membres inférieurs: étude de pratique professionnelle chez 262 patients.

PURPOSE: Antiplatelet agents (APA), statins and angiotensin converting enzyme inhibitors (ACEI) are effective to reduce the risk of cardio-vascular events in patients with peripheral arterial disease (PAD). Few data are available on the actual prescription of these drugs in outpatients and on the effect of hospital care on the level of prescription. METHODS: Retrospective study of patients hospitalized with a confirmed diagnosis of PAD over a one-year period. Comparison of medical treatments on admission and on discharge. RESULTS: 262 patients were included. Mean age was 73 +/- 11 years, and 29% of the patients were women. APA were present in 64% on admission and in 83% when discharged (P < 0.0001). A statin was present in 29% on admission and in 38% when discharged (P = 0.001). ACEI were present in 27% on admission and in 32% when discharged (P= 0.02). A vasodilator was present in 47% on admission and 52% when discharged (P = 0.1). 35% of the patients had isolated PAD. Compared to the patients with associated clinical coronary or cerebro-vascular disease, they were less frequently discharged on statins (respectively 26 and 45%, p = 0.003) and on ACEI (respectively 23 et 38%, P = 0.016) whereas APA were equally prescribed (respectively 82 and 84%, P= 0.7). CONCLUSION: APA were prescribed to a majority of outpatients and the level of prescription was further improved when patients were discharged from the hospital. Statins and ACEI were insufficiently prescribed. On the other hand, vasodilator therapy remained still largely prescribed, despite the lack of any strong effect on morbidity and survival.

[Two cases of polyarteritis nodosa with a good prognosis?]. / Deux périartérites noueuses de bon pronostic?

INTRODUCTION: Polyarteritis nodosa is a systemic necrotizing vasculitis that may become serious, even with no usual poor prognosis factors. EXEGESIS: We report two cases of polyarteritis nodosa with negative histology, starting only with an extensive necrosis of the extremities. The treatment, associating corticosteroids and, secondarily, immunosuppressors, did not prevent a bilateral half-leg amputation for the two patients. In the first case the disease stabilized, but in the second one, it worsened, leading to death within 2 years. CONCLUSION: This clinical aspect of the disease is unusual and should be identified because of its bad prognosis. It might benefit from a treatment from the outset associating corticosteroids and immunosuppressors, even with no usual bad prognosis factors.

[Homocystinuria in adulthood]. / L'homocystinurie à l'âge adulte.

Homocystinuria is a genetically determined inborn error of the methionine amino acid pathway characterized by increased plasma homocysteine. In its major form, homocystinuria, is due to cystathionine beta synthase deficiency. Treatment of these adulthood patients lead physicians to call up on the skilled advices of pediatricians. But prevention and treatment of age related vascular and osteoporotic complications are still to be evaluated.

[Vascular complications of homocystinuria: a retrospective multicenter study]. / Les manifestations vasculaires de l'homocystinurie: étude rétrospective multicentrique.

PURPOSE: Arterial or venous thromboses are frequent in patients with homocystinuria. Because severe homocystinuria is rare, prevalence of thrombosis, especially in France, is still unknown. METHODS: Review of the clinical outcome of 37 patients with homocystinuria due to cystathionine-cystathionine beta-synthase deficiency (34) and 5,10-methylenetetrahydrofolate reductase (three) lead us to describe vascular complications occurring in 12 (32%) of them. RESULTS: Venous thromboembolism is the earlier and the most frequent one and is mainly found in untreated late-diagnosed cases. Under specific treatment of homocystinuria, thromboses are rare and always a complication of surgery associated with high thromboembolic risk. Association with factor V Leiden increased the risk of venous thrombosis.

[Cardiac amyloidosis: a restrictive cardiopathy with no single prognosis]. / L'amylose cardiaque: une cardiopathie restrictive au pronostic non univoque.

Cardiac amyloidosis is expressed as a restrictive myocardiopathy. Echocardiography suggests the diagnosis. There is a great difference between the prognosis of senile cardiac amyloidosis and "AL" amyloidosis. We illustrate this point with two case reports.