Impact of the COVID-19 pandemic on sexual behaviour and welfare of HIV preexposure prophylaxis users: a mixed-method study

COVID-19 pandemic can affect people using HIV preexposure prophylaxis (PrEP). To assess its consequences on PrEP users' sexual behaviour and welfare, we conducted a mixed-method study. A self-administered questionnaire was given to PrEP users during scheduled consultation in Tourcoing Hospital from February to May 2021. In addition, a qualitative study included 14 participants who took part in semi-structured in-depth interviews (IDIs). Ninety-four PrEP users completed the questionnaire. During lockdown, 62% of participants continued PrEP. After lockdown release, the average number of sexual intercourses and partners increased from 6 ± 12 to 13 ± 17 intercourses/month (p < 0.001) and from 3 ± 11 to 11 ± 34 partners/month (p < 0.001). Similarly, the proportion of PrEP users who engaged in group sex, sex with alcohol or chemsex increased respectively from 28% to 55% (p < 0.001), 28% to 45% (p < 0.001) and 28% to 38% (p < 0.001). Analysis of IDIs revealed emotional deprivation and sexual frustration during the lockdown. After its release, frequent clandestine chemsex parties and curfew forcing overnight stay increased fears of intimate violence and overdoses. In conclusion, PrEP users reduced their sexual activity during the lockdown. Its release led to an increase in sexual risk-taking. Social distancing measures could favour medical and social harm of sexual risk-taking.

Performance and Impact on Antibiotic Prescriptions of a Multiplex PCR in a Real-Life Cohort of Critically Ill Patients with Suspected Ventilated Pneumonia: A Retrospective Monocentric Observational Study

Pulmonary multiplex polymerase chain reaction (m-PCR) allows rapid pathogen detection. We aimed to assess its impact on initial antibiotic prescriptions in ventilated patients with suspected pneumonia. Between November 2020 and March 2022,ventilated patients with suspected pneumonia hospitalized in our ICU who benefited from respiratory sampling simultaneously tested using conventional microbiological methods and m-PCR were included. The proportion of appropriate changes in the initial antibiotic therapy following m-PCR results was assessed. We analyzed 104 clinical samples. Of the 47 negative m-PCR results, 16 (34%) led to an appropriate antibiotic strategy: 8 cessationsand 8 lack of initiation. Of the 57 positive m-PCR results, 51 (89%) resulted in an appropriate antibiotic strategy: 33 initiations, 2 optimizations, and 9 de-escalations. In the multivariate analysis, a positive m-PCR was associated with an appropriate antibiotic change (OR: 96.60; IC95% [9.72; 960.20], p < 0.001). A higher SAPS II score was negatively associated with an appropriate antibiotic change (OR: 0.96; IC95% [0.931; 0.997], p = 0.034). In our cohort, a positive m-PCR allowed for early initiation or adjustment of antibiotic therapy in almost 90% of cases. A negative m-PCR spared antibiotic use in onethird of cases. The impact of m-PCR results was reduced in the most severe patients.

Antibiotic Prescriptions in Critically Ill Patients with Bloodstream Infection Due to ESBL-Producing Enterobacteriaceae: Compliance with the French Guidelines for the Treatment of Infections with Third-Generation Cephalosporin-Resistant Enterobacteriaceae-A Multicentric Retrospective Cohort Study

National and international guidelines were recently published regarding the treatment of Enterobacteriaceae resistant to third-generation cephalosporins infections. We aimed to assess the implementation of the French guidelines in critically ill patients suffering from extended-spectrum β-lactamase-producing Enterobacteriaceae bloodstream infection (ESBL-E BSI). We conducted a retrospective observational cohort study in the ICU of three French hospitals. Patients treated between 2018 and 2022 for ESBL-E BSI were included. The primary assessment criterion was the proportion of adequate empirical carbapenem prescriptions, defined as prescriptions consistent with the French guidelines. Among the 185 included patients, 175 received an empirical anti-biotherapy within 24 h of ESBL-E BSI onset, with a carbapenem for 100 of them. The proportion of carbapenem prescriptions consistent with the guidelines was 81%. Inconsistent prescriptions were due to a lack of prescriptions of a carbapenem, while it was recommended in 25% of cases. The only factor independently associated with adequate empirical carbapenem prescription was ESBL-E colonization (OR: 107.921 [9.303-1251.910], p = 0.0002). The initial empirical anti-biotherapy was found to be appropriate in 83/98 patients (85%) receiving anti-biotherapy in line with the guidelines and in 56/77 (73%) patients receiving inadequate anti-biotherapy (p = 0.06). Our results illustrate the willingness of intensivists to spare carbapenems. Promoting implementation of the guidelines could improve the proportion of initial appropriate anti-biotherapy in critically ill patients with ESBL-E BSI.

HIV pre-exposure prophylaxis (PrEP) knowledge among general practitioners in 2020: A French survey

INTRODUCTION

Since 2017, pre-exposure prophylaxis (PrEP) has been one of the tools in combination HIV prevention strategies. The objective of our questionnaire was to analyze the knowledge and the position of general practitioners in Hauts-de-France on PrEP.

METHOD

This quantitative, observational, cross-sectional study was conducted in 2020 using an anonymous questionnaire sent by post to a sample of 3007 GPs.

RESULTS

Four hundred and forty-four questionnaires (14.8 %) were included. The GPs were predominantly male (n = 253, 57 %) with a median age of 47 years. The median interest shown by respondents was 7/10. One hundred and sixty participating GPs (36%) were aware of the principles of PrEP, one hundred and sixty were only aware of the title (36%) and 124 (28%) showed no awareness at all. Out of the 160 GPs who knew about PrEP, 72 % considered it effective, 30 % knew about it from a patient and 34 % declared having at least one patient using PrEP. GPs who knew about PrEP were more likely to: have graduated less than 10 years before, having seen in consultation men who have sex with men (MSMs) and, lastly; using screening practices for sexually transmitted infections that were better aligned with the recommendations than those who reported not knowing about PrEP.

CONCLUSION

Although PrEP remains insufficiently known to GPs, many expressed eagerness to be involved. The training of health professionals and the highlighting of GPs' role in prevention could help to optimize the fight against HIV.

Transient viral exposure drives functionally-coordinated humoral immune responses in HIV-1 post-treatment controllers

HIV-1 post-treatment controllers are rare individuals controlling HIV-1 infection for years after antiretroviral therapy interruption. Identification of immune correlates of control in post-treatment controllers could aid in designing effective HIV-1 vaccine and remission strategies. Here, we perform comprehensive immunoprofiling of the humoral response to HIV-1 in long-term post-treatment controllers. Global multivariate analyses combining clinico-virological and humoral immune data reveal distinct profiles in post-treatment controllers experiencing transient viremic episodes off therapy compared to those stably aviremic. Virally-exposed post-treatment controllers display stronger HIV-1 humoral responses, and develop more frequently Env-specific memory B cells and cross-neutralizing antibodies. Both are linked to short viremic exposures, which are also accompanied by an increase in blood atypical memory B cells and activated subsets of circulating follicular helper T cells. Still, most humoral immune variables only correlate with Th2-like circulating follicular helper T cells. Thus, post-treatment controllers form a heterogeneous group with two distinct viral behaviours and associated immune signatures. Post-treatment controllers stably aviremic present “silent” humoral profiles, while those virally-exposed develop functionally robust HIV-specific B-cell and antibody responses, which may participate in controlling infection.

A highly virulent variant of HIV-1 circulating in the Netherlands

We discovered a highly virulent variant of subtype-B HIV-1 in the Netherlands. One hundred nine individuals with this variant had a 0.54 to 0.74 log₁₀ increase (i.e., a ~3.5-fold to 5.5-fold increase) in viral load compared with, and exhibited CD4 cell decline twice as fast as, 6604 individuals with other subtype-B strains. Without treatment, advanced HIV-CD4 cell counts below 350 cells per cubic millimeter, with long-term clinical consequences-is expected to be reached, on average, 9 months after diagnosis for individuals in their thirties with this variant. Age, sex, suspected mode of transmission, and place of birth for the aforementioned 109 individuals were typical for HIV-positive people in the Netherlands, which suggests that the increased virulence is attributable to the viral strain. Genetic sequence analysis suggests that this variant arose in the 1990s from de novo mutation, not recombination, with increased transmissibility and an unfamiliar molecular mechanism of virulence.

History of COVID-19 Symptoms and Seroprevalence of SARS-CoV-2 Antibodies in HIV-Infected Patients in Northern France after the First Wave of the Pandemic

To assess the prevalence of COVID-19 in people living with HIV (PLWHIV), we performed an epidemiological survey from 1 April through 1 August 2020 in an HIV reference center in Northern France. PLWHIV completed a questionnaire about risk exposures and symptoms consistent with COVID-19 and performed a SARS-CoV-2 serology. Among the 600 PLWHIV included, 16 have been infected with SARS-CoV-2. Symptoms consistent with COVID-19 were frequent both in SARS-CoV-2 positive and negative patients (67% vs. 32%, p = 0.02). Among SARS-CoV-2 infected patients, one (6%) has been hospitalized and five (31%) have been asymptomatic. Close contact with a confirmed COVID-19 case was the only factor associated with COVID-19 acquisition (40% vs. 13%, p = 0.01). The prevalence of COVID-19 in PLWHIV was 2.5%, half of the overall population estimate after the first wave of the pandemic in France. In conclusion, proportion of asymptomatic COVID-19 was high in PLWHIV. The prevalence of COVID-19 in PLWHIV was two times lower than in the general population.

Assessment of intra-sample variability in HIV-1 DNA drug resistance genotyping

BACKGROUND AND OBJECTIVES

HIV-1 drug resistance testing can be performed in proviral DNA. The non-homogenous distribution of viral variants in cells can impact the performance of this method. We assessed the variability of HIV-1 DNA genotyping results in the same blood sample using a next-generation sequencing (NGS) method.

METHODS

For each included patient, a blood sample from a single venipuncture was split into five 1 mL aliquots, which were independently tested in the same run. HIV-1 DNA was quantified in blood samples using real-time PCR, and NGS was performed with the Sentosa platform combined with the Sentosa SQ HIV genotyping Assay.

RESULTS

A total of 60 aliquots from 12 samples (12 patients) were tested. The median age was 45.50 years old, and all patients were treated with antiretrovirals. A significant variability can sometimes be observed in HIV-1 DNA quantification between aliquots from the same sample, with a coefficient of variation ranging from 23% to 89%. The analysis of resistance-associated mutations (RAMs) with a 20% cut-off found some discordances in RAMs profile between aliquots from the same sample for 5, 3 and 3 patients in the reverse transcriptase, protease and integrase genes, respectively. The analysis with a lower cut-off (10%) showed additional mutations, but did not improve the intra-sample concordance.

CONCLUSIONS

There is an intra-sample variability in HIV-1 DNA resistance test results, and repetition may sometimes bring additional information, but the extent of its clinical impact still requires further investigation.

Évaluation de l’impact de la pandémie de la COVID-19 chez les patients vivants avec le VIH

Introduction

Le SARS-CoV-2, est apparu en Chine fin décembre 2019, pour se répandre dans le monde et en France en 2020. Pour faire face à cette pandémie, des mesures sanitaires de confinement national ont été appliquées en France, un premier confinement de mars à mai 2020, le second d’octobre à novembre 2020 et un troisième débuté en mars 2021. Cette pandémie et les mesures de confinement peuvent avoir un impact sur les patients ayant une pathologie chronique dont les patients vivants avec le VIH (PVVIH). Les objectifs de cette étude étaient de déterminer la prévalence déclarée de l’infection à SARS-CoV-2 dans une cohorte de PVVIH et d’évaluer l’impact de la pandémie et des mesures sanitaires sur leur suivi et leur prise en charge médicale.

Matériels et méthodes

Il s’agit d’une étude prospective, interventionnelle, multicentrique. Depuis le mois de janvier 2021, les PVVIH suivis dans 3 centres hospitaliers et disposant d’une adresse email dans leur dossier médical NADIS® ont été invités à compléter tous les mois un questionnaire en ligne (plateforme Limesurvey®). Ce questionnaire comporte des données socioprofessionnelles et médicales concernant la COVID-19 et leur suivi habituel. Les sérologies SARS-CoV-2 ont été proposées aux patients se rendant dans les centres dans le cadre de leur suivi.

Résultats

Au total, 421 PVVIH sur 1426 ont répondu au questionnaire. À la date du 26 mars 2021, la prévalence d’infection à SARS-CoV-2 était de 5,5 %. Sur les 23 PVVIH infectés, 12 ont été confirmés par PCR, 9 par sérologie et 3 (0,7 %) ont été hospitalisés. Cependant, 51 PVVIH (12,1 %) déclaraient avoir ressenti des signes d’infection à SARS-CoV-2.

Lors du premier confinement national, 96 PVVIH (22,8 %) ont poursuivi une activité professionnelle présentielle totale et/ou partielle ; 17 PVVIH (4 %) ont exprimé une difficulté à accéder et poursuivre leur traitement antirétroviral et 87 (20 %) n’ont pas pu bénéficier de leur consultation de suivi du VIH. Durant le deuxième confinement, 176 PVVIH (41,8 %) ont poursuivi une activité professionnelle présentielle totale et/ou partielle. Ils étaient 9 patients (2,1 %) à avoir présenté des difficultés d’accès à leur traitement et 32 (7,6 %) à ne pas avoir pu bénéficier de leur consultation de suivi.

Conclusion

Dans cette étude, la prévalence de COVID-19 chez les PVVIH est similaire à celle de la population générale française évaluée entre 3 à 7 % sur la même période. Un impact des mesures sanitaires est démontré sur le suivi et la prise en charge des PVVIH, surtout lors du premier confinement national, plus strict que le second et probablement aussi en raison de la nécessité d’une réorganisation des services pour les accompagner au mieux.

L’étude est toujours en cours et sera poursuivie jusqu’au 30/06/2022. Elle nous permettra d’évaluer l’évolution de la prévalence de la COVID-19 chez ces PVVIH mais aussi d’évaluer l’impact des modifications de l’organisation des services hospitaliers réalisées dans l’objectif d’optimiser la prise en charge des PVVIH en période de crise sanitaire.

Le fardeau de la COVID-19 chez les personnes vivant avec le VIH après la première vague de la pandémie

Introduction

Un nouveau coronavirus, le SARS-CoV-2 est apparu à Wuhan en Chine fin décembre 2019. Il est responsable d’infections respiratoires, pouvant mener à un syndrome de détresse respiratoire aigu (SDRA) et au décès. Ce virus s’est rapidement répandu dans le monde. En France, les premiers cas ont été diagnostiqués fin janvier 2020. Un confinement national a été mis en place de mars à avril 2020 pour tenter de contenir l’épidémie. L’objectif de notre étude était de déterminer le poids de la COVID-19 chez les personnes vivant avec le VIH (PVVIH) après la première vague de la pandémie.

Matériels et méthodes

Nous avons réalisé une enquête épidémiologique du 1^er avril au 1^er août 2020 dans un centre de référence pour la prise en charge des PVVIH. Lors de leur première visite de suivi après la levée du confinement, les PVVIH ont rempli un questionnaire sur les facteurs d’exposition et les symptômes compatibles avec la COVID-19. Une sérologie SRAS-CoV-2 était prélevée lors de la consultation. La prévalence, l’incidence et les facteurs de risque de la COVID-19 chez les PVVIH ont été déterminés.

Résultats

Six cent PVVIH ont été inclus. Une infection à SARS-CoV-2 était confirmée chez 16 d’entre eux. Les symptômes compatibles avec la COVID-19 étaient fréquents chez les PVVIH en présence ou non d’une infection confirmée à SARS-CoV-2 (67 % vs 32 %, p = 0,02). Parmi les PVVIH ayant présenté une infection à SARS-CoV-2 confirmée, une (6 %) a été hospitalisée, 5 (31 %) sont restées asymptomatiques. Il n’y avait pas de différence concernant l’âge, le sexe, les comorbidités associés, et les variables liées à l’infection par le VIH entre les PVVIH ayant ou non contracté la COVID-19. Seul un contact rapproché avec une personne infectée par le SARS-CoV-2 était associé à l’acquisition de la COVID-19 (40 % vs 13 %, p = 0,01). La prévalence de la COVID-19 chez les PVVIH était de 2,5 %, la moitié de celle observée dans la population générale après la première vague de la pandémie en France. L’incidence était estimée à 0,16 pour 100 patients/semaine.

Conclusion

La prévalence de la COVID-19 chez les PVVIH était 2 fois moindre que celle observée dans la population générale. Seul un contact rapproché avec une personne infectée par le SARS-CoV-2 était associé à l’acquisition de la COVID-19. La proportion d’infections à SARS-CoV-2 asymptomatiques était élevée chez les PVVIH.

Microelimination or Not? The Changing Epidemiology of Human Immunodeficiency Virus-Hepatitis C Virus Coinfection in France 2012–2018

Background

The arrival of highly effective, well-tolerated, direct-acting antiviral agents (DAA) led to a dramatic decrease in hepatitis C virus (HCV) prevalence. Human immunodeficiency virus (HIV)-HCV–coinfected patients are deemed a priority population for HCV elimination, while a rise in recently acquired HCV infections in men who have sex with men (MSM) has been described. We describe the variations in HIV-HCV epidemiology in the French Dat’AIDS cohort.

Methods

This was a retrospective analysis of a prospective cohort of persons living with HIV (PLWH) from 2012 to 2018. We determined HCV prevalence, HCV incidence, proportion of viremic patients, treatment uptake, and mortality rate in the full cohort and by HIV risk factors.

Results

From 2012 to 2018, 50 861 PLWH with a known HCV status were followed up. During the period, HCV prevalence decreased from 15.4% to 13.5%. HCV prevalence among new HIV cases increased from 1.9% to 3.5% in MSM but remained stable in other groups. Recently acquired HCV incidence increased from 0.36/100 person-years to 1.25/100 person-years in MSM. The proportion of viremic patients decreased from 67.0% to 8.9%. MSM became the first group of viremic patients in 2018 (37.9%). Recently acquired hepatitis represented 59.2% of viremic MSM in 2018. DAA treatment uptake increased from 11.4% to 61.5%. More treatments were initiated in MSM in 2018 (41.2%) than in intravenous drug users (35.6%). In MSM, treatment at the acute phase represented 30.0% of treatments in 2018.

Conclusions

A major shift in HCV epidemiology was observed in PLWH in France from 2012 to 2018, leading to a unique situation in which the major group of HCV transmission in 2018 was MSM.

Clinical Trials Registration. NCT02898987.

Accuracy of endobronchial ultrasound-guided transbronchial needle aspiration in HIV-infected patients with thoracic lymphadenopathy in a tuberculosis low-burden area

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an innovative technique to explore hilar and mediastinal lymphadenopathy. We aimed to assess its diagnostic accuracy in HIV-infected patients in a tuberculosis low-burden area. A retrospective review was performed of all HIV-infected patients with thoracic lymphadenopathy referred for EBUS-TBNA between January 2012 and January 2019 in 3 Northern French Hospitals. A total of 15 patients was included during the study period. Our patients were predominantly male (80%), with a mean age of 50 ± 11 years. Six patients (43%) had a CD4 cells count of less than 200/mm³. Eleven patients (73%) were receiving antiretroviral therapy, and 7 (47%) reached undetectable viral load. Adequate lymphnode sampling was accomplished in all patients. No serious complications were reported. EBUS-TBNA led to a definitive diagnosis in 12 out of 15 patients (80%). It identified 4 neoplasia, 3 atypical mycobacterial diseases, 2 tuberculosis, 1 Castleman disease, 1 sarcoidosis, and 1 professional dustiness. In 3 cases, sampling revealed normal lymphoid tissue. Active surveillance confirmed the suspected diagnosis of HIV adenitis with regression of lymphadenopathy on antiretroviral therapy in 2 cases. In one case of negative sampling, thoracoscopy led to the diagnosis of tuberculosis. In our cohort, accuracy of EBUS-TBNA was 92%. EBUS-TBNA appeared to be a safe and accurate tool in the investigation of mediastinal lymphadenopathy in HIV-infected patients in settings of tuberculosis low-prevalence. It can avoid more invasive procedures such as mediastinoscopy.

Trajectories of Hospitalization in COVID-19 Patients: An Observational Study in France

Describing the characteristics of COVID-19 patients in the hospital is of importance to assist in the management of hospital capacity in the future. Here, we analyze the trajectories of 1321 patients admitted to hospitals in northern and eastern France. We found that the time from onset to hospitalization decreased with age, from 7.3 days in the 20-65 year-olds to 4.5 in the >80 year-olds (p < 0.0001). Overall, the length of stay in the hospital was 15.9 days, and the death rate was 20%. One patient out of four was admitted to the intensive care unit (ICU) for approximately one month. The characteristics of trajectories changed with age: fewer older patients were admitted to the ICU and the death rate was larger in the elderly. Admission shortly after onset was associated with increased mortality (odds-ratio (OR) = 1.8, Confidence Interval (CI) 95% [1.3, 2.6]) as well as male sex (OR = 2.1, CI 95% [1.5, 2.9]). Time from admission within the hospital to the transfer to ICU was short. The age- and sex-adjusted mortality rate decreased over the course of the epidemic, suggesting improvement in care over time. In the SARS-CoV-2 epidemic, the urgent need for ICU at admission and the prolonged length of stay in ICU are a challenge for bed management and organization of care.

Addition of Maraviroc Versus Placebo to Standard Antiretroviral Therapy for Initial Treatment of Advanced HIV Infection: A Randomized Trial

BACKGROUND

Patients diagnosed with advanced HIV infection have a poor prognosis despite initiation of combined antiretroviral therapy (c-ART).

OBJECTIVE

To assess the benefit of adding maraviroc, an antiretroviral drug with immunologic effects, to standard c-ART for patients with advanced disease at HIV diagnosis.

DESIGN

Randomized controlled trial. (ClinicalTrials.gov: NCT01348308).

SETTING

Clinical sites in France (n = 25), Italy (n = 5), and Spain (n = 20).

PARTICIPANTS

416 HIV-positive, antiretroviral-naive adults with CD4 counts less than 0.200 × 109 cells/L and/or a previous AIDS-defining event (ADE).

INTERVENTION

C-ART plus placebo or maraviroc (300 mg twice daily with dose modification) for 72 weeks.

MEASUREMENTS

The primary end point was first occurrence of severe morbidity (new ADE, selected serious infections, serious non-ADE, immune reconstitution inflammatory syndrome, or death). Prespecified secondary outcomes included primary outcome components, biological and pharmacokinetic measures, and adverse events graded 2 or higher.

RESULTS

409 randomly assigned participants (207 in the placebo group and 202 in the maraviroc group) who received more than 1 dose were included in the analysis. During 72 weeks of follow-up, incidence of severe morbidity was 11.1 per 100 person-years in the maraviroc group and 11.2 per 100 person-years in the placebo group (hazard ratio, 0.97 [95% CI, 0.57 to 1.67]). Incidence of adverse events graded 2 or higher was 36.1 versus 41.5 per 100 person-years (incidence rate ratio, 0.87 [CI, 0.65 to 1.15]).

LIMITATIONS

Sixty-four participants discontinued therapy during follow-up. The study was not designed to evaluate time-dependent outcomes or effect modification.

CONCLUSION

Addition of maraviroc to standard c-ART does not improve clinical outcomes of patients initiating therapy for advanced HIV infection.

PRIMARY FUNDING SOURCE

INSERM-ANRS (French National Agency for Research on AIDS).

Virological Outcome After Choice of Antiretroviral Regimen Guided by Proviral HIV-1 DNA Genotyping in a Real-Life Cohort of HIV-Infected Patients

Issues have been raised concerning clinical relevance of HIV-1 proviral DNA genotypic resistance test (DNA GRT). To assess impact of DNA GRT on choice of antiretroviral therapy (ART) and subsequent virological outcome, we retrospectively reviewed decision-making and viral load (VL) evolution following DNA GRT performed in our center between January 2012 and December 2017, except those prescribed within the framework of a clinical trial. A total of 304 DNA GRTs were included, 185 (62%) performed in a context of virological success. Only 34% of tests were followed by ART change, more frequently in situation of virological success (39% vs. 26%, p = 0.02). In this situation, ART change guided by DNA GRT led to VL >20 copies/mL after 6 months in 5% of cases. In multivariate analysis, higher HIV DNA quantification (p = 0.01) was associated with occurrence of viremia. A higher nadir of CD4 count (p = 0.04) and a longer time with VL <20 copies/mL (p = 0.04) were independently associated with a lower risk of viremia. In situation of low-level viremia, ART change guided by DNA GRT led to VL <20 copies/mL after 6 months in 52% of cases, while decision to maintain the same treatment led to VL <20 copies/mL in 74% of cases. In multivariate analysis, longer time with VL >20 copies/mL (p = 0.02) was associated with persistence of virological replication. In conclusion, in situation of virological success, use of DNA GRT in addition to analysis of historical RNA GRT to guide ART optimization appears safe. Its prescription framework in situation of low-level viremia deserves to be better defined.

Routine drug resistance testing in HIV-1 proviral DNA, using an automated next- generation sequencing assay

BACKGROUND

HIV-1 DNA genotypic drug resistance testing is increasingly performed to guide treatment switching or simplification in controlled patients. The Sentosa NGS platform is a fully automated system marketed for drug resistance testing on HIV-1 RNA samples.

OBJECTIVES

The aim of this study was to evaluate this automated NGS solution for routine resistance genotypic resistance testing in proviral HIV-1 DNA.

STUDY DESIGN

Sanger sequencing (SS) of the reverse transcriptase (RT), protease (PR) and integrase (IN) genes was performed using the French ANRS protocol. NGS was performed retrospectively on frozen samples, using the Sentosa platform combined with the Sentosa SQ HIV genotyping Assay.

RESULTS

A total of 77 samples were run once using NGS. A successful sequencing of the three HIV-1 genes (RT, PR, IN) was obtained for 45 samples. The number of cumulated RAMs was 179, 185 and 219 with SS, NGS 20% and NGS 10% respectively; however most of them were minor mutations in the PR region. The mutation detection rate was similar between SS and NGS 20%. Several discordances were observed between both methods in the RT and PR regions, mainly due to the use of different DNA extracts, and hypermutation.

CONCLUSIONS

HIV-1 DNA genotypic resistance testing can be performed with the Sentosa platform. Few technical optimizations are still needed to include the extraction step and to improve the sequencing efficiency.

Routine drug resistance testing in proviral HIV-1 DNA: Prevalence of stop codons and hypermutation, and associated factors

We investigated the presence of stop codons (SC) and/or hypermutation (HM) in HIV-1 DNA sequences generated for routine drug resistance testing in proviral HIV-1 DNA, and sought for associated factors. At least one SC was identified in 6.2% of HIV-1 DNA sequences, among which 54.8% were hypermutated. The defective virus group (SC w/o HM) was similar to the non-SC group regarding the characteristics of HIV-1 infection, and before drug exposure. In addition, the HIV-1 DNA levels were not different between both groups. Sequences with SC/HM displayed a higher proportion of RAMs. The impact of the SC/HM associated RAMs on clinical responses requires further investigation.

Factors of loss to follow-up during tuberculosis treatment in a low-incidence region

OBJECTIVE

The proportion of successfully treated tuberculosis (TB) patients remains below the WHO target in France, because of a high proportion of loss to follow-up. We aimed to identify factors associated with loss to follow-up in northern France, a low-incidence area.

METHODS

Between 1997 and 2017, all consecutive patients diagnosed with TB at the Tourcoing Hospital, except those infected with multidrug-resistant or extensively drug-resistant strains, were included in a retrospective cohort study. A logistic regression analysis was performed to determine factors associated with loss to follow-up.

RESULTS

One hundred and ninety patients were included. Previous TB treatment was reported in 32 patients (17%), extrapulmonary TB in 107 (56%), and HIV infection in 44 (23%). The proportion of loss to follow-up was 15%. In multivariate analysis, the risk of loss to follow-up decreased in case of first TB treatment (OR 0.36; 95% CI: 0.14-0.92, P=0.03) and increased in non-HIV-infected patients (OR 7.67; 95% CI: 1.00-59.0, p=0.05). Support for compliance was more frequent in HIV-infected patients (23% vs. 7%, p=0.005).

CONCLUSION

The proportion of loss to follow-up was high. HIV infection was associated with a lower risk of loss to follow-up, likely to be due to more frequent support for compliance.

Mycobacterium mucogenicum bacteremia: major role of clinical microbiologists

Introduction

Mycobacterium mucogenicum is a rare but emerging cause of infections, especially in immunocompromised patients.

Case presentation

We describe a new case of M. mucogenicum catheter-related bloodstream infection in a 34-year-old woman with ovarian cancer. M. mucogenicum was at first considered as a contaminant, and susceptibility testing was not performed. Usual susceptibility of M. mucogenicum motivated prescription of clarithromycin and moxifloxacin. Finally, our isolate was confirmed susceptible to both drugs. Clinical outcome was favorable with no relapse of infection after antibiotics discontinuation despite concomitant chemotherapy.

Conclusion

Our case illustrates the need for a clinician-microbiologist dialogue in case of suspected M. mucogenicum infection to avoid delaying appropriate management.

Direct-acting antiviral treatment against hepatitis C virus infection in HIV-Infected patients - "En route for eradication"?

OBJECTIVES

Direct-Acting Antivirals (DAAs) opened a new era in HCV treatment. We report the impact of HCV treatment in French HIV-HCV coinfected patients.

METHODS

All HIV-HCV patients from the Dat'AIDS cohort followed between 2012 and 2015 were included. HCV status was defined yearly as naive, spontaneous cure, sustained virological response (SVR12), failure or reinfection.

RESULTS

Among 32,945 HIV-infected patients, 15.2% were positive for anti-HCV antibodies. From 2012 to 2015, HCV incidence rate increased from 0.35%PY to 0.69%PY in MSM, while median incidence was 0.08%PY in other patients. Median reinfection rate was 2.56%PY in MSM and 0.22%PY in other patients. HCV treatment initiation rate rose from 8.2% in 2012 to 29.6% (48.0% in pre-treated patients vs 22.6% in naïve patients). SVR12 rate increased from 68.7% to 95.2%. By the end of 2015, 62.7% of the patients were cured either spontaneously or following SVR.

CONCLUSIONS

HCV treatment dramatically increased in HIV-HCV patients in France from 2012 to 2015 resulting in HCV cure in nearly two-thirds of the patients in this cohort. Combined with a declining HCV prevalence, the prevalence of active HCV infection among HIV patients will drastically decrease in the forthcoming years.

Comparison of terminal extubation and terminal weaning as mechanical ventilation withdrawal in ICU patients

BACKGROUND

Terminal extubation (TE) is applied in some Intensive Care Units (ICU) patients when a decision of withdrawal of mechanical ventilation is decided. Other units prefer terminal weaning (TW) with no removal of the endotracheal tube. We report our experience with these two procedures.

METHODS

We conducted a retrospective study analyzing patients deceased in our ICU after a decision of life sustained therapy (LST) during the year 2013. TE was proposed to family members for patients presenting with two medical conditions: lack of vasoactive drugs (VAD) and SaO2>95% with a FIO2<50%. TW, defined by the reduction of oxygenation and/or the discontinuation of VAD, was proposed for patients receiving a FIO2≥50% and/or VAD. The two procedures were performed after obtaining a Cambridge Score-5 with sedatives.

RESULTS

Sixty eight patients died after withdrawal of LST. TE was performed for 22 patients and TW for 46. There was no difference in mean age, mean length of ICU stay, cause of ICU admission and dose of sedatives used during withdrawal procedure between the two groups. All family members approved the decision of TE. In this group, family members of each patient were present in ICU room at time of death, while they were present at this moment for 32 (69.5%) patients with TW.

CONCLUSIONS

In our Unit, TE is a practice largely approved by family members. This procedure does not require higher doses of sedatives and allows the nearest relatives to be present at time of death.

Community acquired fungemia caused by Candida pulcherrima: diagnostic contribution of MALDI-TOF mass spectrometry

BACKGROUND

Community-onset candidemia constitute a distinct clinical entity the incidence of which is increasing. Contribution of non-albicans Candida species is rising.

CASE PRESENTATION

We describe here the first reported case of community acquired fungemia due to Candida pulcherrima. Identification to the species level was performed by MALDI-TOF mass spectrometry. Treatment with fluconazole was successful.

CONCLUSION

This case confirms the pathogenic role of C. pulcherrima and the contribution of MALDI-TOF mass spectrometry for identification of rare Candida species.

Complications following intravesical bacillus Calmette-Guerin treatment for bladder cancer: a case series of 22 patients

BACKGROUND

Intravesical bacillus Calmette-Guerin (BCG) therapy is an effective and widely used treatment for superficial bladder carcinoma. Local complications are frequent whereas systemic complications are rare but can be serious, and their management is not well known.

METHODS

We describe retrospectively the records of 22 patients treated in 3 infectious disease departments, for complications related to intravesical BCG therapy as treatment of bladder cancer.

RESULTS

All the patients were male, with a median age of 68 years (range 56-88). Complications occurred after a median of 5 instillations (range 1-11) and were observed within 24 h following BCG instillation for 14 patients. Common symptoms were fever (n = 20), impaired general condition (n = 14), and shortness of breath (n = 7). Six patients had a systemic septic reaction leading to transfer into the intensive care unit for five of them. Lung infiltration was the most frequent presentation (n = 11). Mycobacterium bovis was isolated from only two patients, but histology showed the presence of a granuloma in nine patients. Antimycobacterial treatment was initialized in 17 patients; the outcome was favorable in 16 patients, with a median length of symptoms resolution of 22.5 days (range 5-425 days). Eleven patients received corticosteroids in addition to specific treatment and had a more rapid improvement. One patient died with disseminated BCGitis proved by biopsy.

CONCLUSIONS

Complications following intravesical BCG therapy are rare but can be severe and fatal. Histology seems to be the method that contributes most in confirmation of the diagnosis. Antimycobacterial therapy is effective, and probably more efficient when combined with corticosteroids, but the regimen and duration of the treatment are not standardized.

Rapid containment of coincident outbreaks with 2 carbapenem-resistant Klebsiella pneumoniae strains in an intensive care unit

In our intensive care unit, coincident outbreaks were caused by concomitant cross-transmission of 2 carbapenem-resistant Klebsiella pneumoniae strains harboring distinct mechanisms of resistance. One strain produced extended-spectrum ß-lactamase in combination with reduced permeability. The other produced oxacillinase-48 carbapenemase. Rapid phenotypic detection of carbapenemase production allowed timely implementation of appropriate infection control measures.

Tropical infection after a case of total hip arthroplasty

In non-endemic areas, malaria is mainly an imported disease. This article reports a case of transfusion-related Plasmodium falciparum malaria in a non-endemic area. Despite initial clinical signs consistent with malaria, the diagnosis was not elicited because of the absence of any identified epidemiological risk factors. The case indicates that transfusion-transmitted malaria still occurs in non-endemic countries. The role of laboratory testing to prevent and diagnose transfusion-transmitted malaria in non-endemic malaria countries is crucial.

Management and control of a carbapenem-resistant Acinetobacter baumannii outbreak in an intensive care unit

OBJECTIVE

We had for aim to describe the identification and management of a 14-clonal carbapenem-resistant Acinetobacter baumannii (CRAB) outbreak, following admission of a known CRAB-infected patient in an ICU.

METHODS

We reviewed the carriers' files and outbreak management procedures.

RESULTS

The index patient was admitted with strict isolation precautions. The outbreak started 2 months after his discharge. It persisted despite reinforcement of strict isolation precautions, staff and patient cohorting, and extensive environmental decontamination including 2 rounds of routine terminal cleaning and disinfection or 1 round of cleaning and disinfection followed by hydrogen peroxide treatment. A second epidemic peak, after 4 weeks without any case, led to another wide environmental sampling and decontamination rounds. The source of the CRAB outbreak was suspected to be the blood pressure cuffs Velcro. Switching to cuffs submersible in a disinfectant stopped the outbreak.

CONCLUSIONS

CRAB outbreaks are difficult to manage and sources of persistent colonization can be unexpected.

Intra-abdominal aortic graft infection: prognostic factors associated with in-hospital mortality

BACKGROUND

Mortality associated with aortic graft infection is considerable. The gold standard for surgical treatment remains explantation of the graft. However, prognostic factors associated with early mortality due to this surgical procedure are not well-known.

METHODS

Retrospective analysis of patients admitted in our center between January 2006 and October 2011 for aortic graft infection. The primary endpoint was in-hospital mortality. A bivariate analysis of characteristics of patients associated with in-hospital outcome was performed.

RESULTS

Twenty five evaluable patients were studied. All patients were male. Their mean age was 67 ± 8.4 years. Most of them (92%) had severe underlying diseases. An in situ prosthetic graft replacement, mainly using cryopreserved arterial allografts, was performed in all patients, excepted one who underwent extra-anatomic bypass. Causative organisms were identified in 23 patients (92%). The in-hospital mortality rate was 48%. Among pre-operative characteristics, age ≥ 70 years, creatinine ≥ 12 mg/L and C reactive protein ≥ 50 mg/L were significantly associated with in-hospital mortality. Hospital mortality rates increased with the number of risk factor present on ICU admission, and were 0%, 14.3%, 85.7% and 100% for 0, 1, 2 and 3 factors, respectively. The only intra-operative factor associated with prognosis was an associated intestinal procedure due to aorto-enteric fistula. SAPS II, SOFA score and occurrence of medical or surgical complications were postoperative characteristics associated with in-hospital mortality.

CONCLUSION

Morbidity and mortality associated with surgical approach of aortic graft infections are considerable. Age and values of creatinine and C Reactive protein on hospital admission appear as the most important determinant of in hospital mortality. They could be taken into account for guiding the surgical strategy.

Clostridium difficile colitis acquired in the intensive care unit: outcome and prognostic factors

PURPOSE

We assessed factors associated with mortality and complicated course in the case of Clostridium difficile infection (CDI) acquired in the intensive care unit (ICU).

METHOD

Retrospective cohort study conducted from 1 January 2002 through 1 January 2012. All patients who acquired CDI in our ICU were included.

RESULTS

Thirty-one patients were included. Twenty patients (65 %) had mild colitis, 8 (25 %) moderate colitis, and 3 (10 %) severe colitis. Initial antibiotherapy was metronidazole (n = 30, 97 %) and vancomycin (n = 1, 3 %). Seventeen patients (55 %) experienced at least one complication: failure of initial treatment (n = 16, 52 %), shock (n = 11, 34 %), need for surgery (n = 1, 3 %) or renal replacement (n = 4, 13 %), or death (n = 8, 26 %). Risk factors of ICU mortality were history of corticosteroids prescription, prolonged ICU stay, low serum albumin level, and high Sequential Organ Failure Assessment (SOFA) score at the time of CDI diagnosis. Factors associated with a complicated course were high Simplified Acute Physiology Score (SAPS II), high SOFA score, and low serum albumin level at the time of CDI onset.

CONCLUSION

Risk factors of poor outcome in patients with CDI acquired in the ICU are different from those in the general population suffering from CDI. The implementation of treatment algorithms taking into account these factors may reduce complication rates in this specific population.

Improvement in process of care and outcome in patients requiring intensive care unit admission for community acquired pneumonia

Background

The present study was performed to assess the prognosis of patients admitted to the intensive care unit (ICU) for community acquired pneumonia (CAP) after implementation of new processes of care.

Methods

Two groups of patients with CAP were admitted to a 16-bed multidisciplinary ICU in an urban teaching hospital during two different periods: the years 1995–2000, corresponding to the historical group; and 2005–2010, corresponding to the intervention group. New therapeutic procedures were implemented during the period 2005–2010. These procedures included a sepsis management bundle derived from the Surviving Sepsis Campaign, use of a third-generation cephalosporin and levofloxacin as the initial empirical antimicrobial regimen, and noninvasive mechanical ventilation following extubation.

Results

A total of 317 patients were studied: 142 (44.8%) during the historical period and 175 (55.2%) during the intervention period. Sequential Organ Failure Assessment scores were higher in patients in the intervention group (7.2 ± 3.7 vs 6.2 ± 2.8; p=0.008). Mortality changed significantly between the two studied periods, decreasing from 43.6% in the historical group to 30.9% in the intervention group (p < 0.02). A restrictive transfusion strategy, use of systematic postextubation noninvasive mechanical ventilation in patients with severe chronic respiratory or cardiac failure patients, less frequent use of dobutamine and/or epinephrine in patients with sepsis or septic shock, and delivery of a third-generation cephalosporin associated with levofloxacin as empirical antimicrobial therapy were independently associated with better outcomes.

Conclusion

Positive outcomes in ICU patients with CAP have significantly increased in our ICU in recent years. Many new interventions have contributed to this improvement.

Clinical spectrum and outcome of critically ill patients suffering from prosthetic joint infections

PURPOSE

To report the clinical characteristics and prognosis of prosthetic joint infections (PJIs) in Intensive care units (ICUs).

METHODS

Forty-one patients consecutively admitted to ICUs for PJIs between January 2004 and June 2011 were included in a retrospective case series.

RESULTS

A majority of patients (73 %) had severe underlying disease. Acute infection affected 26 patients (63 %). Blood cultures were positive in 16 patients (39 %). Staphylococcus species were the most commonly implicated causative organisms (n = 36, 88 %). The surgical strategy was two-stage replacement in 25 cases (61 %). The surgical procedure leading to ICU admission was mainly prosthesis removal with spacer implantation (n = 13, 32 %). Initial antibiotherapy was a broad-spectrum beta-lactam antibiotic combined with a glycopeptide, linezolid, or daptomycin in 26 cases (63 %). Mortality in the ICU was 20 %. In nonsurvivors, diabetes, acute infection, and American Society of Anesthesiologists (ASA) score >3 were more frequent. The distribution of surgical strategies and procedures was not statistically different in survivors and nonsurvivors. The proportion of patients treated with antibiotherapy adjusted according to previous microbiological findings was higher in nonsurvivors (50 vs. 12 %, p = 0.02).

CONCLUSIONS

In our case series of critically ill patients suffering from PJI, factors associated with a poor outcome were diabetes mellitus, ASA score >3, and acute infection. Surgical strategies and surgical procedures had no significant impact on the ICU mortality. Adjustment of initial antibiotherapy according to previous microbiological findings should be made with caution.

Impact of combination therapy with aminoglycosides on the outcome of ICU-acquired bacteraemias

Pharmacodynamic studies report on the rapid bactericidal activity of aminoglycosides, conferring them as being of theoretical interest for bacteraemia treatment. We assessed this issue in a retrospective study of patients with intensive care unit (ICU)-acquired bacteraemias. To determine the impact of aminoglycosides in antimicrobial combination on the outcome of patients with bacteraemia, we performed a monovariate analysis and a logistic regression analysis comparing patients treated with or without aminoglycosides. Forty-eight bacteraemias in 48 patients were included. Eighteen patients received aminoglycosides. Baseline characteristics as well as adaptation and adequation of antibiotherapy did not differ in patients who did or did not receive aminoglycosides. Patients who received aminoglycosides had longer time alive away from the ICU (11.3 ± 8.9 (10 [0–20]) vs. 3.2 ± 6.6 (0 [0–2] days; p = 0.002) and free from mechanical ventilation (12.5 ± 9.3 (14 [0–21] vs. 5.5 ± 9.2 (0 [0–10] days; p = 0.02) on day 28. The ICU mortality was 16% in the aminoglycoside group versus 46% (p = 0.03). In the multivariate analysis, patients treated with aminoglycosides were 6 times less likely to die than those treated without aminoglycosides (confidence interval [CI] = [1.3–28.9]; p = 0.02). Our study supports the hypothesis that combination short-term antibiotherapy with an aminoglycoside for ICU-acquired bacteraemias could increase survival.

Induction of the skin endogenous protective mitochondrial MnSOD by Vitreoscilla filiformis extract

Vitreoscilla filiformis (Vf), a filamentous bacteria living in fresh water is thought to contribute to the observed beneficial effects of Spa water on skin. An active fraction obtained from a Vf biomass was evaluated for its ability to modulate mRNA expression in cultured skin cells. cDNA array analysis was conducted first using a customized membrane including 1176 selected and fully identified genes involved in skin physiology and homeostasis then the newly developed full genome U133 plus 2.0 GeneChip from Affymetrix. The mitochondrial protective manganese superoxide dismutase (MnSOD/SOD-2) was identified as a preferentially induced mRNA target in both normal human dermal fibroblasts and keratinocytes. Induction at the transcriptional level in both cell types was confirmed using quantitative real time/polymerase chain reaction and a kinetic analysis revealed a maximal increase in mRNA expression 20 h after stimulation with Vf extract (Vfe). Using immunofluorescent (fluorescent cell sorter) analysis, an induction of MnSOD protein in both normal human dermal skin fibroblasts (x1.6; P < 0.01) and epidermal keratinocytes (x1.4; P < 0.01) was confirmed. As MnSOD is a major inducible free-radical scavenger in skin, these results suggest that the Vfe could induce skin cells to produce their own endogenous protective defences in vivo against both exogenous environmental stressors such as UV irradiation or microflora as well as to combat endogenous sources of deleterious free radicals involved in skin ageing. Finally, in order to confirm the in vivo potential of this original extract in human, we evaluated its protective activity vs. placebo on the generation of sunburn cells in epidermis under UVB stress. As expected from in vitro profiling, Vfe was indeed found to significantly inhibit the appearance of sunburn cells in UVB-exposed areas, a signature of skin alteration which has been suggested to be linked to a defect in MnSOD protective activity. Altogether, those data suggest that the combination of a suitable protective UV filter together with this bioactive Vfe might improve skin protection through complementary pathways.

Incidence and impact on clinical outcome of infections with piperacillin/tazobactam resistant Escherichia coli in ICU: a retrospective study

BACKGROUND

Escherichia coli infections are frequent in ICU patients. The increased resistance to fluoroquinolones and amoxicillin/clavulanate of this pathogen mandates the prescription of broad-spectrum antibiotics such as piperacillin/tazobactam (PIP-TAZ) or third generation cephalosporins (3GC).

METHODS

To assess incidence and impact on clinical outcome of infections with PIP-TAZ resistant E. coli in ICU patients, we conducted a retrospective cohort study with infections due to PIP-TAZ resistant (PIP-TAZ R) or to PIP-TAZ susceptible strains (PIP-TAZ S) between 1 January 2002 and 30 June 2004.

RESULTS

Of 83 strains, 13 were PIP-TAZ R: 2 strains produced an extended-spectrum beta-lactamase (2%), 11 produced a high level penicillinase (13%). Prior amoxicillin or amoxicillin/clavulanate prescription was reported in 7 cases (54%) of infections with PIP-TAZ R isolates and in 15 cases (21%) of infections with PIP-TAZ S isolates (p = 0.03). Time of onset of the infection from hospital admission was longer in case of infections with PIP-TAZ R than with PIP-TAZ S isolates (22 +/- 32 vs 10 +/- 21 days, p = 0.01). The overall ICU mortality rate was 38%. Mortality and length of stay in ICU were similar in case of infections with PIP-TAZ R isolates and with PIP-TAZ S isolates.

CONCLUSION

Infections with PIP-TAZ R E. coli are frequent in ICU patients. No prognostic impact of this pattern of resistance was found. Prescription of PIP-TAZ for empirical treatment of E. coli infections in ICU however exposes to inappropriate therapy.