Tobacco, alcohol, cannabis, and illicit drug use and their association with CD4/CD8 cell count ratio in people with controlled HIV: a cross-sectional study (ANRS CO3 AQUIVIH-NA-QuAliV)

BACKGROUND

To evaluate drug use (alcohol, tobacco, cannabis and other drugs) and its association with mean CD4/CD8 T cell count ratio, a marker of chronic inflammation, in virally suppressed people living with HIV-1 (PLWH) in Nouvelle Aquitaine, France.

METHODS

A multi-centric, cross-sectional analysis was conducted in 2018-19 in the QuAliV study-ANRS CO3 AQUIVIH-NA cohort. Tobacco, alcohol, cannabis, and other drug use (poppers, cocaine, amphetamines, synthetic cathinones, GHB/GBL) were self-reported. CD4 and CD8 T cell counts and viral load measures, ± 2 years of self-report, and other characteristics were abstracted from medical records. Univariable and multivariable linear regression models, adjusted for age, sex, HIV risk group, time since HIV diagnosis, and other drug use were fit for each drug and most recent CD4/CD8 ratio.

RESULTS

660 PLWH, aged 54.7 ± 11.2, were included. 47.7% [315/660] had a CD4/CD8 ratio of < 1. Their mean CD4/CD8 ratio was 1.1 ± 0.6. 35% smoked; ~ 40% were considered to be hazardous drinkers or have alcohol use disorder; 19.9% used cannabis and 11.9% other drugs. Chemsex-associated drug users' CD4/CD8 ratio was on average 0.226 (95% confidence interval [95% CI] - 0.383, - 0.070) lower than that of non-users in univariable analysis (p = 0.005) and 0.165 lower [95% CI - 0.343, 0.012] in multivariable analysis (p = 0.068).

CONCLUSIONS

Mean differences in CD4/CD8 ratio were not significantly different in tobacco, alcohol and cannabis users compared to non-users. However, Chemsex-associated drug users may represent a population at risk of chronic inflammation, the specific determinants of which merit further investigation.

TRIAL REGISTRATION NUMBER

NCT03296202.

Severe bacterial non-AIDS infections in persons with HIV: the epidemiology and evolution of antibiotic resistance over an 18-year period (2000-2017) in the ANRS CO3 AquiVih-Nouvelle-Aquitaine cohort

BACKGROUND

Severe non-AIDS bacterial infections (SBIs) are one of the leading causes of hospital admissions among persons with HIV (PWH) in regions with high ART coverage.

METHODS

This large prospective cohort study of PWH examined the types of infections, bacterial documentation, and evolution of antibiotic resistance among PWH hospitalized with SBIs over an 18-year period.

RESULTS

Between 2000 and 2017, 459 PWH had at least one SBI with bacterial documentation. Among the 847 SBIs, there were 280 cases of bacteremia, 269 cases of pneumonia, and 240 urinary tract infections. The 1025 isolated bacteria included Enterobacteriaceae (n = 394; mainly Escherichia coli), Staphylococcus aureus (n = 153) and Streptococcus pneumoniae (n = 82). The proportion of S. pneumoniae as the causative agent in pneumonia and bacteremia decreased sharply over time, from 34% to 8% and from 21 to 3%, respectively.The overall antibiotic resistance of S. aureus and S. pneumoniae decreased progressively but it increased for Enterobacteriaceae (from 24% to 48% for amoxicillin-clavulanate, from 4 to 18% for cefotaxime, and from 5% to 27% for ciprofloxacin). Cotrimoxazole prophylaxis was associated with higher nonsusceptibility of S. pneumoniae to amoxicillin and erythromycin, higher nonsusceptibility of Enterobacteriaceae to beta-lactams and fluoroquinolones, and a higher risk of extended-spectrum β-lactamase producing Enterobacteriaceae.

CONCLUSIONS

The bacterial resistance pattern among PWH between 2014 and 2017 was broadly similar to that in the general population, with the exception of a higher resistance profile of Enterobacteriaceae to fluoroquinolones. The use of cotrimoxazole as prophylaxis was associated with an increased risk of antibiotic resistance.

HCV cure: an appropriate moment to reduce cannabis use in people living with HIV? (ANRS CO13 HEPAVIH data)

BACKGROUND

Thanks to direct-acting antivirals, hepatitis C virus (HCV) infection can be cured, with similar rates in HCV-infected and HIV-HCV co-infected patients. HCV cure is likely to foster behavioral changes in psychoactive substance use, which is highly prevalent in people living with HIV (PLWH). Cannabis is one substance that is very commonly used by PLWH, sometimes for therapeutic purposes. We aimed to identify correlates of cannabis use reduction following HCV cure in HIV-HCV co-infected cannabis users and to characterize persons who reduced their use.

METHODS

We used data collected on HCV-cured cannabis users in a cross-sectional survey nested in the ANRS CO13 HEPAVIH cohort of HIV-HCV co-infected patients, to perform logistic regression, with post-HCV cure cannabis reduction as the outcome, and socio-behavioral characteristics as potential correlates. We also characterized the study sample by comparing post-cure substance use behaviors between those who reduced their cannabis use and those who did not.

RESULTS

Among 140 HIV-infected cannabis users, 50 and 5 had reduced and increased their use, respectively, while 85 had not changed their use since HCV cure. Cannabis use reduction was significantly associated with tobacco use reduction, a decrease in fatigue level, paying more attention to one's dietary habits since HCV cure, and pre-HCV cure alcohol abstinence (p = 0.063 for alcohol use reduction).

CONCLUSIONS

Among PLWH using cannabis, post-HCV cure cannabis reduction was associated with tobacco use reduction, improved well-being, and adoption of healthy behaviors. The management of addictive behaviors should therefore be encouraged during HCV treatment.

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.

An Infected Arterial Aneurysm and a Dog Bite: Think at Capnocytophaga canimorsus!

We describe the fourth cases of arterial aneurysm consecutive to Capnocytophaga canimorsus infection in a 77-year-old man. The infection occurred after a dog bite. He presented fever. The thoracic-abdominal computed tomography angiography revealed aneurysms on the abdominal aorta, left common femoral artery, and left popliteal artery. The diagnosis was performed by a blood culture positive for Capnocytophaga canimorsus. The outcome was favorable with surgery and antibiotic therapy.

Experience of ultrasound performed by infectiologists, an innovating approach for the management of patients

INTRODUCTION

Ultrasound imaging has many clinical applications, but there is a lack of data about its use by infectiologists. The aim of this study was to describe ultrasound performed routinely by infectiologists and to assess the diagnostic performance of ultrasound with aspirate and fluid analysis in prosthetic joint infections.

METHODS

Retrospective study between 1^st June 2019 and 1^st June 2020 in an infectious and tropical diseases unit in a tertiary University Hospital.

RESULTS

One hundred and thirty-one ultrasounds were performed on 127 patients by the infectious diseases team. These included 64 musculoskeletal ultrasounds (31 in native joints and 33 in prosthetic joints including 15 knees, 13 hips and 5 spacers) and 33 led to a fluid aspirate. Fourteen lung ultrasounds were done, 11 confirmed pneumopathy and 7 resulted in pleural puncture. Twenty-three vascular ultrasounds were done, 17 to insert a catheter, and four to perform a blood test. Five ultrasounds explored adenopathy, of which one node tuberculosis and one Bartonella infection were diagnosed. In prosthetic joint infections, sensitivity and specificity of ultrasound with fluid aspirate and analysis were respectively 100% and 100% for the knee and 40% and 100% for the hip.

CONCLUSION

Ultrasound performed by infectiologists is useful and contributes to a faster diagnosis. Furthermore, the specificity of ultrasound with aspirate and fluid analysis is very high in prosthetic joint infection. Ultrasound training courses should be considered for infectiologists including residents.

Severe adverse events during medical and surgical treatment of hip and knee prosthetic joint infections

INTRODUCTION

The management of prosthetic joint infection requires a complex treatment procedure and can be associated with complications. However, the occurrence of severe adverse events during this intervention has been poorly evaluated.

PATIENTS AND METHODS

A 5-year multicentric retrospective study including patients from 3 hospitals in the South-Western France referral center for complex bone and joint infections (Crioac GSO) and treated for hip or knee prosthetic joint infection with 1 or 2-stage implant exchanges. The objective was to describe grade≥3 adverse events, according to the CTCAE classification, occurring within 6 weeks after surgery and to identify their associated factors.

RESULTS

One hundred and eighteen patients were identified. We observed 71 severe events in 50 patients (42.3%; 95% confidence interval [CI95%]: 33.8-51.4%). Sixteen severe events were an evolution of the infection. The remaining 55 others (47 grade 3 and 8 grade 4) occurred in 41 patients (34.7%; CI95%: 26.8-43.7%). They were distributed as follows: 27 (49.1%) medical complications, 21 (38.2%) surgical complications and 7 (12.7%) antibiotic-related complications. The main identified risk factor was a two-stage prosthetic exchange with OR=3.6 (CI95% [1.11-11.94], P=0.032). Obesity was limit of significance with OR=3.3 (CI95% [0.9-12.51], P=0.071). Infection with coagulase negative Staphylococcus was a protective factor with OR=0.3 (CI95% [0.12-0.99], P=0.047).

CONCLUSION

Severe adverse events are frequent following prosthetic exchange for PJI (34.7%) and are related to the high frequency of comorbidities in this population and to the complex surgical procedures required. The risk factor significantly associated with these events was a two-stage exchange.

One-stage versus two-stage prosthesis replacement for prosthetic knee infections

INTRODUCTION

Periprosthetic knee infection is a severe complication. Confirmed criteria are lacking to choose between one-stage or two-stage prosthesis replacement to treat the infection. The one-stage replacement could lead to a satisfactory control of the infection and to better functional results.

METHOD

Retrospective study conducted between January 1, 2009 and December 31, 2014. The objectives of this study were to compare the infection outcome and functional results between the one-stage and two-stage replacement procedures. Functional results were evaluated using the IKS score, KOOS score, and SF-12 quality of life score.

RESULTS

Forty-one patients underwent a two-stage replacement procedure and 21 patients a one-stage replacement. The average follow-up was 22 months after surgery. The infection was cured in 78% of patients who underwent a two-stage replacement and 90% of patients who underwent a one-stage replacement (P=0.3). The flexion range of motion was significantly better in the one-stage group than in the two-stage group (P=0.04). Results of the IKS score and of the KOOS score were better in the one-stage group. No difference was observed for the SF-12 score.

CONCLUSION

The one-stage replacement procedure for periprosthetic knee infection was associated with a similar healing frequency as the two-stage replacement procedure, and with better knee function.

Added value of [18F]fluorodeoxyglucose positron emission tomography/computed tomography for the diagnosis of post-operative instrumented spine infection

PURPOSE

Post-operative instrumented spine infection (PISI) is an infrequent complication. Diagnosis of spinal implant infection can be difficult, especially in case of chronic infection.

METHODS

This retrospective study attempts to evaluate the diagnostic performance of [¹⁸F]fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) in PISI. Imagings were performed between April 2010 and June 2018 among patients referred for suspected chronic spinal implant infection. PET/CT were performed more than 12 weeks after surgery. PET/CT images were re-interpreted independently by two nuclear medicine physicians without knowledge of the patient's conditions. PET/CT data were analyzed both visually and semi-quantitatively (SUV_max). MRI results were collected from medical records. The final diagnosis of infection was based on bacteriological cultures or a twelve-month follow-up.

RESULTS

Forty-nine PET/CT were performed in 44 patients (22 women, median age 65.0 years). Twenty-two patients had a diagnosis of infection during follow-up. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for PET/CT were 86.4%, 81.5%, 79.2%, and 88.0%. Sensitivity, specificity, PPV and NPV were 66.7%, 75.0%, 66.0%, 75.0% respectively for MRI and 50.0%, 92.6%, 84.6% and 69.4% for serum C-reactive protein (CRP). Although these values were higher for PET/CT than for MRI or CRP, the differences were not statistically significant. In this setting, false positives with PET/CT can be observed in case of previous spine infection or adjacent segments disc disease. False negatives can result of extensive instrumented arthrodesis or infection with low virulence bacteria.

CONCLUSION

PET/CT is useful for the diagnosis of PISI. These results should be evaluated in further prospective study.

Contribution of a multiplex serological test for the preoperative diagnosis of prosthetic joint infection: a prospective study

BACKGROUND

Prosthetic joint infection (PJI) is a severe complication of orthopaedic surgery. Preoperative diagnosis, although sometimes difficult, is key to choose the relevant treatment.

METHODS

We conducted a prospective study aimed at evaluating the diagnostic performance of a multiplex serological test for the pre-operative diagnosis of PJI. Blood samples were collected between 1 July 2016 and 31 July 2017 among patients referred for suspected PJI that occurred at least six weeks prior. Infection diagnosis was confirmed using intraoperative bacteriological cultures during prosthetic exchange.

RESULTS

Seventy-one patients were included, with a median age of 73 years (interquartile range [IQR]: 66-81) and 40 (56%) were male. Twenty-six patients had aseptic loosening and 45 patients had PJI. Among the latter, median time since the last surgery was 96 weeks (IQR: 20-324). Intraoperative cultures found Staphylococcus spp, Streptococcus spp or both in 39, 5 and 1 patients, respectively. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 81.8, 95.4, 97.3 and 72.4%, respectively, for all patients and 87.5, 93.5, 94.6 and 85.3%, respectively, for staphylococcal infections. Patients with false negative (FN) results had a significantly lower blood lymphocyte count (p = .045).

CONCLUSIONS

Multiplex serological test performed well among patients with chronic staphylococcal prosthetic infection. This approach could contribute to PJI diagnosis especially in patients for whom the pre-operative analysis of joint fluid is not informative.

Tigecycline-based prolonged salvage therapy in patients presenting with complex bone and joint infection

OBJECTIVES

To assess the clinical experience of tigecycline-based salvage therapy in patients presenting with Bone and Joint Infections (BJI).

PATIENTS AND METHODS

Multicenter retrospective cohort study in France and Turkey (2007-2014).

RESULTS

Thirty-six patients (age 58.2±17.8 years; 21 men) were included. The most frequently isolated bacteria were Enterobacteriaceae and staphylococci. Tigecycline (50mg BID, mainly in combination (69.4%), mean duration of 58 days) was indicated for multidrug resistance (90.6%) and/or previous antibiotic intolerance (36.1%), and/or as second- or third-line therapy (69.4%). Six patients (16.7%) experienced early treatment discontinuation for adverse event (4 severe vomiting, 1 pancreatitis, 1 asymptomatic lipase increase). Clinical success was observed in 23 of 30 assessable patients who completed the tigecycline therapy (mean follow-up: 54.1±57.7 weeks).

CONCLUSION

Prolonged tigecycline-based therapy could be an alternative in patients presenting with BJI requiring salvage therapy, especially if multidrug-resistant Enterobacteriaceae and/or staphylococci are involved.

Nontuberculous Mycobacterial Infections in a French Hospital: A 12-Year Retrospective Study

Background

Nontuberculous mycobacteria (NTM) are environmental organisms associated with a range of infections. Reports of NTM epidemiology are mainly focused on pulmonary infections and isolations, and extrapulmonary infections are less frequently described.

Methods

We conducted a retrospective study of NTM infections at the Bordeaux University Hospital, France, between January 2002 and December 2013. We used the microbiologic component of the American Thoracic Society/Infectious Diseases Society of America's pulmonary NTM disease criteria to define cases of pulmonary NTM, and patients with isolates from a normally sterile site were classified as having extrapulmonary disease.

Results

In our setting, 170 patients were included. Pulmonary cases predominated (54.1%), followed by skin and soft tissue infections (22.9%), disseminated cases (10.6%), lymphadenitis (7.7%), bone and joint infections (2.9%) and the remaining 1.8% catheter-related infections. Overall, 16 NTM species were isolated. Mycobacterium avium (31.8%) and M. intracellulare (20%) were the most common species identified, followed by M. marinum (13.5%), M. kansasii (10.6%), M. xenopi (9.4%), rapidly growing mycobacteria (9.4%) and other slowly growing mycobacteria (5.3%). In general, NTM isolates were largely prevalent in people older than 50 (62.4%); patients aged 1–10 year-old exclusively yielded M. avium from lymph nodes, almost cases having being diagnosed after 2007. Among the 121 patients with complete follow-up, 78 (64.5%), 24 (19.8%), and 19 (15.7%) were cured, experienced relapse, or died, respectively.

Conclusion

In our study, extrapulmonary NTM infections represented almost half of cases, consisting mainly in skin and soft tissue infections. The increase lymphadenitis cases in children after 2007 could be linked to the cessation of mandatory BCG vaccination in France. We observed similar cure rates (64%) between pulmonary and extrapulmonary infections.

Efficacy of debridement, antibiotic therapy and implant retention within three months during postoperative instrumented spine infections

BACKGROUND

Postoperative instrumented spine infection (PISI) is a severe complication of invasive spine procedures.

METHODS

Retrospective study of patients treated for PISI between 1st January 2008 and 31st December 2012 in a French University Hospital. The objectives of this study were to describe the outcome of patients treated with debridement-irrigation, antibiotic therapy and implant retention (DAIR) within three months after the occurrence of PISI and to identify factors associated with relapse.

RESULTS

Among 4290 patients who underwent spinal arthrodesis surgery during the 5-year study period, 129 had PISI treated by debridement-irrigation in the first three months (3.0%, 95% confidence interval [95%CI]: 2.5-3.5). Fifty-two (40%) were female and the median age was 57 years. Fourteen patients (10.8%) had diabetes and 73 (56.6%) had a BMI (Body Mass Index) ≥25 kg/m². Staphylocccus aureus, enterobacteria or polymicrobial infections were identified in 44.0, 18.0 and 13.0% of cases, respectively. One hundred and six patients (82.2%) and one hundred and twenty-one patients (93.8%) were cured after one DAIR and after two DAIR, respectively. In multivariate logistic analysis, polymicrobial infection was associated with relapse (Odd Ratio [OR] = 3.81; 95%CI: 1.06-13.66; p = .03), while a BMI ≥25 kg/m² was a protective factor (OR =0.25; 95%CI: 0.07-0.89; p = .03).

CONCLUSION

DAIR may be effective for PISI when performed within the first 3 months after onset of infection. Relapses are significantly associated with polymicrobial infection and negatively associated with moderate overweight. These results need to be confirmed in future prospective studies.

Interest of [(18)F]fluorodeoxyglucose positron emission tomography/computed tomography for the diagnosis of relapse in patients with spinal infection: a prospective study

Relapse after treatment of a spinal infection is infrequent and difficult to diagnose. The aim of this study was to assess the diagnostic performance of [(18)F]fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) in this setting. Thirty patients (21 men, nine women; median age 61.2 years) with a suspected spinal infection relapse were prospectively included between March 2010 and June 2013. The initial diagnosis of spinal infection was confirmed by positive bacterial cultures. The patients underwent [(18)F]FDG PET/CT and magnetic resonance imaging (MRI) 1 month after antibiotic treatment interruption. PET/CT data were interpreted both visually and semi-quantitatively (SUVmax). The patients were followed for ≥12 months and the final diagnosis of relapse was based on new microbiological cultures. Seven patients relapsed during follow up. Sensitivity, specificity, positive predictive value and negative predictive value were 66.6%, 61.9%, 33.3% and 86.6%, respectively for MRI and 85.7, 82.6, 60.0 and 95.0 for PET/CT. Although these values were higher for PET/CT than for MRI, the difference was not statistically significant (p=0.3). [(18)F]FDG PET/CT may be useful for diagnosing a relapse of spinal infections, in particular if metallic implants limit the performance of MRI.

Primary liver abscess due to CC23-K1 virulent clone of Klebsiella pneumoniae in France

Since the mid-1980s, Klebsiella pneumoniae hypermucoviscous isolates have emerged in Taiwan and other Asian countries. We reported the first autochthonous European liver abscess due to an ST57 isolate, which belongs to virulent clonal complex CC23-K1. This case highlights the emergence in France and Europe of hypermucoviscous virulent K. pneumoniae isolates.

Cold Bone Defect on Granulocytes Labelled with Technetium-99m-HMPAO Scintigraphy: Significance and Usefulness for Diagnosis and Follow-up of Osteoarticular Infections

We wished to determine the frequency and significance of cold bone defect on granulocytes labelled with technetium-99-m-hexamethylpropyleneamine oxime (99mTc-HMPAO-PMN) in non-spinal bone infection. Cold bone defect was investigated as part of a retrospective review during a 2-y period. Patients who had possible osteoarticular infection underwent bone scintigraphy combined with 99mTc-HMPAO-PMN for diagnosis and follow-up. Osteomyelitis was confirmed by isolation of the responsible pathogen. Among 210 patients who had possible infection, 17 (8%) demonstrated a cold bone defect. The site of cold bone defect was for all patients the hip. All 17 patients had proven bacterial orthopaedic hardware-related infection. The single causative micro-organism was staphylococcus. Whatever the outcome, cold bone defect was constant regardless of follow-up equal to or longer than 18 months. These data suggest that this uncommon scintigraphic pattern is an indication of an infectious process similar to increased uptake.

Association between psoas abscess and prosthetic hip infection: a case-control study

BACKGROUND AND PURPOSE

The relationship between prosthetic hip infection and a psoas abscess is poorly documented. We determined the frequency of prosthetic hip infections associated with psoas abscesses and identified their determinants.

METHODS

We conducted a 2-year observational study. Data from patients with psoas abscesses that were associated with prosthetic hip infections were examined in a case-control study.

RESULTS

Of 106 patients admitted to the Infectious Diseases Department with prosthetic hip infection, 13 also had a psoas abscess (12%; 95% CI: 6-19). By conditional logistic regression analysis, psoas abscesses were observed more frequently in cases of hematogenous prosthetic infections (OR = 93, p = 0.06) and in patients with a history of neoplasm (OR = 20, p = 0.03).

INTERPRETATION

Our results suggest that the presence of psoas abscesses is a frequent but under-diagnosed complication of prosthetic hip infection. We recommend that an abdominal CT scan be performed on patients with hematogenous prosthetic hip infection or with a history of neoplasm.

[Management of 315neutropenic febrile episodes in a cancer center]

Management of febrile neutropenic patients is described in guidelines. Each cancer center can adapt these according to its local bacterial ecology. We present a retrospective study made in a cancer center from 2001 to 2003.

METHOD

Three hundred and fifteen febrile neutropenic episodes after chemotherapy (66% for solid tumor) were analysed.

RESULTS

For 279 episodes, no antibiotic therapy was given before admission. Clinical or radiological manifestations occurred in 46%; microbiologically documented infections by hemocultures in 28% (Gram positive: 42%; Gram negative: 51%) and by puncture in 14% (Gram negative: 58%). The length of pyrexia was inferior to 7 days in 88% and neutropenia inferior 7 days in 80.8%. 79.7% of episodes were treated with one of the three antibiotic therapy recommended by the center (ceftriaxone+tobramycin; ceftriaxone+ciprofloxacin; ceftriaxone+ofloxacin); 13.3% were treated with an other therapy; 7% received no antibiotic therapy. 68.5% of patients treated with one of the three antibiotic therapies, became afebrile without changing the antibiotic protocol.

CONCLUSION

In our study, there were a majority of Gram negative bacteria except for Pseudomonas aeruginosa. The three antibiotic therapy recommended by the center (third generation cephalosporin+aminoglycosides or fluoroquinolones) were effective and glycopeptide was not necessary in first intention treatment.

99mTc-HMPAO labelled white blood cell scintigraphy in patients with osteoarticular infection: the value of late images for diagnostic accuracy and interobserver reproducibility

The objectives of this study were to evaluate the diagnostic value of 99mTc-HMPAO labelled white blood cell scintigraphy (WBCS) in patients with suspected osteomyelitis using late images and to study interobserver reproducibility. This study prospectively included 120 patients, and after a follow-up of one year, only 70 patients (n = 49 with implants, n = 21 without implants) were selected. The final diagnosis of infection was based either on microbiological data (n = 54) or follow-up (n = 16). We performed WBCS with 4 h and 24 h scans. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 77%, 72%, 83%, 64%, and 75% at 4 h, and 74%, 87%, 91%, 59%, and 79% at 24 h, respectively. The interobserver reproducibility shows a 63% prevalence of agreement between results (kappa = 0.5) at 4 h and 80% (kappa = 0.74) at 24 h, respectively. WBCS with 24-h images improves specificity and interobserver reproducibility in patients with suspected osteoarticular sepsis.

Necrotizing external otitis: a report of 46 cases

OBJECTIVES

To define germs involved, clinical presentation, treatment regimen, and prognostic factors in necrotizing external otitis.

PATIENTS AND METHODS

Retrospective study reviewing a series of 46 patients treated during 10 years in a tertiary care center. Diagnosis was confirmed by using otomicroscopy, computed tomographic and/or magnetic resonance imaging scan and bone scintigraphy (Te 99 and Ga 26 bone scan). Patients were provided ceftazidime and ciprofloxacin intravenously and monitored using a Ga-67 bone scan. The following were assessed: presenting symptoms, general context, bacteriological analysis, imaging protocol sensitivity, complications, delay to healing, and cure rate.

RESULTS

Sex ratio was 2.29 (mean age, 73.6 yr). The most common presenting symptoms were otalgia and otorrhea in 97.8 and 91.3%, respectively. Facial paralysis was present in 19.6% of cases. Thirty patients had diabetes mellitus (65.2%), and 8 were immunocompromised (17.4%). Pseudomonas aeruginosa was isolated in 69.2% of cases and was resistant to ciprofloxacin in 18.5%, but was susceptible to ceftazidime in all cases. Four patients died during the treatment (4.4%), but only 2 of disease. The mean delay to healing was 14 weeks (SD, 9.7). Healing rate was 95.6%. No relapse was observed after a mean follow-up of 78.4 weeks (SD, 36.5 wks). Two factors significantly influenced the prognosis: facial paralysis and existence of systemic factors for immune deficiency (p = 0.023 and 0.038, respectively).

CONCLUSION

The association of ciprofloxacin and ceftazidime was efficient in countering the increasing resistance of P. aeruginosa to quinolones. We propose a prognostic classification of necrotizing external otitis based on the presence of facial paralysis and/or systemic factors.

Prognostic factors in adult community-acquired bacterial meningitis: a 4-year retrospective study

The aim of this 4-year, observational, single-center study was to identify prognostic factors and evaluate the need for intensive care in cases of bacterial meningitis. During the study period, 60 cases of adult bacterial meningitis were identified. Fifty-one patients were transferred to the intensive care unit at various times during their hospital stay. In the multivariate analysis, factors significantly associated with the need for mechanical ventilation and/or vasopressive drugs included comorbidity and a Glasgow coma score of less than 12 at hour 6 following presentation. The results indicate patients with a decreased level of consciousness, neurological deficit or comorbidity should be admitted to the intensive care unit at an early stage of illness. When patients lack these criteria 6 h following presentation, admission to the medical ward is reasonable.

Drug–drug interactions with systemic antifungals in clinical practice

PURPOSE

We describe drug-drug interactions (DDIs) encountered with antifungals in clinical practice.

METHODS

Retrospective observational study of hospitalized adults receiving systemic antifungal treatment in the intensive care unit (ICU) and in the infectious diseases unit (IDU) of the University Hospital of Bordeaux, France between 1996 and 2001. All treatment episodes with antifungal agent were examined and all prescribed concomitant medication identified for potential drug-drug interactions (PDDI)-serious events occurring during treatment were adjudicated for clinical DDI.

RESULTS

There were 150 treatment episodes with antifungal agent in 105 patients. Fluconazole was used in 48% of the treatment episodes, amphotericin B in 46%, itraconazole in 4.7% and flucytosine in 1.3%. One hundred and sixteen PDDIs were identified related to the use of amphotericin B (81.0%), fluconazole (17.2%) or itraconazole (1.7%). Of these, 22 were associated with a clinical evidence of adverse interaction (hypokalemia, increased creatininemia or nephrotoxicity). All these clinical drug-drug interactions (CDDIs) were with amphotericin B. They were due to furosemide (36.4%), cyclosporine (31.8%) and hydrocortisone (18.2%). PDDIs were mostly associated with leukaemia (40.4%), HIV infection (24.6%) and cancer (10.5%).

CONCLUSIONS

In ICU and IDU, systemic antifungal treatments lead to many PDDIs, mainly related to the type of antifungal used and to the pathology treated. Clinical DDI seem more common with amphotericin.

Tolérance et efficacité d’une entretoise articulée dans les reprises en deux temps de prothèses de genou infectées

PURPOSE OF THE STUDY

Two-stage reimplantation remains the most popular solution for infected total knee arthroplasty. We have used articulated spacers since their introduction in 2000. We evaluated tolerance, joint motion under general anesthesia before reimplantation and also the infectious and functional long-term outcome.

MATERIAL AND METHODS

Between June 2000 and April 2003, we implanted an articulated spacer in 28 patients who required revision of their total knee arthroplasty. Postoperatively, contact weight bearing was allowed with unlimited knee motion depending on pain control. Mean time between implant removal and reimplantation was eight weeks (range 6-16 weeks).

RESULTS

There was one dislocation due to excessive play between the two components. Passive joint motion before reimplantation was 53 degrees (range 5-80 degrees ). At last follow-up, 24 patients were free of overt infection and all antibiotic regimens had been discontinued for at least 20 months (20-48 months). Two patients required a second two stage revision. One had an arthrodesis and in one only suppressive antibiotic therapy was possible.

DISCUSSION

Spacer removal appears easy at reimplantation. Good knee flexion (greater than 40 degrees in ten patients and greater than 60 degrees in eight) facilitated exposure, avoiding the need for tilting of the tibial tuberosity in seven patients. Functional and infectious outcomes were similar to those reported in the literature.

CONCLUSION

The spacer appears to improve patient comfort between the two operations. It also facilitates the reimplantation procedure because of the easier exposure and greater knee flexion compared with a mono-bloc spacer or an external fixator. There must however be enough bone stock to hold the articulated spacer in place.

HIV infection and tobacco smoking behaviour: prospects for prevention? ANRS CO3 Aquitaine Cohort, 2002

OBJECTIVE

To provide up-to-date and covariate-specific estimates on tobacco smoking prevalence in a representative cohort of French human immunodeficiency virus (HIV) 1 infected patients in 2002.

DESIGN

We conducted a cross-sectional analysis of the Aquitaine Cohort of HIV-infected patients. A logistic regression model was used to estimate associations between regular tobacco smoking and sex, age, HIV transmission categories, duration and immuno-virological status of HIV infection and duration of antiretroviral therapy. Smoking prevalence estimates were compared with the general French population values after stratification on age and sex.

RESULTS

Among 2036 patients included in the analysis, 51% were regular smokers (95%CI 49-53). Smoking prevalence was significantly higher with younger age (OR 1.7 among those < or = 45 years of age), among injecting drug users (OR 4.3), among those whose infection was not controlled (OR 1.2) and those whose HIV infection had been diagnosed for > or = 5 years (OR 1.5). The main difference with the general population was the peak smoking prevalence among HIV-positive patients infected through injecting drug use.

CONCLUSIONS

HIV-infected patients are highly exposed to tobacco smoking, which is implicated in multiple conditions occurring in the course of HIV infection. Adapted smoking cessation programmes should become one of the priorities of the medical care of HIV-infected individuals.

[Linezolid, the first oxazolidinone antibiotic]

The spread of multiresistant Staphylococcus and Enterococcus strains required the development of new drugs. Linezolid is the first molecule of a new antibiotic family, oxazolidinones, with an original mechanism of action. In this general review, the authors first present its antibacterial activity, its pharmacokinetic properties, its therapeutic uses in serious Gram-positive infections, pneumonia, skin and soft tissue infections, and also in other indications. They then explain the rules for administration and tolerability.