Impact of therapeutic drug monitoring of antibiotics in the management of infective endocarditis

Treatment of infective endocarditis (IE) is based on high doses of antibiotics with a prolonged duration. Therapeutic drug monitoring (TDM) allows antibiotic prescription optimization and leads to a personalized medicine, but no study evaluates its interest in the management of IE. We conducted a retrospective, bicentric, descriptive study, from January 2007 to December 2019. We included patients cared for IE, defined according to Duke's criteria, for whom a TDM was requested. Clinical and microbiological data were collected after patients' charts review. We considered a trough or steady-state concentration target of 20 to 50 mg/L. We included 322 IE episodes, corresponding to 306 patients, with 78.6% (253/326) were considered definite according to Duke's criteria. Native valves were involved in 60.5% (185/306) with aortic valve in 46.6% (150/322) and mitral in 36.3% (117/322). Echocardiography was positive in 76.7% (247/322) of cases. After TDM, a dosage modification was performed in 51.5% (166/322) (decrease in 84.3% (140/166)). After initial dosage, 46.3% (82/177) and 92.8% (52/56) were considered overdosed, when amoxicillin and cloxacillin were used, respectively. The length of hospital stay was higher for patient overdosed (25 days versus 20 days (p = 0.04)), and altered creatinine clearance was associated with overdosage (p = 0.01). Our study suggests that the use of current guidelines probably leads to unnecessarily high concentrations in most patients. TDM benefits predominate in patients with altered renal function, but probably limit adverse effects related to overdosing in most patients.

Suction drainage fluid culture during septic orthopaedic surgery, a retrospective study

We evaluated the usefulness of suction drainage fluid culture after septic orthopaedic surgery to predict early surgical reintervention. We conducted a retrospective observational study, at the Groupe Hospitalier Paris Saint-Joseph between 2014 and 2019. All the patients undergoing septic orthopaedic surgery, with perioperative samples and a postoperative suction drainage device, were enrolled. We compared the group with positive or negative postoperative drainage fluid cultures, respectively, on surgical outcome. We included 246 patients. The drainage fluid culture was positive in 42.3% of the cases. Early surgical reintervention concerned 14.6% of the cases (n = 36), including 61.1% of patients with positive drainage fluid culture (n = 22/36). The risk factors associated with positive drainage fluid cultures were the debridement of the infected site (without orthopaedic device removal), an infection located at the spine, perioperative positive cultures to Staphylococcus aureus. The complete change of the orthopaedic device, and coagulase-negative staphylococci on the preoperative samples, was associated with negative drainage fluid cultures. Positive drainage fluid culture was predictive of early surgical reintervention, and coagulase-negative staphylococci in the preoperative samples and knee infection were predictive of surgical success. Postoperative drainage fluid cultures were predictive of early surgical reintervention. Randomized multicentric studies should be further conducted.

Dynamique de l’excrétion virale chez les patients infectés par le SARS-CoV-2

Introduction

La durée de contagiosité d’un patient infecté par le SARS-CoV-2 n’est à ce jour pas encore clairement définie. Dans l’attente de nouvelles données, des recommandations sur les critères de levées d’isolement (précautions gouttelettes et contact), ont été émises par le Haut Conseil de santé publique. Ces recommandations se basent sur des critères cliniques et temporels et recommandent une durée totale d’isolement d’au moins 14 jours après le début des symptômes en population générale et d’au moins 24 jours chez les patients immunodéprimés. D’autres recommandations internationales (notamment celles de l’eCDC et des Chinoises) associent aux critères de levée d’isolement, une à deux PCR de contrôle sur écouvillons nasopharyngés. Notre établissement centralise depuis le début de l’épidémie les prélèvements pour recherche de SARS-CoV-2 par RT-PCR sur écouvillons nasopharyngés pour 7 établissements de santé. L’objectif de notre étude a été d’évaluer la proportion de patients gardant une PCR positive à SARS-CoV-2 au-delà de 24 jours après la première PCR positive.

Matériels et méthodes

Étude rétrospective incluant l’ensemble des patients ayant eu un dépistage par PCR nasopharyngée (3 mars–10 juin 2020) au sein des 7 établissements. Les données analysées ont inclus l’âge des patients, le délai de réalisation (en jours) entre 2 PCR, le service clinique.

Résultats

À la date du 10 juin, 3603 dépistages (dont 37 non-rendus pour problèmes techniques) ont été réalisés chez 3032 patients ; parmi ces patients, 348 ont eu plusieurs dépistages : 278 ont été dépistés deux fois, 47 trois fois, et 23 quatre fois ou plus. La répartition des patients gardant une PCR positive au moins 24 jours après la première était la suivante :

– 20 patients ont eu un dépistage de contrôle entre 24 et 29 jours après le premier dépistage : 1 patient était encore positif à j27 (5 %) ;

– 42 patients ont eu un dépistage de contrôle entre 30 et 41 jours : 8 étaient encore positifs (19 %) ;

– 34 patients ont eu un dépistage de contrôle après 42 jours : 3 étaient encore positifs (9 %).

Les 12 patients gardant une PCR positive au moins 24 jours après la première, avaient été hospitalisés, avaient une moyenne d’âge de 66 ans et 7 d’entre eux avaient un cancer sous-jacent ou avaient nécessité une prise en charge en réanimation.

Conclusion

Plus de 10 % des patients dépistés au moins 24 jours après le diagnostic microbiologique gardait une PCR nasopharyngée positive. Même si l’excrétion d’ARN viral n’équivaut pas directement à l’infectiosité, au vu des inconnues encore importantes sur le SARS-CoV-2, la levée précoce de l’isolement doit être réfléchie au cas par cas, en particulier pour les formes graves et les patients immunodéprimés.

Multidisciplinary advisory teams to manage multidrug-resistant tuberculosis: the example of the French Consilium

SETTING: The World Health Organization (WHO) recommends that multidrug-resistant tuberculosis (MDR-TB) treatment should be managed in collaboration with multidisciplinary advisory committees (consilia). A formal national Consilium has been established in France since 2005 to provide a centralised advisory service for clinicians managing MDR-TB and extensively drug-resistant (XDR-TB) cases.OBJECTIVE: Review the activity of the French TB Consilium since its establishment.DESIGN: Retrospective description and analysis of the activity of the French TB Consilium.RESULTS: Between 2005 and 2016, 786 TB cases or contacts of TB cases were presented at the French TB Consilium, including respectively 42% and 79% of all the MDR-TB and XDR-TB cases notified in France during this period. Treatment regimens including bedaquiline and/or delamanid were recommended for 42% of the cases presented at the French TB Consilium since 2009. Patients were more likely to be presented at the French TB Consilium if they were born in the WHO Europe Region, had XDR-TB, were diagnosed in the Paris region, or had resistance to additional drugs than those defining XDR-TB.CONCLUSION: The French TB Consilium helped supervise appropriate management of MDR/XDR-TB cases and facilitated implementation of new drugs for MDR/XDR-TB treatment.

Clinical evaluation of subcutaneous administration of cefepime

OBJECTIVES

Cefepime is a fourth-generation cephalosporin active against Pseudomonas aeruginosa and most Enterobacteriaceae. Intravenous (IV) administration is the standard route of prescription. However, subcutaneous administration (SC) may represent an interesting alternative. We aimed to evaluate SC administration of cefepime versus the IV route in geriatric patients.

PATIENTS AND METHODS

Multicenter retrospective analysis in patients treated with cefepime by SC route who underwent plasma concentration monitoring.

RESULTS

Twelve patients were included in the SC group and matched to 12 patients in the IV group. The median and mean C_min levels were 29.05mg/L [14.2-48.2]; 33.4mg/L (±21.8) in the SC group and 31.9mg/L [26.5-51.7]; 39.6mg/L (±27) (P=NS) in the IV group. No local SC administration-related complications were reported. No relapse was observed over six months of follow up.

CONCLUSION

Subcutaneous use of cefepime seems to have the same clinical and microbiological effectiveness as parenteral administration.

Infective endocarditis: Clinical presentation, etiology, and early predictors of in-hospital case fatality

OBJECTIVE

We aimed to assess the clinical presentation, microbial etiology and outcome of patients presenting with infective endocarditis (IE).

PATIENTS AND METHODS

We conducted a four-year retrospective study including all patients presenting with IE.

RESULTS

We included 121 patients in the study. The median age was 74.8years. Most patients had native valve IE (57%). Staphylococcus aureus accounted for 24.8% of all IE. Surgery was indicated for 70 patients (57.9%) but actually performed in only 55 (44.7%). Factors associated with surgery were younger age (P=0.002) and prosthetic valve IE (P=0.001). Risk factors associated with in-hospital mortality were diabetes mellitus (OR=3.17), chronic renal insufficiency (OR=6.62), and surgical indication (OR=3.49). Mortality of patients who underwent surgery was one sixth of that of patients with surgical indication who did not have the surgery (P<0.001).

Intrapartum GBS screening and antibiotic prophylaxis: a European consensus conference

Group B streptococcus (GBS) remains worldwide a leading cause of severe neonatal disease. Since the end of the 1990s, various strategies for prevention of the early onset neonatal disease have been implemented and have evolved. When a universal antenatal GBS screening-based strategy is used to identify women who are given an intrapartum antimicrobial prophylaxis, a substantial reduction of incidence up to 80% has been reported in the USA as in other countries including European countries. However recommendations are still a matter of debate due to challenges and controversies on how best to identify candidates for prophylaxis and to drawbacks of intrapartum administration of antibiotics. In Europe, some countries recommend either antenatal GBS screening or risk-based strategies, or any combination, and others do not have national or any other kind of guidelines for prevention of GBS perinatal disease. Furthermore, accurate population-based data of incidence of GBS neonatal disease are not available in some countries and hamper good effectiveness evaluation of prevention strategies. To facilitate a consensus towards European guidelines for the management of pregnant women in labor and during pregnancy for the prevention of GBS perinatal disease, a conference was organized in 2013 with a group of experts in neonatology, gynecology-obstetrics and clinical microbiology coming from European representative countries. The group reviewed available data, identified areas where results were suboptimal, where revised procedures and new technologies could improve current practices for prevention of perinatal GBS disease. The key decision issued after the conference is to recommend intrapartum antimicrobial prophylaxis based on a universal intrapartum GBS screening strategy using a rapid real time testing.

Nosocomial outbreak of staphylococcal scalded skin syndrome in neonates: epidemiological investigation and control

Over a three-month period, 13 neonates developed staphylococcal scalded skin syndrome (SSSS) in a maternity unit, between four and 18 days after their birth. An epidemiological and descriptive study followed by a case-control study was performed. A case was defined as a neonate with blistering or peeling skin, and exfoliative toxin A Staphylococcus aureus positive cultures. Controls were selected at random from the asymptomatic, non-colonized neonates born on the same day as the cases. All staff members and all neonates born during the outbreak period were screened for carriage by nasal swabs and umbilical swabs, respectively. S. aureus isolates were polymerase chain reaction (PCR) screened for etA gene and genotyped by pulsed-field gel electrophoresis (PFGE). Two clusters of eight and five cases were identified. Receiving more than one early umbilical care procedure by the same ancillary nurse was the only risk factor identified in the case-control study (odds ratio=15, 95% confidence intervals 2-328). The ancillary nurse suffered from chronic dermatitis on her hands that favoured S. aureus carriage. Exfoliative-toxin-A-producing strains, as evidenced by PCR and indistinguishable by PFGE, were isolated from all but one of the SSSS cases, from four asymptomatic neonates, from two staff members and from the ancillary nurse's hands. Removal of the ancillary nurse from duty, infection control measures (isolation precautions, chlorhexidine handwashing and barrier protections), and treatment of the carriers (nasal mupirocin and chlorhexidine showers) led to control of the epidemic. In conclusion, this study emphasizes the need for tight surveillance of chronic dermatitis in healthcare workers.