Characteristics of Pseudomonas aeruginosa infection in intensive care unit before (2007-2010) and after (2011-2014) the beginning of an antimicrobial stewardship program

Objectives

To investigate the factors associated with Pseudomonas aeruginosa isolates in intensive care unit (ICU) before and after an antimicrobial stewardship program.

Materials

Monocentric retrospective cohort study. Patients admitted to the ICU in 2007-2014 were included. Characteristics of P. aeruginosa patients were compared to overall ICU population. Clinical and microbiological characteristics of P. aeruginosa patients before (2007-2010) and after (2011-2014) the beginning of the AMP were compared.

Results

Overall, 5,263 patients were admitted to the ICU, 274/5,263 (5%) had a P. aeruginosa isolate during their staying. In 2011-2014, the percentage P. aeruginosa isolates reduced (7% vs 4%, P ≤ .0001). Patients with P. aeruginosa had higher rates of in-hospital death (43% vs 20%, P < .0001) than overall ICU population. In 2011-2014, rates of multidrug-resistant (11% vs 2%, P = .0020), fluoroquinolone-resistant (35% vs 12%, P < .0001), and ceftazidime-resistant (23% vs 8%, P = .0009) P. aeruginosa reduced. Treatments by fluoroquinolones (36% vs 4%, P ≤ .0001), carbapenems (27% vs 9%, P = .0002), and third-generation cephalosporins (49% vs 12%, P ≤ .0001) before P. aeruginosa isolation reduced while piperacillin (0% vs 13%, P < .0001) and trimethoprim-sulfamethoxazole (8% vs 26%, P = .0023) increased. Endotracheal intubation reduced in 2011-2014 (61% vs 35%, P < .0001). Fluoroquinolone-resistance was higher in patients who received endotracheal intubation (29% vs 17%, P = .0197). Previous treatment by fluoroquinolones (OR = 2.94, P = .0020) and study period (2007-2010) (OR = 2.07, P = .0462) were the factors associated with fluoroquinolone-resistance at the multivariate analysis.

Conclusions

Antibiotic susceptibility in P. aeruginosa isolates was restored after the reduction of endotracheal intubation, fluoroquinolones, carbapenems, and third-generation cephalosporins and the increased use of molecules with a low ecological footprint, as piperacillin and trimethoprim-sulfamethoxazole.

Identifying General Practitioners' Antibiotic Prescribing Profiles Based on National Health Reimbursement Data

Background

Antibiotic selection pressure in human medicine is a significant driver of antibiotic resistance in humans. The primary aspect of antibiotic consumption is associated with general practitioner (GP) prescriptions. We aimed to identify prescriber profiles for targeted antimicrobial stewardship programs using novel indicators.

Methods

A cross-sectional study was conducted in 2018 investigating GPs' antibiotic prescriptions in a French department, utilizing the reimbursement database of the national health service. Three antibiotic prescribing indicators were used. Specific targets were established for each indicator to identify the antibiotic prescribers most likely contributing to the emergence of resistance.

Results

Over 2018, we had 2,908,977 visits to 784 GPs, leading to 431,549 antibiotic prescriptions. Variations between GPs were shown by the 3 indicators. The median antibiotic prescription rate per visit was 13.6% (interquartile range [IQR], 9.8%-17.7%). Median ratios of the prescriptions of low-impact antibiotics to the prescriptions of high-impact antibiotics and of amoxicillin prescriptions to amoxicillin-clavulanic acid prescriptions were 2.5 (IQR, 1.7-3.7) and 2.94 (IQR, 1.7-5), respectively. We found 163 (21%) high prescribers of antibiotics with 3 distinct patterns: The first group overuses broad-spectrum antibiotics but without an overprescription rate per visit, the second group displays an overprescription rate but no excessive use of broad-spectrum antibiotics, and the third group shows both an overprescription rate and excessive use of broad-spectrum antibiotics.

Conclusions

Prescription-based indicators enable the identification of distinct profiles of antibiotic prescribers. This identification may allow for targeted implementation of stewardship programs focused on the specific prescribing patterns of each profile.

One Hundred Explicit Definitions of Potentially Inappropriate Prescriptions of Antibiotics in Hospitalized Older Patients: The Results of an Expert Consensus Study

BACKGROUND

In geriatrics, explicit criteria for potentially inappropriate prescriptions (PIPs) are useful for optimizing drug use.

OBJECTIVE

To produce an expert consensus on explicit definitions of antibiotic-PIPs for hospitalized older patients.

METHODS

We conducted a Delphi survey involving French experts on antibiotic stewardship in hospital settings. During the survey's rounds, the experts gave their opinion on each explicit definition, and could suggest new definitions. Definitions with a 1-to-9 Likert score of between 7 and 9 from at least 75% of the participants were adopted. The results were discussed during consensus meetings after each round.

RESULTS

Of the 155 invited experts, 128 (82.6%) participated in the whole survey: 59 (46%) infectious diseases specialists, 45 (35%) geriatricians, and 24 (19%) other specialists. In Round 1, 65 explicit definitions were adopted and 21 new definitions were suggested. In Round 2, 35 other explicit definitions were adopted. The results were validated during consensus meetings (with 44 participants after Round 1, and 54 after Round 2).

CONCLUSIONS

The present study is the first to have provided a list of explicit definitions of potentially inappropriate antibiotic prescriptions for hospitalized older patients. It might help to disseminate key messages to prescribers and reduce inappropriate prescriptions of antibiotics.

Yellow fever vaccine-associated neurologic and viscerotropic disease: a 10-year case series of the French National Reference Center for Arboviruses with clinical and immunological insights

BACKGROUND

Immunization against the Yellow fever virus (YFV) with the 17D live-attenuated vaccine is the most effective way to prevent the disease. However, unexpected severe adverse events can occur. They consist in a neurological impairment - neurological disease (YEL-AND), a YF-like illness - viscerotropic disease (YEL-AVD) or anaphylaxis. In this article, we describe the epidemiology, clinical and biological features of YEL-AND and YEL-AVD cases reported to the French National Reference Center for Arboviruses (NRCA) in the past 10 years.

METHODS

We conducted a national, retrospective study using the database of the NRCA from June 2012 to June 2022. All patients whose biological samples were sent to the NRCA for detection of YFV by serology and/or RT-qPCR for a suspected vaccine-associated adverse event were included. We collected data by reading medical records and conducted complementary neuro-immunological analysis, followed by a search for autoimmunity against type-1-interferon when samples were available at the NRCA.

RESULTS

There were 10 cases of YEL-AND and 2 cases of YEL-AVD reported to the NRCA in the past 10 years, which represented an overall incidence of 0.6 for 100 000 doses. A total of 6/12 cases were previously healthy patients (50%, mean age 31 years), and 4/12 cases had cardiovascular co-morbidities (42%, mean age 56 years). The majority of YEL-AND had a favourable outcome at 6 months of follow up. One YEL-AVD patient passed. In secondary analyses, we evidenced a significant blood cerebrospinal fluid (CSF) barrier dysfunction, without intrathecal synthesis of immunoglobulin and without argument for a neuron damage. We further detected a significant rate of anti-type-1alpha interferon antibodies in 3/10 tested patients (2 YEL-AND and 1 YEL-AVD).

CONCLUSION

YEL-AND and YEL-AVD are rare events that can underlie defect in the innate immunity of apparently healthy or mild co-morbid subjects. Outcome was generally favourable in the YEL-AND cases of our series, but still life-threatening or even fatal in the YEL-AVD cases.

Antibiotic prescription in ambulatory care for COVID-19 patients: a cohort analysis in four European countries

OBJECTIVE

To analyse antibiotic prescription rates in ambulatory care for COVID-19 patients by general practitioners (GPs) in four European countries.

METHODS

A total of 4,513,955 anonymised electronic prescribing records of 3656 GPs in four European countries were analysed. Diagnosis and prescriptions were retrieved. Antibiotic prescription rates during COVID-19 consultations were analysed and compared between France, the UK, Belgium and Romania.

RESULTS

Overall prescription rate was in France and Belgium (6.66 and 7.46%). However, analysing median GP prescribing rates, we found that 33.9% of the GPs in Belgium prescribed antibiotics with a median of 16 prescriptions per 100 COVID-19 consultations, while 55.21% of the GPs in France prescribed a median of 8 antibiotic prescriptions per 100 COVID-19 consultations. Overall antibiotic prescription rates were less in Romania than in the UK (22% vs 32%); however, 73% of the Romanian GPs vs 57% of the British GPs prescribed antibiotics. Depending on the country, the proportion of each type of antibiotic was statistically different, with the proportion of azithromycin being more than 50% of all antibiotics in each country except for the UK where it was less than 1%.

CONCLUSION

Both individual GPs prescribing patterns in addition to overall consumption patterns should be analysed in order to implement a tailored antimicrobial stewardship programme. Furthermore, antibiotic prescribing rates in COVID-19 are lower than other respiratory tract infections.

Updated mortality and causes of death in 2020-2021 in people with HIV: a multicenter study in France

OBJECTIVE

The aim of this study was to assess updated mortality and causes of death in people with HIV (PWH) in France.

DESIGN AND METHODS

We analyzed all deaths in PWH followed up between January 1, 2020, and December 31, 2021, in 11 hospitals in the Paris region. We described the characteristics and causes of death among deceased PWH, and evaluated the incidence of mortality and associated risk factors using a multivariate logistic regression.

RESULTS

Of the 12 942 patients followed in 2020--2021, 202 deaths occurred. Mean annual incidence of death [95% confidence interval (95% CI)] was 7.8 per 1000 PWH (6.3-9.5). Forty-seven patients (23%) died from non-AIDS nonviral hepatitis (NANH)-related malignancies, 38 (19%) from non-AIDS infections (including 21 cases of COVID-19), 20 (10%) from AIDS, 19 (9%) from cardiovascular diseases (CVD), 17 (8.4%) from other causes, six (3%) from liver diseases, and five (2.5%) from suicides/violent deaths. The cause of death was unknown in 50 (24.7%) patients. Risks factors for death were age [adjusted odds ratio (aOR) 1.93; 1.66-2.25 by additional decade), AIDS history (2.23; 1.61-3.09), low CD4 + cell count (1.95; 1.36-2.78 for 200-500 cells/μl and 5.76; 3.65-9.08 for ≤200 versus > 500 cells/μl), and viral load more than 50 copies/ml (2.03; 1.33-3.08), both at last visit.

CONCLUSION

NANH malignancies remained in 2020-2021 the first cause of death. COVID-19 accounted for more than half of the mortality related to non-AIDS infections over the period. Aging, AIDS history, and a poorer viro-immunological control were associated with death.

Knowledge of recommended antibiotic treatments for community-acquired infections in general medical practice: a cross-sectional study in Occitanie region, France

To assess and analyse the knowledge of recommended antibiotic treatments, focusing on the appropriate drugs and treatment durations for the most common community-acquired infections in general medical practice in Occitanie region, France. A web-based survey was conducted over a 3-month period, from October, 2018 to January, 2019. All participants answered directly through the online platform. For the analysis of overtreatment risk, a score based system was adopted and two scores were produced: the duration score and the treatment score. 413 general practitioners completed the survey. The overall rate of concordance with guidelines in terms of both drug choice and treatment length was 2974/4956 (60%) answers. Diseases with at least 70% good answers included cystitis, group A streptococcal pharyngitis, and bacterial superficial skin infections. Diseases with fewer than 50% good answers included pyelonephritis, dog bite wounds, and community-acquired pneumonia in patients aged ≥ 65 years. Factors associated with the risk of overtreatment were age > 40 years, country setting and hospital employment. Knowledge of treatment durations is satisfactory with 60% of recommendations being met. However, varying levels were observed according to different diseases. This study highlighted a very high rate of adherence when recommendations were clear. In contrast, low levels of adherence were observed when recommendations were ambiguous or when conflicting guidelines existed.

Survey on infectious disease telephone hotlines in primary care: General practitioners' satisfaction and compliance with advice

OBJECTIVES

Infectious disease (ID) advice is a major part of antimicrobial stewardship programs. The objective of this study was to assess general practitioners' (GPs)' opinions and compliance with advice given by ID hotlines.

PATIENTS AND METHODS

This multicenter survey was based on the 7-day assessment of initial advice requested by GPs to a hotline set up by volunteer hospital ID teams to record advice for 3 years. The primary endpoint was the GPs' satisfaction with the advice given by ID specialists.

RESULTS

Ten ID teams participated in the study and recorded 4138 requests for advice, of which 1325 requests included a proposal for antibiotic therapy and justified a follow-up call at seven days. Only 398 follow-up calls (30%) were carried out because many GPs were not reachable. GPs were very satisfied with ID hotlines: 58% considered them indispensable and 38% very useful. The recommendations provided by ID specialists were followed by GPs in more than 80% of cases. The two main motivations for GPs to call the hotline were to get quick advice (86%) and to receive help in managing a patient (76%).

CONCLUSIONS

The ID telephone consultations and advice systems for GPs are highly appreciated and are effective in terms of following the recommendations.

Fatal neonatal listeriosis following L. monocytogenes horizontal transmission highlights neonatal susceptibility to orally acquired listeriosis

We report a case of fulminant fatal neonatal listeriosis due to horizontal transmission of Listeria monocytogenes (Lm) in a neonatal double room. Genomic analyses reveal a close genetic relationship between clinical isolates, supporting cross-contamination. Oral inoculation experiments in adult and neonatal mice show that neonates are susceptible to a low Lm inoculum and that this susceptibility results from the immaturity of the neonatal gut microbiota. Infected neonates should therefore be isolated for as long as they shed Lm in their feces to avoid horizontal transmission and its dire consequences.

Optimizing Betalactam Clinical Response by Using a Continuous Infusion: A Comprehensive Review

INTRODUCTION

Antimicrobial resistance is a major healthcare issue responsible for a large number of deaths. Many reviews identified that PKPD data are in favor of the use of continuous infusion, and we wanted to review clinical data results in order to optimize our clinical practice.

METHODOLOGY

We reviewed Medline for existing literature comparing continuous or extended infusion to intermittent infusion of betalactams.

RESULTS

In clinical studies, continuous infusion is as good as intermittent infusion. In the subset group of critically ill patients or those with an infection due to an organism with high MIC, a continuous infusion was associated with better clinical response.

CONCLUSIONS

Clinical data appear to confirm those of PK/PD to use a continuous infusion in severely ill patients or those infected by an organism with an elevated MIC, as it is associated with higher survival rates. In other cases, it may allow for a decrease in antibiotic daily dosage, thereby contributing to a decrease in overall costs.

Management of imported malaria in the emergency department: Adequacy compared to guidelines, and impact of the SARS-CoV-2 pandemic

OBJECTIVES

Adequacy of imported malaria management with respect to guidelines in emergency departments (ED) is low. We aimed to identify factors associated with this non-compliance, and a potential impact of the SARS-CoV-2 pandemic.

PATIENTS AND METHODS

Patients presenting with imported malaria at the ED of the hospital of Melun (France), from January 1, 2017 to February 14, 2022 were retrospectively included.

RESULTS

Among 205 adults and 25 children, biological criteria of severity were fully assessed in 10% of cases; lactates (40%) and blood pH (21%) levels were the main missing variables. Of 74 patients (32%) with severe malaria, 13 were misclassified as uncomplicated malaria. The choice and dosage of treatment were adequate in 85% and 92% of cases, respectively. Treatment conformity was lower in severe malaria cases than in non-severe malaria cases (OR 0.15 [95% CI 0.07-0.31]), with oral treatment in 17 patients with severe malaria; conformity was higher in the intensive care unit (OR 4.10 [95% CI 1.21-13.95]). Patients with severe malaria were more likely to start treatment within 6hours than patients with uncomplicated malaria (OR 1.97 [95% CI 1.08-3.43]), as were patients infected by P.falciparum compared to other species (OR 4.63 [95% CI 1.03-20.90]). Consulting during the SARS-CoV-2 pandemic was the only organizational factor associated with a lower probability of adequate management (OR 0.42 [95% CI 0.23-0.75]).

CONCLUSION

Initial evaluation of malaria severity and time to treatment administration could be improved. These have been adversely impacted by the SARS-CoV-2 pandemic.

Infectious disease hotlines to provide advice to general practitioners: a prospective study

BACKGROUND

Telephone hotlines in infectious diseases (ID) are part of antimicrobial stewardship programs designed to provide support and expertise in ID and to control antibiotic resistance. The aim of the study was to characterize the activity of the ID hotlines and estimate their usefulness for general practitioners (GPs).

METHODS

This was a multicenter prospective observational study in different French regions. ID teams involved in antimicrobial stewardship with a hotline for GPs were asked to record their advice from April 2019 to June 2022. In these regions, all GPs were informed of the ID hotline's operating procedures. The main outcome was usage rate of the hotlines by GPs.

RESULTS

Ten volunteer ID teams collected 4138 requests for advice from 2171 GPs. The proportion of GPs using the hotline varied pronouncedly by region, from 54% in the Isere department, to less than 1% in departments with the lowest usage. These differences were associated with the number of physicians in ID teams and with the age of the hotline. These results highlighted the value of working time as a means of ensuring the permanence of expertise. The main reasons for calling were: a diagnostic question (44%); choice of antibiotic (31%). The ID specialist provided advice on antibiotic therapy (43%) or a proposal for specialized consultation or hospitalization (11%).

CONCLUSIONS

ID hotlines could help to strengthen cooperation between primary care and hospital medicine. However, the deployment and perpetuation of this activity require reflection concerning its institutional and financial support.

Prescription of antibiotics by general practitioners in patients with a diagnosis of SARS- CoV-2 infection: analysis of an electronic French health record

OBJECTIVE

To define the factors associated with overprescription of antibiotics by general practitioners for patients diagnosed with COVID-19 during the first wave.

METHODS

Anonymized electronic prescribing records of 1370 physicians were analyzed. Diagnosis and prescriptions were retrieved. The initiation rate by physician for 2020 was compared to 2017-2019. Prescribing habits of physicians who initiated antibiotics for more than 10% of COVID-19 patients were compared to those who did not. Regional differences in prescribing habits of physicians who have seen at least one COVID-19 patient were also analyzed.

RESULTS

For the March-April 2020 period, physicians who initiated antibiotics for more than 10% of COVID-19 patients had more consultations than those who did not. They also prescribed antibiotics more frequently for non-COVID-19 patients consulting with rhinitis. They also prescribed broad-spectrum antibiotics more frequently for treatment of cystitis. Finally, doctors in Île-de-France region saw more COVID-19 patients and initiated antibiotics more frequently. General Practitioners in southern France had a higher but non-significant ratio of azithromycin initiation rate over total antibiotics initiation rate.

CONCLUSION

We identified a subset of physicians with overprescribing profile not only for COVID-19 but also for other viral infection, and also with a tendency to prescribe broad spectrum antibiotics for a long duration. There were also regional differences concerning antibiotics initiation rate and the ratio of azithromycin prescribed. It will be necessary to evaluate the evolution of prescribing practices during subsequent waves.

Factors associated with delay in seeking healthcare for imported malaria: a retrospective study in a French hospital

BACKGROUND

Delayed treatment is associated with a higher risk of severe malaria. In malaria-endemic areas, the main factors associated with delay in seeking healthcare are low educational level and traditional beliefs. In imported malaria, determinants of delay in seeking healthcare are currently unknown.

METHODS

We studied all patients presenting with malaria from January 1st, 2017, to February 14, 2022, in the hospital of Melun, France. Demographic and medical data were recorded for all patients, and socio-professional data in a subgroup of hospitalized adults. Relative-risks and 95% confidence intervals were determined using univariate analysis by cross-tabulation.

RESULTS

234 patients were included, all travelling from Africa. Among them, 218 (93%) were infected with P. falciparum, 77 (33%) had severe malaria, 26 (11%) were younger than 18 years old, and 81 were included during the SARS-CoV-2 pandemic. There were 135 hospitalized adults (58% of all patients). The median time to first medical consultation (TFMC), defined by the period from onset of symptoms to first medical advice, was 3 days [IQR 1-5]. A TFMC ≥3 days tended to be more frequent in travellers visiting friends and relatives (VFR) (RR 1.44, 95% CI [1.0-2.05], p = 0.06), while it was less frequent in children and teenagers (RR 0.58, 95% CI [0.39-0.84], p = 0.01). Gender, African background, unemployment, living alone, and absence of referring physician were not associated with delay in seeking healthcare. Consulting during the SARS-CoV-2 pandemic was not associated with a longer TFMC, nor with a higher rate of severe malaria.

CONCLUSION

In contrast to an endemic area, socio-economic factors did not impact on delay in seeking healthcare in imported malaria. Prevention should focus on VFR subjects, who tend to consult later than other travellers.

Advocacy for Responsible Antibiotic Production and Use

Antibiotic-resistant bacteria have become one of humankind’s major challenges, as testified by the UN’s Call to Action on Antimicrobial Resistance in 2021. Our knowledge of the underlying processes of antibiotic resistance is steadily improving. Beyond the inappropriate use of antimicrobials in human medicine, other causes have been identified, raising ethical issues and requiring an approach to the problem from a “One Health” perspective. Indeed, it is now clear that the two main issues regarding the subject of antibiotics are their misuse in the global food industry and their method of production, both leading to the emergence and spread of bacterial resistance.

Infection nosocomiale et clusters intra hospitalier d'infection à SARS cov 2 dans un centre hospitalier Général : Bilan d'une année de pandémie

Introduction

La mise à disposition large des tests PCR SARS cov2 et la stratégie de dépistage systématique autour d'un cas a permis de mettre en évidence la survenue de transmissions croisées entrainant des infections nosocomiales au sein des services de soins. Un cluster est défini par la présence d'au moins 3 cas dans un service de soins dans un délai de 14 jours. L'objectif de l'étude est de définir le nombre de cas d'infection nosocomiale et de phénomène de cluster hospitalier aux décours de la 2ème et 3ème vague d'infection à SARS cov 2 dans un centre hospitalier Général.

Matériels et méthodes

Etude rétrospective des infections nosocomiales et des clusters intra hospitalier entre avril 2020 et avril 2021 L'infection nosocomiale est définie par la négativité d'une PCR d'entrée et la positivité d'une PCR à plus de 7 jours de l'entrée. Un cluster est défini par au moins trois cas d'infection nosocomiale dans une même unité de lieux et de temps (14jours). La deuxième vague comprend les cas identifiés entre les mois d'octobre et décembre 2020 et janvier avril 2021 pour la troisième.

Résultats

Quatre mille deux cents cinq PCR positives ont été détectées entre avril 2020 et avril 2021. Le nombre covid nosocomiaux était de 123 des 1654 patients hospitalisés (7.4 %) et ayant un diagnostic virologique d'infection à SARScov2. Cent onze (79 %) des cas nosocomiaux étaient liés à des clusters. Durant la deuxième vague, 14 clusters ont été détectés dans 8 services différents (moyenne de 5 patients par épisodes avec au minimum 3 et au maximum 18 patients par cluster). Pendant la troisième vague, 4 clusters ont été identifiés dans 4 services. La durée moyenne de résolution des clusters a été de 14 jours. Les clusters ont été détectés pour 58 cas (47 %)en secteur médecine chirurgie obstétrique et pour 65 (53 %) cas en secteur soins de suite et rééducation.

La moyenne d'âge des cas nosocomiaux était de 83 ans, 85,37 % présentaient au moins une comorbidité et la mortalité a été de 22,76 % contre 19 % pour les cas communautaire (Xhi² = 1.03 NS).

Conclusion

L'acquisition nosocomiale du virus SARS cov 2 a été est un phénomène bien réel entrainant une surmortalité en milieu hospitalier. Ces données patients permettent de justifier les mesures spécifiques comme la vaccination précoce et obligatoire des personnels soignants et des patients à risque, un renforcement des mesures d'hygiène et un contrôle des visites.

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Facteurs associés au portage de BMR à l'entrée en réanimation des patients infectés par la COVID-19 : analyse de cohorte rétrospective

Introduction

Une étude précédente réalisée dans notre hôpital, montrait un taux de portage de bactéries multirésistantes (BMR) à l'entrée en réanimation, chez les patients développant une pneumopathie acquise sous ventilation, différent chez les patients infetés par la COVID-19 par rapport aux non infectés (30 % VS 16 %, p=0,043). Nous avons analysé les facteurs de risque (FDR) d'un tel portage et son impact sur la survie des patients.

Matériels et méthodes

Analyse rétrospective, monocentrique, des patients hospitalisés en service de réanimation ou de soins continus pour une infection à COVID-10 pendant les vagues 1 (01/03/20 au 01/05/20) et 2 (15/10/21) ayant bénéfié d'un dépistage systématique de BMR à leur entrée dans le service.

Résultats

141 patients (98 homes et 43 femmes) ont été inclus dans l'étude, 68 durant la première vague et 73 durant la seconde. 24 des 141 patients (17 %) étaient porteurs de BMR à l'entrée en réanimation. Nous n'observons pas de différence significative du taux de portage entre les deux vagues (13/68 (19 %) et 11/73 (15 %) patients respectivement p=0,65).

Les facteurs associés au portage de BMR sont le passage dans une strucutre d'hospitalisation autre que notre hôpital (p=0,02) en particulier chez les patients venant d'une autre réanimation (5/13, 38,5 %), d'un service d'urgences (2/6, 33 %) ou d'une unité conventionnelle (6/24, 25 %) par rapport à ceux directement hospitalisés dans la réanimation de notre hôpital (11/98, 11,2 %).

L'autre FDR de portage de BMR est l'exposition à une antibiothérapie au cours de la période d'hospitalisation ayant précédée la réanimation ou les soins continus, notamment aux Bêta-lactamines (13/49 vs 11/92, p=0,035) et aux macrolides (10/30 vs 14/111, p=0,01).

Nous n'avons pas retrouvé d'association significative avec les FDR usuels tels que : vie en institution, présence d'une néoplasie en cours de traitement, traitement immunosuppresseur ou BPCO. Il n'y a pas non plus de différence liée à la consommation d'antibiotiques en ambulatoire dans les 15 jours précédents l'hospitalisation (3/24 (13 %) vs 21/118 (17 %) p=0,76) ou la durée d'hospitalisation avant le transfert en réanimation (2.1 vs 2.3 jours p=0,86).

Dans notre étude, le portage de BMR à l'entrée en réanimation est associée à un sur-risque de mortalité avec un taux de survie de 41,7 % (10/24) chez les patients porteurs de BMR contre 67,2 % (79/117) chez les patients non porteurs de BMR (p=0,02).

Conclusion

Le portage de BMR à l'entréer en réanimation ou soins continus chez les patients infectés par la COVID-19 dans notre hôpital est significativement associé au transfert depuis un autre hôpital et à la prise d'antibiotiques en hospitalisation conventionnelle avant l'admission en service réanimatoire, notamment la prise de Bêta-lactamines et/ou de macrolides. Ce portage est associée à une mortalité plus élevée.

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Tuberculosis in the Elderly

The tuberculosis (TB) epidemic is most prevalent in the elderly, and there is a progressive increase in the notification rate with age. Most cases of TB in the elderly are linked to the reactivation of lesions that have remained dormant. The awakening of these lesions is attributable to changes in the immune system related to senescence. The mortality rate from tuberculosis remains higher in elderly patients. Symptoms of active TB are nonspecific and less pronounced in the elderly. Diagnostic difficulties in the elderly are common in many diseases but it is important to use all possible techniques to make a microbiological diagnosis. Recognising frailty to prevent loss of independence is a major challenge in dealing with the therapeutic aspects of elderly patients. Several studies report contrasting data about poorer tolerance of TB drugs in this population. Adherence to antituberculosis treatment is a fundamental issue for the outcome of treatment. Decreased completeness of treatment was shown in older people as well as a higher risk of treatment failure.

Bacterial Epidemiology of Surgical Site Infections after Open Fractures of the Lower Limb: A Retrospective Cohort Study

Open lower limb fractures are common injuries, and the occurrence of infectious complications after open fractures is a usual problem. The rate of surgical site infections (SSIs) and the nature and resistance of the germs responsible for SSIs remain poorly described. Our aim was to describe the bacterial epidemiology of SSIs after surgical management of an open lower limb fracture. We conducted a retrospective monocentric cohort study from 1 January 2012 to 31 December 2020 based on the analysis of inpatient records in a non-university hospital of Ile de France region. All patients who underwent surgery for an open lower limb fracture were included. A total of 149 patients were included. In our population, 19 (12.7%) patients developed an SSI. Of these 19 patients, the sample was polymicrobial in 9 (47.4%) patients. In 9 (45%) cases, the samples identified a group 3 enterobacteria, Enterobacter cloacae being the main one in 7 (36.9%) cases. Staphylococci were identified in 11 patients, with Staphylococcus aureus in 9 (47.4%). All Staphylococcus aureus were susceptible to methicillin, and all enterobacteria were susceptible to C3G. Among all SSI, 10 (58.8%) contained at least one germ resistant to amoxicillin/clavulanic acid (AMC). The SSIs rate was 12.7%. The main pathogens identified were Enterobacter cloacae and Staphylococcus aureus. The presence of early SSI caused by group 3 Enterobacteriaceae renders current antibiotic prophylaxis protocols inadequate with AMC in half the cases.

Streptococcal and enterococcal endocarditis: time for individualized antibiotherapy?

Recommendations for the treatment of streptococcal and enterococcal endocarditis are based on old efficacy studies, but the starting doses have never been reassessed and are associated with significant adverse events. Based on data from other serious infections, we suggest that maintaining a concentration of β-lactams higher than 4-6 times the responsible bacteria MIC 100% of the time in the heart of the vegetation would be a pertinent therapeutic objective. The data point to a diffusion gradient of β-lactams in the vegetation. Yet, so far as is known, the ratio of antibiotic concentration at steady state between plasma and vegetation cannot be completely determined. Answering this crucial question would make it possible for each patient to have a targeted β-lactam plasma concentration, according to the MIC for the responsible bacteria. This would lead the way to personalized antibiotherapy and allow a safe switch to oral medication.

Factors Associated With Treatment Failure in Moderately Severe Community-Acquired Pneumonia: A Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE

Failure of treatment is the most serious complication in community-acquired pneumonia (CAP).

OBJECTIVE

To assess the potential risk factors for treatment failure in clinically stable patients with CAP.

DESIGN, SETTING, AND PARTICIPANTS

This secondary analysis assesses data from a randomized clinical trial on CAP (Pneumonia Short Treatment [PTC] trial) conducted from December 19, 2013, to February 1, 2018. Data analysis was performed from July 18, 2019, to February 15, 2020. Patients hospitalized at 1 of 16 centers in France for moderately severe CAP who were clinically stable at day 3 of antibiotic treatment were included in the PTC trial and analyzed in the per-protocol trial population.

INTERVENTIONS

Patients were randomly assigned (1:1) on day 3 of antibiotic treatment to receive β-lactam (amoxicillin-clavulanate [1 g/125 mg] 3 times daily) or placebo for 5 extra days.

MAIN OUTCOMES AND MEASURES

The main outcome was failure at 15 days after first antibiotic intake, defined as a temperature greater than 37.9 °C and/or absence of resolution or improvement of respiratory symptoms and/or additional antibiotic treatment for any cause. The association among demographic characteristics, baseline clinical and biological variables available (ie, at the first day of β-lactam treatment), and treatment failure at day 15 among the per-protocol trial population was assessed by univariate and multivariable logistic regressions.

RESULTS

Overall, 310 patients were included in the study; this secondary analysis comprised 291 patients (174 [59.8%] male; mean [SD] age, 69.6 [18.5] years). The failure rate was 26.8%. Male sex (odds ratio [OR], 1.74; 95% CI, 1.01-3.07), age per year (OR, 1.03; 95% CI, 1.01-1.05), Pneumonia Severe Index score (OR, 1.01; 95% CI, 1.00-1.02), the presence of chronic lung disease (OR, 1.85; 95% CI, 1.03-3.30), and creatinine clearance (OR, 0.99; 95% CI, 0.98-1.00) were significantly associated with failure in the univariate analysis. When the Pneumonia Severe Index score was excluded to avoid collinearity with age and sex in the regression model, only male sex (OR, 1.92; 95% CI, 1.08-3.49) and age (OR, 1.02; 95% CI, 1.00-1.05) were associated with failure in the multivariable analysis.

CONCLUSIONS AND RELEVANCE

In this secondary analysis of a randomized clinical trial, among patients with CAP who reached clinical stability after 3 days of antibiotic treatment, only male sex and age were associated with higher risk of failure, independent of antibiotic treatment duration and biomarker levels. Another randomized clinical trial is needed to evaluate the impact of treatment duration in populations at higher risk for treatment failure.

Ventilator-Associated Pneumonia in COVID-19 Patients: A Retrospective Cohort Study

INTRODUCTION

Aim of this study is to analyse the characteristics of ventilator-associated pneumonia (VAP) inpatients infected by severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2).

MATERIALS AND METHODS

A retrospective study was conducted, including coronavirus infectious disease 2019 (COVID-19) patients who developed VAP from March to May 2020 (VAP COVID-19). They were compared to non-COVID-19 patients who developed VAP from January 2011 to December 2019 (VAP NO COVID-19) and COVID-19 patients who did not develop VAP (NO VAP COVID-19).

RESULTS

Overall, 42 patients were included in the VAP COVID-19group, 37 in the NO VAP COVID-19 group, and 188 in the VAP NO COVID-19 group. VAP COVID-19 had significantly higher rates of shock (71% vs. 48%, p = 0.009), death in ICU (52% vs. 30%, p = 0.011), VAP recurrence (28% vs. 4%, p < 0.0001), positive blood culture (26% vs. 13%, p = 0.038), and polymicrobial culture (28% vs. 13%, p = 0.011) than VAP NO COVID-19. At the multivariate analysis, death in patients with VAP was associated with shock (p = 0.032) and SARS-CoV-2 (p = 0.008) infection.

CONCLUSIONS

VAP in COVID-19 patients is associated with shock, bloodstream, and polymicrobial infections.

Hydroxychloroquine in mild-to-moderate coronavirus disease 2019: a placebo-controlled double blind trial

OBJECTIVES

To determine whether hydroxychloroquine decreases the risk of adverse outcome in patients with mild to moderate coronavirus disease 2019 (COVID-19) at high risk of worsening.

METHODS

We conducted a multicentre randomized double-blind placebo-controlled trial evaluating hydroxychloroquine in COVID-19 patients with at least one of the following risk factors for worsening: need for supplemental oxygen, age ≥75 years, age between 60 and 74 years and presence of at least one co-morbidity. Severely ill patients requiring oxygen therapy >3 L/min or intensive care were excluded. Eligible patients were randomized in a 1:1 ratio to receive either 800 mg hydroxychloroquine on day 0 followed by 400 mg per day for 8 days or a placebo. The primary end point was a composite of death or start of invasive mechanical ventilation within 14 days following randomization. Secondary end points included mortality and clinical evolution at days 14 and 28, and viral shedding at days 5 and 10.

RESULTS

The trial was stopped after 250 patients were included because of a slowing down of the pandemic in France. The intention-to-treat population comprised 123 and 124 patients in the placebo and hydroxychloroquine groups, respectively. The median age was 77 years (interquartile range 58-86 years) and 151/250 (60.4%) patients required oxygen therapy. The primary end point occurred in 9/124 (7.3%) patients in the hydroxychloroquine group and 8/123 (6.5%) patients in the placebo group (relative risk 1.12; 95% CI 0.45-2.80). The rates of positive SARS-CoV-2 RT-PCR tests at days 5 and 10 were 72.8% (75/103) and 57.1% (52/91) in the hydroxychloroquine group, versus 73.0% (73/100) and 56.6% (47/83) in the placebo group, respectively. No difference was observed between the two groups in any of the other secondary end points.

CONCLUSION

In this underpowered trial involving mainly older patients with mild to moderate COVID-19, patients treated with hydroxychloroquine did not experience better clinical or virological outcomes than those receiving the placebo.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04325893 (https://clinicaltrials.gov/ct2/show/NCT04325893).

Coexistence of Acquired Hemophilia and Antiphospholipid Serology in Monoclonal Gammopathy Patient

Acquired hemophilia is a rare coagulopathy with hemorrhage into the skin, muscle, or soft tissues and mucous membranes and caused by inhibitor antibodies, mainly against FVIII. We report a case of acquired hemophilia presenting with diffuse cutaneous hemorrhage and hemothorax. The patient was found to have acquired an FVIII inhibitor and a high titer of anti β2 glycoprotein 1 IgG and IgM, and anticardiolipin IgM in the context of IgA kappa-type monoclonal gammopathy. He received 3 injections of recombinant factor VII (rFVIIa) and blood transfusion. He was started on steroids and oral cyclophosphamide for 6 weeks. Thromboprophylaxis with aspirin at 100 mg/day was started 3 months after discharge. Antiphospholipid antibodies remained positive after 3 months as well as prolonged aPTT, factor VIII raised at 100%, and the inhibitor was not detected. The association between acquired hemophilia and antiphospholipid antibodies is rare and its distinction is mandatory because clinical presentation ranges from massive hemorrhage to thrombosis.

Discontinuing β-lactam treatment after 3 days for patients with community-acquired pneumonia in non-critical care wards (PTC): a double-blind, randomised, placebo-controlled, non-inferiority trial

BACKGROUND

Shortening the duration of antibiotic therapy for patients admitted to hospital with community-acquired pneumonia should help reduce antibiotic consumption and thus bacterial resistance, adverse events, and related costs. We aimed to assess the need for an additional 5-day course of β-lactam therapy among patients with community-acquired pneumonia who were stable after 3 days of treatment.

METHODS

We did this double-blind, randomised, placebo-controlled, non-inferiority trial (the Pneumonia Short Treatment [PTC]) in 16 centres in France. Adult patients (aged ≥18 years) admitted to hospital with moderately severe community-acquired pneumonia (defined as patients admitted to a non-critical care unit) and who met prespecified clinical stability criteria after 3 days of treatment with β-lactam therapy were randomly assigned (1:1) to receive β-lactam therapy (oral amoxicillin 1 g plus clavulanate 125 mg three times a day) or matched placebo for 5 extra days. Randomisation was done using a web-based system with permuted blocks with random sizes and stratified by randomisation site and Pneumonia Severity Index score. Participants, clinicians, and study staff were masked to treatment allocation. The primary outcome was cure 15 days after first antibiotic intake, defined by apyrexia (temperature ≤37·8°C), resolution or improvement of respiratory symptoms, and no additional antibiotic treatment for any cause. A non-inferiority margin of 10 percentage points was chosen. The primary outcome was assessed in all patients who were randomly assigned and received any treatment (intention-to-treat [ITT] population) and in all patients who received their assigned treatment (per-protocol population). Safety was assessed in the ITT population. This study is registered with ClinicalTrials.gov, NCT01963442, and is now complete.

FINDINGS

Between Dec 19, 2013, and Feb 1, 2018, 706 patients were assessed for eligibility, and after 3 days of β-lactam treatment, 310 eligible patients were randomly assigned to receive either placebo (n=157) or β-lactam treatment (n=153). Seven patients withdrew consent before taking any study drug, five in the placebo group and two in the β-lactam group. In the ITT population, median age was 73·0 years (IQR 57·0-84·0) and 123 (41%) of 303 participants were female. In the ITT analysis, cure at day 15 occurred in 117 (77%) of 152 participants in the placebo group and 102 (68%) of 151 participants in the β-lactam group (between-group difference of 9·42%, 95% CI -0·38 to 20·04), indicating non-inferiority. In the per-protocol analysis, 113 (78%) of 145 participants in the placebo treatment group and 100 (68%) of 146 participants in the β-lactam treatment group were cured at day 15 (difference of 9·44% [95% CI -0·15 to 20·34]), indicating non-inferiority. Incidence of adverse events was similar between the treatment groups (22 [14%] of 152 in the placebo group and 29 [19%] of 151 in the β-lactam group). The most common adverse events were digestive disorders, reported in 17 (11%) of 152 patients in the placebo group and 28 (19%) of 151 patients in the β-lactam group. By day 30, three (2%) patients had died in the placebo group (one due to bacteraemia due to Staphylococcus aureus, one due to cardiogenic shock after acute pulmonary oedema, and one due to heart failure associated with acute renal failure) and two (1%) in the β-lactam group (due to pneumonia recurrence and possible acute pulmonary oedema).

INTERPRETATION

Among patients admitted to hospital with community-acquired pneumonia who met clinical stability criteria, discontinuing β-lactam treatment after 3 days was non-inferior to 8 days of treatment. These findings could allow substantial reduction of antibiotic consumption.

FUNDING

French Ministry of Health.

Home intravenous antibiotherapy and the proper use of elastomeric pumps: Systematic review of the literature and proposals for improved use

Over several decades, the economic situation and consideration of patient quality of life have been responsible for increased outpatient treatment. It is in this context that outpatient antimicrobial treatment (OPAT) has rapidly developed. The availability of elastomeric infusion pumps has permitted prolonged or continuous antibiotic administration by dint of a mechanical device necessitating neither gravity nor a source of electricity. In numerous situations, its utilization optimizes administration of time-dependent antibiotics while freeing the patient from the constraints associated with infusion by gravity, volumetric pump or electrical syringe pump and, more often than not, limiting the number of nurse interventions to one or two a day. That much said, the installation of these pumps, which is not systematically justified, entails markedly increased OPAT costs and is liable to expose the patient to a risk of therapeutic failure or adverse effects due to the instability of the molecules utilized in a non-controlled environment, instability that necessitates close monitoring of their use. More precisely, a prescriber must take into consideration the stability parameters of each molecule (infusion duration, concentration following dilution, nature of the diluent and pump temperature). The objective of this work is to evaluate the different means of utilization of elastomeric infusion pumps in intravenous antibiotic administration outside of hospital. Following a review of the literature, we will present a tool for optimized antibiotic prescription, in a town setting by means of an infusion device.

Psychological impact of the SARS-CoV-2 outbreak on the staff of a French hospital

Background

The outbreak of SARS-CoV-2 has resulted in anxiety, depression and post-traumatic stress disorder (PTSD) among hospital staff. The factors associated with this psychological impact remain to be determined.

Methods

A cross-sectional study using an online questionnaire completed by the staff of a French hospital, two months after the SARS-CoV-2 outbreak.

Results

Among the 353 participants (of whom 67% were healthcare professionals), 32% had symptoms of anxiety, 16% of depression and 16% of PTSD. Eleven per cent had initiated or increased treatment with sleeping pills, and 6% with anxiolytics. In a multivariate analysis, factors independently associated with anxiety were: change of professional team, having a relative infected by SARS-CoV-2 and a new/increased treatment with sleeping pills or anxiolytics. The only factor associated with depression was the feeling of risk during professional practice. The factors associated with PTSD were: having a relative infected by SARS-CoV-2, the feeling of risk during professional practice, the increase in smoking and treatment with sleeping pills. The observance of transmission preventive measures (TPM) was not associated with the psychological impact of SARS-CoV-2. A personal history of SARS-CoV-2 infection and age < 36 years were associated with insufficient use of protective equipment. Age < 36 years, and being a healthcare professional were associated with the non-observance of social distancing.

Conclusion

The hospital staff displayed psychological consequences, resulting in the use of anxiolytics and sleeping pills. Belonging to a group with low-risk of severe disease was associated with lower observance of TPM.

The place of 18F FDG PET/CT in the management of patients with eosinophilic fasciitis: a case report

Eosinophilic fasciitis is a rare connective tissue disease with a clinical presentation of scleroderma-like disease. We report a case of a 36-year-old female patient with a 6-month history of progressive stiffness involving her forearms and legs with joint pain. Laboratory examinations showed hypereosinophilia and elevated C-reactive protein. 18F FDG PET/CT showed diffuse and symmetrical increased uptake in the fasciae of the upper and lower limbs, sparing both muscles and fat tissues. Guided biopsy and histologic examination confirmed the diagnosis of eosinophilic fasciitis. 18F FDG PET/CT is of great help in the diagnosis of eosinophilic fasciitis, as it can guide the biopsy where FDG uptake is strongest and also help rule out possible associated neoplasms.

Successful therapeutic plasma exchange in cold autoimmune hemolytic anemia in patient with disseminated tuberculosis

An association of autoimmune hemolytic anemia with disseminated tuberculosis is an exceedingly rare entity. We describe herein a case of cold hemolytic autoimmune anemia associated with miliary tuberculosis resolved with blood transfusions, therapeutic plasma exchange, and antituberculous agents. We discuss the advantages of therapeutic plasma exchange at an early stage in the management of this condition.

Clinical features and medical care factors associated with mortality in French nursing homes during the COVID-19 outbreak

Objectives

This study aimed to identify demographic, clinical and medical care factors associated with mortality in three nursing homes in France.

Methods

Two nursing homes were hospital-dependent, had connections with infection prevention and control departments, and had permanent physicians. A third nursing home had no direct connection with a general hospital, no infection control practitioner, and no permanent physician. The main outcome was death.

Results

During the first 3 months of the outbreak, 224 of 375 (59.7%) residents were classified as COVID-19 cases and 57 of 375 (15.2%) died. The hospital-dependent nursing homes had lower COVID-19 case fatality rates in comparison with the non-hospital-dependent nursing home (15 [6.6%] vs 38 [25.8%], OR 0.20 [0.11–0.38], p = 0.001). During the first 3 weeks of the outbreak, mortality in COVID-19 patients decreased if they had a daily clinical examination (OR: 0.09 [0.03–0.35], p = 0.01), three vital signs measurement per day (OR: 0.06 [0.01–0.30], p = 0.001) and prophylactic anticoagulation (OR: 0 [0.00–0.24], p = 0.001).

Conclusions

This study suggested that high mortality rates in some nursing homes during the COVID-19 outbreak might have been contributed by a lack of medical care management. Increasing human and material resources, encouraging presence of nursing home physicians and establishing a connection with general hospitals should be considered to deal with present and future health disasters in nursing homes.

Does a 5-day course of antibiotics in elderly patients with community-acquired pneumonia achieve the established criteria of clinical stability?

OBJECTIVE

We aimed to determine the proportion of elderly patients hospitalised for community-acquired pneumonia (CAP) in whom a 5-day antibiotic therapy would achieve clinical stability according to American Thoracic Society (ATS) criteria.

METHODS

Patients aged≥75 years, hospitalised for CAP between November 2018 and August 2019, were analysed retrospectively. The American Thoracic Society (ATS) clinical stability criteria (temperature≤37°C, heart rate≤100/min, respiratory rate≤24/min, systolic blood pressure≥90mmHg, oxygen saturation≥90% in room air) were assessed after five days of antibiotic therapy.

RESULTS

Seventy-five patients (mean age 88 years, 49% requiring oxygen therapy) were included. Six died, and at day 5, 36/69 (52%) fulfilled 4/5 stability criteria. The median duration of treatment was 9 days. In 28 patients (41%), it was ≤7 days.

CONCLUSION

In 52% of elderly patients with CAP, a 5-day treatment regimen resulted in clinical stability.

Efficacité d’un traitement par lopinavir/ritonavir chez des patients hospitalisés pour pneumopathie précoce à SARS-CoV-2 : une étude rétrospective

Introduction

Actuellement, il n’existe pas de traitement antiviral spécifique pour la prise en charge des pneumopathies sévères à SARS-CoV-2. Le Haut Conseil de santé publique français a recommandé l’utilisation du lopinavir/ritonavir (LPV/RTV) qui a montré une efficacité in vitro contre ce virus. La charge virale atteignant son maximum dans la première semaine de l’infection, l’efficacité de ce traitement est probablement optimale s’il est administré pour des formes de pneumopathies précoces survenant au cours de cette première semaine.

Matériels et méthodes

Nous avons conduit une étude rétrospective à partir des données du dossier patient d’un hôpital de 350 lits, comparant 2 prises en charge des pneumopathies précoces à SARS-CoV-2 : soins de support (SDS) seuls versus SDS associés à un traitement par LPV/RTV (400 mg/100 mg) 2 fois par jour, à l’exclusion de tout autre traitement. Les patients âgés de 18 à 80 ans, hospitalisés pour pneumopathie précoce à SARS-CoV-2 avec PCR positive, en service médecine hors unité de soins intensifs (USI), ayant reçu au moins 48 h de traitement par LPV/RTV débuté dans les 10 jours à partir du début des symptômes ont été inclus dans l’analyse. Le critère de jugement principal était le transfert en USI. Les critères de jugement secondaires étaient : la mortalité hospitalière, la mortalité à j7, la survenue d’un syndrome de détresse respiratoire aigu, et la durée totale d’hospitalisation.

Résultats

Entre le 2 mars et le 12 avril 2020, 59 patients parmi les 225 (26 %) hospitalisés pour infection à SARS-CoV-2 étaient éligibles pour l’analyse. Vingt (34 %) avaient reçu un traitement par LPV/RTV + SDS et 39 (66 %) avaient reçu des SDS seuls. Le délai médian entre le début des symptômes et l’hospitalisation était de 4 jours (IQR [3–6]) et la durée médiane de traitement par LPV/RTV était de 6 jours, (IQR [5–7]). Les 2 groupes étaient comparables en termes de comorbidité (âge [médiane 56 ans, IQR (46–65)], sexe, IMC, diabète, insuffisance cardiaque et respiratoire). Dix patients ont été transférés en USI : 3/29 (15 %) dans le groupe LPV/RTV + SDS et 7/39 (18 %) dans le groupe traitement par SDS seuls (p = 0,37). La mortalité hospitalière était similaire (2 patients dans le groupe SDS seuls et aucun dans le groupe LPV/RTV + SDS, p = 0,4). Nous n’avons pas retrouvé de différence pour les autres critères de jugement. Dans le modèle de régression logistique incluant le sexe, l’âge, et la prise de LPV/RTV, aucun facteur n’était associé de manière significative à une réduction du transfert en USI.

Conclusion

L’utilisation de LPV/RTV dans les pneumopathies précoces à SARS-CoV-2 n’a pas diminué significativement le taux de passage en USI ni la mortalité hospitalière. Nos résultats justifient cependant que la stratégie d’administration précoce d’une thérapie antivirale soit évaluée dans le cadre d’un essai clinique randomisé plus important.

Gestion d’une épidémie active de COVID-19 sur un camp de Roms étendu et séroprévalence élevée en post-épidémie

Introduction

Les consultations dédiées aux personnes en situation de précarité ont été arrêtés au début de la vague épidémique. Plusieurs résidents d’un grand camp de Roms originaires de Moldavie (composé de plus de 600 habitants) ont été hospitalisés pour des formes sévères de COVID-19. L’objectif de ce travail est de dresser le bilan de l’intervention mise en place et de décrire la séroprévalence du Covid-19 sur le camp en post-épidémie.

Matériels et méthodes

Fin mars, une « équipe mobile précarité Covid » hospitalière multidisciplinaire a été créée pour intervenir quotidiennement directement sur les camps et détecter et prendre en charge les cas probables de COVID-19. En post-épidémie, une action de dépistage sérologique du COVID-19, de la varicelle (chez les 11–40 ans sans antécédents) et du VIH-VHB-VHC a été réalisée. Une analyse descriptive des données cliniques et biologiques recueillies est présentée.

Résultats

L’équipe mobile est intervenue quotidiennement sur le camp du 31/03 au 27/05 (43 interventions) et a effectué un total de 841 consultations dont 128 (15,2 %) pour Covid probable et 106 (12,6 %) pour Covid possible (toux sans fièvre, rhinite). Vingt-deux patients (2,6 %) ont été évacués sur les urgences et 7 ont été secondairement hospitalisés. Seuls 4 cas de Covid probables ou prouvés ont accepté un hébergement en centre Covid, tous les autres ayant refusé. Sur la période, 42 cas ont été confirmés par PCR lorsqu’ils étaient hospitalisés ou quand les PCR ont pu être réalisées par l’équipe mobile à partir de mi-avril. La majorité des consultations sollicitées par les habitants du camp concernait des pathologies variées autres (diabète, HTA, grossesse, ectoparasitose, viroses infantiles, etc.). Suite à l’hospitalisation d’un cas de varicelle, à l’incertitude sur le niveau d’immunité varicelle et Covid et à la disponibilité des tests sérologiques sur l’hôpital, il a été décidé de réaliser une action de dépistage et de vaccination large sur une durée de 10 jours (25/5–5/6). Parmi les 211 personnes prélevées (65 % de femmes, âge médian 42 ans [26–51], 26 ≤ 18 ans), la séroprévalence du contact avec le SARS-CoV2 est de 75,6 % (152/211), du VIH de 3,5 % (6/170 dont 2 femmes enceinte), du VHC de 10,6 % (17/160), de l’AgHBs de 1,8 % (3/164) et de la varicelle de 92,21 % (71/77).

Conclusion

Ce large camps de Roms a fait face à une épidémie massive de SARS-CoV-2 qui n’a pas pu être prévenue mais a pu être gérée directement sur le camp par une équipe d’aller vers. Le diagnostic récent de 4 cas PCR+ questionne le seuil d’immunité de groupe. L’intégration à l’action du dépistage de viroses chroniques méconnues et des consultations de soins primaires a permis de répondre à la demande d’une population rencontrant des difficultés majeures d’accès aux soins exacerbé par le confinement.

Mycobacterium bovis infection of an aortobifemoral bypass graft with Streptococcus intermedius superinfection after intravesical bacillus Calmette-Guérin immunotherapy for bladder cancer

BACKGROUND

The Bacillus Calmette-Guerin (BCG) is a life-attenuated form of Mycobacterium bovis widely used as immunotherapy for localized bladder cancer. Adverse reactions to intravesical BCG instillations are rare.

CASE

We describe a 70-year-old man with a history of an aortobifemoral bypass graft, placement of a synthetic mesh for treatment of a ventral hernia and, most recently, superficial bladder cancer treated with BCG therapy. Ten months after his final intravesical BCG instillation, he complained of fever and asthenia. After 12 months of investigation, he was diagnosed with Mycobacterium bovis infection of his aortobifemoral bypass graft and abdominal mesh, with Streptococcus intermedius superinfection. The bypass graft was excised and replaced with an in situ arterial allograft, the abdominal mesh was removed, and treatment started with amoxicillin, isoniazid, rifampicin and ethambutol. Several additional vascular interventions were needed for allograft degradation, but 12 months after the final procedure, outcome was good.

DISCUSSION AND CONCLUSIONS

Among 35 cases of mycotic aneurysm reported after BCG therapy in the last 10 years, only one involved a vascular prosthesis. Surgical repair of such aneurysms using prosthetic grafts is commonly performed, associated with anti-mycobacterial treatment. Prognosis is poor with mortality of 14% (4/35) and a 26% rate of aneurysm recurrence under treatment (9/35).