Short Antibiotic Treatment Duration for Osteomyelitis Complicating Pressure Ulcers: A Quasi-experimental Study

Background

Osteomyelitis-complicating pressure ulcers are frequent among patients with spinal cord injuries (SCIs), and the optimal management is unknown. In our referral center, the current management is debridement and flap coverage surgeries, followed by a short antibiotic treatment. We aimed to evaluate patients' outcomes a year after surgery.

Methods

We performed a quasi-experimental retrospective before/after study on SCI patients with presumed osteomyelitis associated with perineal pressure ulcers. We included all patients who underwent surgery with debridement and flap covering, followed by effective antibiotic treatment, between May 1, 2016, and October 30, 2020. The effective antimicrobial treatment duration included the 10 days leading up to January 1, 2018 (before period), and the 5 to 7 days after (after period). We also compared the efficacy of 5-7-day vs 10-day antibiotic treatment and performed uni- and multivariable analyses to identify factors associated with failure.

Results

Overall, 415 patients were included (77.6% male patients; mean age ± SD, 53.0 ± 14.4 years). Multidrug-resistant organisms (MDROs) were involved in 20.7% of cases. Favorable outcomes were recorded in 69.2% of cases: 117/179 (65.3%) in the 10-day treatment group vs 169/287 (71.9%) in the 5-7-day treatment group (P = .153). The only factor associated with failure in the multivariate analysis was a positive culture from suction drainage (odds ratio, 1.622; 95% CI, 1.005-2.617; P = .046). Effective treatment duration >7 days and intraoperative samples negative for MDROs were not associated with better outcomes (P = .153 and P = .241, respectively).

Conclusions

A treatment strategy combining surgical debridement and flap covering, followed by 5 to 7 days of effective antibiotic treatment seems safe.

Long-term neuro-functional disability in adult patients with community-acquired bacterial meningitis

PURPOSE

To investigate the prevalence of neuro-functional disability and its determinants 12 months after community-acquired bacterial meningitis (CABM) in adult patients.

METHODS

In a prospective multicenter cohort study (COMBAT), all consecutive cases of CABM were enrolled and followed up for 12 months. Neuro-functional disability at 12 months was evaluated using a combination of the Glasgow Outcome Scale (functional disability), and the modified Rankin Disability Scale (physical disability). Factors associated with neuro-functional disability were identified by multivariate logistic regression.

RESULTS

Among 281 patients, 84 (29.9%) patients exhibited neuro-functional disability at 12 months: 79 (28.1%) with functional disability and 51 (18.1%) with physical disability. Overall, 6 patients (2.1%) died during the follow-up. The most common pathogen identified was Streptococcus pneumoniae (131/272, 48.2%); 77/268 patients (28.7%) had a physical disability at hospital discharge. Factors independently associated with 12-month neuro-functional disability were a pneumococcal meningitis (adjusted OR = 2.8; 95% confidence interval (CI) = [1.3; 6.7]), the presence of a physical disability at hospital discharge (aOR = 2.3; 95%CI = [1.2; 4.4]) and the presence of behavioral disorders at hospital-discharge (aOR = 5.9; 95%CI = [1.6; 28.4]). Dexamethasone use was not significantly associated with neuro-functional disability (OR = 0.2; 95%CI = [< 0.1;1.3]).

CONCLUSION

Neuro-functional disability is frequently reported 12 months after CABM. Detailed neurological examination at discharge is needed to improve the follow-up.

TRIAL REGISTRATION

NCT01730690.

Non-Legionella pneumophila serogroup 1 pneumonia: Diagnosis of a nosocomial legionellosis with the Biofire Pneumonia plus panel

We report a nosocomial case of Legionella pneumophila pneumonia caused by a serogroup 10 strain diagnosed with the Biofire® Pneumonia plus panel. Molecular investigations of the environment of the patient allowed us to identify the source of contamination.

Sarilumab in adults hospitalised with moderate-to-severe COVID-19 pneumonia (CORIMUNO-SARI-1): An open-label randomised controlled trial

Background

Patients with COVID-19 pneumonia can have increased inflammation and elevated cytokines, including interleukin (IL)-6, which might be deleterious. Thus, sarilumab, a high-affinity anti-IL-6 receptor antibody, might improve the outcome of patients with moderate-to-severe COVID-19 pneumonia.

Methods

We did a multicentric, open-label, Bayesian randomised, adaptive, phase 2/3 clinical trial, nested within the CORIMUNO-19 cohort, to test a superiority hypothesis. Patients 18 years or older hospitalised with COVID-19 in six French centres, requiring at least 3L/min of oxygen but without ventilation assistance and a WHO Clinical Progression Scale [CPS] score of 5 were enrolled. Patients were randomly assigned (1:1) via a web-based system, according to a randomisation list stratified on centre and with blocks randomly selected among 2 and 4, to receive usual care plus 400 mg of sarilumab intravenously on day 1 and on day 3 if clinically indicated (sarilumab group) or usual care alone (usual care group). Primary outcomes were the proportion of patients with WHO-CPS scores greater than 5 on the 10-point scale on day 4 and survival without invasive or non-invasive ventilation at day 14. This completed trial is closed to new participants and is registered with ClinicalTrials.gov, NCT04324073.

Findings

165 patients were recruited from March 27 to April 6, 2020, and 148 patients were randomised (68 patients to the sarilumab group and 80 to the usual care group) and followed up for 90 days. Median age was 61·7 years [IQR 53·0–71·1] in the sarilumab group and 62·8 years [56·0–71·7] in the usual care group. In the sarilumab group 49 (72%) of 68 were men and in the usual care group 59 (78%) of 76 were men. Four patients in the usual care group withdrew consent and were not analysed. 18 (26%) of 68 patients in the sarilumab group had a WHO-CPS score greater than 5 at day 4 versus 20 (26%) of 76 in the usual care group (median posterior absolute risk difference 0·2%; 90% credible interval [CrI] −11·7 to 12·2), with a posterior probability of absolute risk difference greater than 0 of 48·9%. At day 14, 25 (37%) patients in the sarilumab and 26 (34%) patients in the usual care group needed ventilation or died, (median posterior hazard ratio [HR] 1·10; 90% CrI 0·69–1·74) with a posterior probability HR greater than 1 of 37·4%. Serious adverse events occurred in 27 (40%) patients in the sarilumab group and 28 (37%) patients in the usual care group (p=0·73).

Interpretation

Sarilumab treatment did not improve early outcomes in patients with moderate-to-severe COVID-19 pneumonia. Further studies are warranted to evaluate the effect of sarilumab on long-term survival.

Funding

Assistance publique—Hôpitaux de Paris

A short course of corticosteroids reduces the risk of mechanical ventilation and death in patients with moderate to severe COVID 19 pneumonia: results of a retrospective monocentric cohort

Background

Reduced mortality at 28 days in patients treated with corticosteroids was demonstrated, but this result was not confirmed by certain large epidemiological studies. Our aim was to determine whether corticosteroids improve the outcomes of our patients hospitalized with COVID-19 pneumonia.

Methods

Our retrospective, single centre cohort study included consecutive patients hospitalized for moderate to severe COVID-19 pneumonia between March 15 and April 15 2020. An early short course of corticosteroids was given during the second phase of the study. The primary composite endpoint was the need for mechanical ventilation or mortality within 28 days of admission. A multivariate logistic regression model was used to estimate the propensity score, i.e. the probability of each patient receiving corticosteroid therapy based on the initial variables.

Results

About 120 consecutive patients were included, 39 in the “corticosteroids group”, 81 in the “no corticosteroids group”; their mean ages (±SD) were 66.4 ± 14.1 and 66.1 ± 15.2 years, respectively. Mechanical ventilation-free survival at 28 days was higher in the “corticosteroids group” than in the “no corticosteroids group” (71% and 29% of cases, respectively, p < .0001). The effect of corticosteroids was confirmed with HR .28 (95%CI .10–.79), p = .02. In older and comorbid patients who were not eligible for intensive care, the effect of corticosteroid therapy was also beneficial (HR .36 (95%CI .16–.80), p = .01).

Conclusion

A short course of corticosteroids reduced the risks of death or mechanical ventilation in patients with moderate to severe COVID-19 pneumonia in all patients and also in older and comorbid patients not eligible for intensive care.

Three New Cases of Melioidosis, Guadeloupe, French West Indies

Melioidosis has been detected in the Caribbean, and an increasing number of cases has been reported in the past few decades, but only 2 cases were reported in Guadeloupe during the past 20 years. We describe 3 more cases that occurred during 2016–2017 and examine arguments for increasing endemicity.

Intérêt de la corticothérapie dans la prise en charge des patients atteints de pneumopathie grave à SARS-CoV-2

Introduction

Au cours des pneumopathies à SARS-CoV-2, plusieurs stratégies thérapeutiques ont été proposées. La description d’une aggravation secondaire liée à un orage cytokinique a justifié l’utilisation de molécules anti-inflammatoires.

Du fait de la disponibilité, du faible coût, de son utilisation dans d’autres pathologies infectieuses, les corticoïdes ont été proposés pour la prise en charge des patients à ce stade de l’infection.

Nous avons analysé l’ensemble des données d’une cohorte de patients hospitalisés pour une infection grave à SARS-CoV-2.

L’objectif principal était d’étudier l’effet des corticoïdes sur l’incidence de ces évènements graves : intubation orotrachéale (IOT) ou décès (DC).

Matériels et méthodes

Les données ont été recueillies de manière rétrospective chez les patients hospitalisés pour une infection grave documentée par PCR (81 %) ou scanner thoracique (93 %) entre le 15/03/2020 et le 15/04/2020. Nous avons inclus les patients avec un score OMS = 5 et nécessitant un débit d’O₂ supérieur à 3 L/min pour maintenir une saturation > 94 %. Les patients décédés ou transférés en réanimation dans les 48 heures suivant l’admission ont été exclus, ainsi que ceux inclus dans des protocoles thérapeutiques.

La corticothérapie était administrée, après discussion pluridisciplinaire, à la posologie de 2 mg/kg équivalent prednisone de j1 à j3 puis 1 mg/kg les 3 jours suivants.

Les malades traités par corticoïdes (groupe CT) ont été comparés aux malades de même niveau de gravité pris en charge avant la mise en place de la RCP le 2 avril, et traités selon le même standard de soin (groupe sans CT).

Le critère d’évaluation principal était la survenue d’une IOT ou le DC.

Résultats

Un total de 120 patients a été analysé : 39 dans le groupe CT, 81 dans le groupe sans CT.

Les 2 groupes avaient la même moyenne d’âge (66,4 ± 14 ans groupe CT, 66,1 ± 15 ans groupe sans CT ; p = −0,9), même sexe ratio (p = 0,4), même niveau d’atteinte sur le TDM, même paramètres d’inflammation à l’entrée (CRP 135 ± 86 mg/L groupe CT et 118 ± 90 mg/L groupe sans CT).

Le nombre de patient en limitation de soin était le même dans chaque groupe, n = 14 (35 %) groupe CT, n = 27 (33 %) groupe sans CT (p = 0,9).

Le nombre de malades IOT ou DC était significativement différent dans le groupe CT n = 9 (23 %), comparativement au groupe sans CT n = 42 (53 %) avec p < 0,01.

Cette différence était plus importante chez les patients sans limitation de soins : groupe CT aucun IOT ou DC, groupe sans CT n = 20 (37 %).

La différence d’incidence d’IOT ou DC n’était pas significative dans le sous-groupe des patients limités, groupe CT n = 9 (64 %) et groupe sans CT n = 22 (81 %) IOT/DC (p = 0,27).

Conclusion

Même si le nombre limité de patients, le caractère rétrospectif et monocentrique de l’étude ne permettent pas d’extrapoler les données, nous confirmons l’intérêt de la corticothérapie pour la prise en charge des patients atteints de pneumopathie à SARS-CoV-2 aigu, à la phase inflammatoire. Les bénéfices à long terme restent à être évalués.

Evaluation of a web-based self-reporting method for monitoring international passengers returning from an area of emerging infection

OBJECTIVES

Emerging infectious diseases are a public health issue of international concern. Identifying methods to limit their expansion is essential. We assessed the feasibility of a screening strategy in which each traveler would actively participate in the screening process after an intercontinental flight by reporting their own health status via a web-based self-administered questionnaire.

PATIENTS AND METHODS

In 2015 and 2017, we invited passengers arriving at or departing from Pointe-à-Pitre international airport to answer an online health questionnaire during the four days following their arrival from or at Paris-Orly international airport. SPIRE 1 was intended for passengers arriving at Pointe-à-Pitre and was conceived as a pilot study. SPIRE 2 was an improved version of SPIRE 1 and consisted in three parts, which permitted to further assess the benefits of pre-flight request and email follow-up. Endpoints were the connection rates and response rates to online health questionnaire.

RESULTS

For SPIRE 1, 4/1038 travelers (0.4%) completed the two steps of the online health questionnaire. In SPIRE 2, response rates ranged from 3/1059 (0.3%) to 19/819 (2.3%). Response rates were significantly better when passengers were approached before their flight.

CONCLUSIONS

The yield of an online health questionnaire was unexpectedly low.

Antiretroviral exposure and comorbidities in an aging HIV-infected population: The challenge of geriatric patients

As HIV-infected adults on successful antiretroviral therapy (ART) are expected to have close to normal lifespans, they will increasingly develop age-related comorbidities. The objective of this cross-sectional study was to compare in the French Dat’AIDS cohort, the HIV geriatric population, aged 75 years and over, to the elderly one, aged from 50 to 74 years. As of Dec 2015, 16,436 subjects (43.8% of the French Dat’AIDS cohort) were aged from 50 to 74 (elderly group) and 572 subjects (1.5%) were aged 75 and over (geriatric group). Durations of HIV infection and of ART were slightly but significantly different, median at 19 and 18 years, and 15 and 16 years in the elderly and geriatric group, respectively. The geriatric group was more frequently at CDC stage C and had a lower nadir CD4. This group had been more exposed to first generation protease inhibitors and thymidine analogues. Despite similar virologic suppression, type of ART at the last visit significantly differed between the 2 groups: triple ART in 74% versus 68.2%, ART ≥ 4 drugs in 4.7% versus 2.7%; dual therapy in 11.6% versus 16.4% in the elderly group and the geriatric group, respectively. In the geriatric group all co-morbidities were significantly more frequent, except dyslipidemia, 4.3% of the elderly group had ≥4 co-morbidities versus18.4% in the geriatric group. Despite more co-morbidities and more advanced HIV infection the geriatric population achieve similar high rate of virologic suppression than the elderly population. A multidisciplinary approach should be developed to face the incoming challenge of aging HIV population.

Preliminary Favorable Outcome for Medically and Surgically Managed Extensively Drug-Resistant Tuberculosis, France, 2009-2014

We report 20 cases of extensively drug-resistant tuberculosis managed in France. Treatment was individualized and included bedaquiline and linezolid for most patients and surgery in 8 patients. At last follow-up (22 months), 19 patients had achieved conversion from positive to negative on culture testing. These promising results of comprehensive management obtained in a small series deserve confirmation.

Seroconversion of neurocysticercosis occurring after anti-helminthic treatment

We report two cases of symptomatic neurocysticercosis in two migrants whose negative serology delayed appropriate treatment for 9 and 6 months, respectively. Seroconversion occurred after treatment, which was associated with paradoxical reaction in one patient. Long-term outcome was good in both patients.

Artesunate for severe acute Plasmodium falciparum infection in a patient with myasthenia gravis

We report a case of severe malaria in a patient with underlying myasthenia gravis who was successfully treated with artesunate. The outcome was favorable. Artesunate seems to be a good option for patients with underlying myasthenia gravis disease because they benefit from a better toxicity profile than quinine.