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International audience; OBJECTIVES: Severe COVID-19 is associated with exaggerated complement activation. We assessed the efficacy and safety of avdoralimab (an anti-C5aR1 mAb) in severe COVID-19. DESIGN: FOR COVID Elimination (FORCE) was a double-blind, placebo-controlled study. SETTING: Twelve clinical sites in France (ICU and general hospitals). PATIENTS: Patients receiving greater than or equal to 5 L oxygen/min to maintain Spo 2 greater than 93% (World Health Organization scale ≥ 5). Patients received conventional oxygen therapy or high-flow oxygen (HFO)/noninvasive ventilation (NIV) in cohort 1; HFO, NIV, or invasive mechanical ventilation (IMV) in cohort 2; and IMV in cohort 3. INTERVENTIONS: Patients were randomly assigned, in a 1:1 ratio, to receive avdoralimab or placebo. The primary outcome was clinical status on the World Health Organization ordinal scale at days 14 and 28 for cohorts 1 and 3, and the number of ventilator-free days at day 28 (VFD28) for cohort 2. MEASUREMENTS AND MAIN RESULTS: We randomized 207 patients: 99 in cohort 1, 49 in cohort 2, and 59 in cohort 3. During hospitalization, 95% of patients received glucocorticoids. Avdoralimab did not improve World Health Organization clinical scale score on days 14 and 28 (between-group difference on day 28 of-0.26 (95% CI,-1.2 to 0.7; p = 0.7) in cohort 1 and-0.28 (95% CI,-1.8 to 1.2; p = 0.6) in cohort 3). Avdoralimab did not improve VFD28 in cohort 2 (between-group difference of-6.3 (95% CI,-13.2 to 0.7; p = 0.96) or secondary outcomes in any cohort. No subgroup of interest was identified. CONCLUSIONS: In this randomized trial in hospitalized patients with severe COVID-19 pneumonia, avdoralimab did not significantly improve clinical status at days 14 and 28 (funded by Innate Pharma, ClinicalTrials.gov number, NCT04371367).

To assess the risk of superinfection in patients with severe COVID-19 in an ICU receiving dexamethasone with or without tocilizumab, we performed an observational cohort study. Of 246 patients, 59 developed superinfections (mainly respiratory) leading to poorer prognoses. Adding tocilizumab to dexamethasone was not associated with an increased risk of superinfection in these patients.

Background: Patients presenting with acute myeloid leukemia (AML) at diagnosis are at high risk of severe complications and death, particularly with high white blood cell (WBC) count. In this retrospective study, we evaluate interest of early and systematic support in the intensive care unit (ICU) for AML with hyperleukocytosis (AML-HL) at diagnosis. Methods: Patients with AML-HL, defined by WBC > 50 × 10 9 /L, primary referred in ICU (“Early ICU”) without organ failure and before initiating chemotherapy induction were compared to patients first admitted in the Hematology Department who required a secondary transfer in ICU ( “Late ICU” ) or not ( “No ICU” ). Primary end point was mortality during the first month, and secondary end points were the use of life-sustaining therapies in ICU and risk factors for ICU transfer and mortality. Results: One hundred fifty-four patients were included: 77 (50%) to the group “No ICU” , 18 (12%) to “Late ICU” and 59 (38%) to “Early ICU” . Mortality at day 30 was higher in “Late ICU” than in "Early ICU" and "No ICU", with 27.8%; 16.9% and 2.6% respectively (P < 0.001). "Late ICU" patients had an increased use of life-sustaining therapy comparing to "Early ICU" patients (56% vs. 29%, P = 0.04). Conclusions: Early referral to ICU reduces morbidity and seems an effective strategy to reduce short-term mortality in AML-HL at diagnosis. J Hematol. 2020;9(4):109-115 doi: https://doi.org/10.14740/jh691

Dalbavancin is a glycopeptide antibiotic with a long half-life, recently marketed in Europe for skin and soft-tissue infections (SSTIs), but its real-life use is not well known. The aim of this study was to describe all first prescriptions in France over an 16-month period. A retrospective study on all adult patients receiving at least one dose of dalbavancin from 1 June 2017 to 31 September 2018 was performed (75 patients from 29 French hospitals). Data were collected via a standard questionnaire. Failure was defined as persistence or reappearance of signs of infection, and/or switch to suppressive antibiotic treatment, and/or death from infection. The main indications were bone and joint infection (BJI) (64.0%), endocarditis (25.3%), and SSTI (17.3%). The main bacteria involved were Staphylococcus aureus (51.4%), including methicillin-resistant S. aureus (MRSA) (19.4%), and coagulase-negative staphylococci (44.4%). Median minimum inhibitory concentrations (MICs) for staphylococci to vancomycin and dalbavancin ranged from 0.875-2.0 mg/L and 0.032-0.064 mg/L, respectively. Dalbavancin was used after a mean of 2.3 ± 1.2 lines of antimicrobial treatment. The main treatment regimens for dalbavancin were a two-dose regimen (1500 mg each) in 38 cases (50.7%) and a single-dose regimen (1500 mg) in 13 cases (17.3%). Overall, at the patient's last visit, clinical cure was observed in 54/68 patients, whilst failure was observed in 14/68 patients. First use of dalbavancin in France was mostly off-label. Most were due to BJI, often as rescue therapy for severe infections. Even in off-label situations, dalbavancin appears safe and effective.

Introduction The morbi-mortality related to infective endocarditis (IE) remains high as the epidemiology has changed over the last years: ageing of patients, comorbidity and healthcare-associated infections. To optimize IE management, a weekly endocarditis multidisciplinary meeting (EMM) was set up at our facility. We present the activity report of the EMM. Patients and methods All patients hospitalized for IE who were presented at the weekly EMM between January 2013 and June 2017 were prospectively included. The main objective was to assess the impact of the EMM on the management of community-acquired IE and healthcare-associated IE by analyzing in-hospital case fatality. Results Of the 1139 cases reported during the EMM for suspicion of IE, 493 (86% were definite cases) were selected for the study: 262 patients had community-acquired IE and 231 had healthcare-associated IE; 43% of IEs involved a valvular prosthesis. Following the EMM, infections were documented in 92% of cases: staphylococci in 45% of healthcare-associated IEs and streptococci in 44% of community-acquired IE cases. A septic embolism was diagnosed in 57% of cases. Finally, 49% of patients underwent surgery. The in-hospital case fatality was 12% with no significant difference between community-acquired IEs and healthcare-associated IEs. Case fatality was also significantly higher in elderly patients, in the absence of surgical treatment, initial heart failure, or Staphylococcus aureus IE. Conclusion The weekly EMM allows our facility to follow the European Society of Cardiology guidelines and to adapt the management of each patient to improve IE prognosis.

Background The role of respiratory coinfections at diagnosis of Pneumocystis jirovecii pneumonia (PcP) on clinical impact has been underestimated. Methods A retrospective observational study was conducted January 2011 to April 2019 to evaluate respiratory coinfections at diagnosis of PcP patients in 2 tertiary care hospitals. Coinfection was defined by identification of pathogens from P. jirovecii-positive samples. Results Of 7882 respiratory samples tested for P. jirovecii during the 8-year study, 328 patients with diagnosis of PcP were included. Mean age was 56.7 (SD 14.9) years, 193 (58.8%) were male, 74 (22.6%) had positive HIV serology, 125 (38.1%) had viral coinfection, 76 (23.2%) bacterial coinfection, and 90-day mortality was 25.3%. In the overall population, 90-day mortality was independently associated with solid tumor underlying disease (odds ratio [OR], 11.8; 95% confidence interval [CI], 1.90–78.0; P = .008), sepsis-related organ failure assessment score (SOFA) at admission (OR, 1.62; 95% CI, 1.34–2.05; P< .001), and cytomegalovirus (CMV) respiratory coinfection (OR, 3.44; 95% CI, 1.24–2.90; P = .02). Among HIV-negative patients, respiratory CMV coinfection was associated with worse prognosis, especially when treated with adjunctive corticosteroid therapy. Conclusions Respiratory CMV coinfection at PcP diagnosis was independently associated with increased 90-day mortality, specifically in HIV-negative patients.

Little data is available on extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E) rectal colonization in cancer patients admitted to the intensive care unit (ICU). We aimed to describe the epidemiology of ESBL-E in cancer patients hospitalized in the ICU compared with non-cancer patients. ESBL-E colonization was detected in 6.6% of 1,013 cancer patients and 6.4% of 1625 non-cancer patients. At admission, among the 172 colonized patients: 48/67 cancer patients and 78/105 non-cancer patients developed an infection, documented with an ESBL-E for 21% and 24% of them, respectively. The in-hospital mortality rate among colonized patients was 33% in cancer patients and 12% in non-cancer patients. In cancer patients, ESBL-E infections are rare but systematic rectal screening identifies high-risk population and guides empirical antibiotic therapy. It also contributes to being aware of the ICU microbiological ecology.

The aim of this study was to assess the diagnostic performances ofPPVE is a major issue in the growing CHD population. Diagnosis is challenging, and usual imaging tools are not always efficient or validated in this specific population. Particularly, the diagnostic yield ofA retrospective multicenter study was conducted in 8 French tertiary centers. Children and adult CHD patients who underwentA total of 66 cases of PPVE suspicion involving 59 patients (median age 23 years, 73% men) were included. Sensitivity, specificity, positive predictive value, and negative predictive value ofUsing

Background Coronavirus disease 2019 (COVID-19)-associated acute kidney injury (AKI) frequency, severity and characterization in critically ill patients has not been reported. Methods Single-centre cohort performed from 3 March 2020 to 14 April 2020 in four intensive care units in Bordeaux University Hospital, France. All patients with COVID-19 and pulmonary severity criteria were included. AKI was defined using Kidney Disease: Improving Global Outcomes (KDIGO) criteria. A systematic urinary analysis was performed. The incidence, severity, clinical presentation, biological characterization (transient versus persistent AKI; proteinuria, haematuria and glycosuria) and short-term outcomes were evaluated. Results Seventy-one patients were included, with basal serum creatinine (SCr) of 69 ± 21 µmol/L. At admission, AKI was present in 8/71 (11%) patients. Median [interquartile range (IQR)] follow-up was 17 (12–23) days. AKI developed in a total of 57/71 (80%) patients, with 35% Stage 1, 35% Stage 2 and 30% Stage 3 AKI; 10/57 (18%) required renal replacement therapy (RRT). Transient AKI was present in only 4/55 (7%) patients and persistent AKI was observed in 51/55 (93%). Patients with persistent AKI developed a median (IQR) urine protein/creatinine of 82 (54–140) (mg/mmol) with an albuminuria/proteinuria ratio of 0.23 ± 20, indicating predominant tubulointerstitial injury. Only two (4%) patients had glycosuria. At Day 7 after onset of AKI, six (11%) patients remained dependent on RRT, nine (16%) had SCr >200 µmol/L and four (7%) had died. Day 7 and Day 14 renal recovery occurred in 28% and 52%, respectively. Conclusion Severe COVID-19-associated AKI is frequent, persistent, severe and characterized by an almost exclusive tubulointerstitial injury without glycosuria.

Current guidelines recommend cefazolin as an alternative to antistaphylococcal penicillins (ASPs) in methicillin-susceptible Staphylococcus aureus (MSSA) infective endocarditis despite the lack of comparative study. The objective of this study was to evaluate the comparative outcomes of cefazolin vs. ASPs in MSSA infective endocarditis.This was a retrospective analysis of an observational multicentre cohort study using prospectively collected data from patients with MSSA endocarditis confirmed by endocarditis team and treated either with cefazolin or ASPs between July 2013 and December 2018. Patients were excluded if they received both treatments. The primary outcome was 90-day all-cause mortality.Of 210 patients included, 53 patients (25.2%) received cefazolin and 157 (74.8%) received ASPs. The overall 90-day mortality rate was 27.6% (58/210 patients), 24.5% (13/53) in the cefazolin group vs. 28.7% (45/157) in the ASP group (p 0.561). Premature antimicrobial discontinuation due to adverse events occurred less frequently with cefazolin than with ASPs (0/53 vs. 13/157 patients; p 0.042). In multivariate analysis, there was no difference in 90-day mortality between cefazolin and ASPs (adjusted odds ratio (aOR), 1.2; 95% confidence interval (CI), 0.49-2.91; p 0.681), while age (aOR, 1.06; 95% CI, 1.03-1.09; p 0.001), Charlson comorbidity index (aOR, 1.18; 95% CI, 1.02-1.36 p 0.023), cerebral embolism (aOR, 2.83; 95% CI, 1.33-6.14; p 0.007) and intensive care unit admission (aOR, 4.16; 95% CI, 1.89-9.59; p 0.001) were factors significantly associated with higher mortality.Cefazolin seems to be a possible alternative to ASPs in MSSA endocarditis. More studies are needed to confirm these results and determine which treatment should be recommended as first-line therapy.

BackgroundCOVID-19-associated acute kidney injury frequency, severity and characterisation in critically ill patients has not been reported.MethodsSingle-center cohort performed from March 3, 2020, to April 14, 2020 in 4 intensive care units in Bordeaux University Hospital, France. All patients with COVID19 and pulmonary severity criteria were included. AKI was defined using KDIGO criteria. A systematic urinary analysis was performed. The incidence, severity, clinical presentation, biological characterisation (transient vs. persistent acute kidney injury; proteinuria, hematuria and glycosuria), and short-term outcomes was evaluated.Results71 patients were included, with basal serum creatinine of 69 ± 21 µmol/L. At admission, AKI was present in 8/71 (11%) patients. Median follow-up was 17 [12–23] days. AKI developed in a total of 57/71 (80%) patients with 35% Stage 1, 35% Stage 2, and 30% Stage 3 acute kidney injury; 10/57 (18%) required renal replacement therapy. Transient AKI was present in only 4/55 (7%) patients and persistent AKI was observed in 51/55 (93%). Patients with persistent AKI developed a median urine protein/creatinine of 82 [54–140] (mg/mmol) with an albuminuria/proteinuria ratio of 0.23 ± 20 indicating predominant tubulo-interstitial injury. Only 2 (4%) patients had glycosuria. At Day 7 onset of after AKI, six (11%) patients remained dependent on renal replacement therapy, nine (16%) had SCr > 200 µmol/L, and four (7%) died. Day 7 and day 14 renal recovery occurred in 28% and 52 % respectively.ConclusionCOVID-19-associated AKI is frequent, persistent severe and characterised by an almost exclusive tubulo-interstitial injury without glycosuria.

Background In the management of infective endocarditis (IE), the presence of extracardiac complications has an influence on both diagnosis and treatment. Current guidelines suggest that systematic thoracoabdominal-pelvic computed tomography (TAP-CT) may be helpful. Our objective was to describe how systematic TAP-CT affects the diagnosis and the management of IE. Methods In this multicenter cohort study, between January 2013 and July 2016 we included consecutive patients who had definite or possible IE according to the Duke modified criteria, validated by endocarditis teams. We analyzed whether the Duke classification and therapeutic management were modified regarding the presence or the absence of IE-related lesion on CT and investigated the tolerance of this examination. Results Of the 522 patients included in this study, 217 (41.6%) had 1 or more IE-related lesions. On the basis of CT results in asymptomatic patients, diagnostic classification was upgraded from possible endocarditis to definite endocarditis for only 4 cases (0.8%). The presence of IE-related lesions on CT did not modify the duration of antibiotic treatment (P = .55), nor the decision of surgical treatment (P = .39). Specific treatment of the lesion was necessary in 42 patients (8.0%), but only 9 of these lesions (1.9%) were asymptomatic and diagnosed only on the TAP-CT. Acute kidney injury (AKI) within 5 days of CT was observed in 78 patients (14.9%). Conclusions The TAP-CT findings slightly affected diagnosis and treatment of IE in a very small proportion of asymptomatic patients. Furthermore, contrast media should be used with caution because of the high risk of AKI.

BACKGROUND: There is currently a lack of evidence for the relative effectiveness of partial resection (PR) and total resection (TR) before managing abdominal aortic graft infection (AGI). Most authorities agree that TR is mandatory for intracavitary AGI in patients with favorable conditions but there is an increasing number of patients with severe comorbidities for whom this approach is not suitable, resulting in a prohibitive mortality rate. The purpose of this study was to determine the most appropriate indication for TR or PR. METHODS: A meta-analysis was conducted on the rates of early/late mortality, amputations and reinfection. A meta-regression was performed with 8 variables: patient age, male prevalence, presence of virulent or nonvirulent organisms, urgency, omentoplasty and follow-up. RESULTS: Twenty-one studies and 1.052 patients were included. For TR and PR the rates of early mortality and reinfection were 16.8% and 10.5%, 11% and 27% respectively. For TR urgency and male gender were associated with increased rate of early mortality and male gender, PDF and virulent organisms were associated with increased risk of reinfection. For PR no statistical correlation was analyzable except for PDF with increased risk of reinfection. CONCLUSIONS: Early mortality rates are higher for TR and reinfection rates are higher for PR. For TR early mortality increases in urgent cases and it is suggested that alternative option must be discussed, reinfection decreases in the presence of nonvirulent organisms and TR seems optimal. For TR and PR reinfection increases in presence of PDF and alternative technique may be more appropriate.

Objective Pneumocystis pneumonia (PCP) is now predominantly observed in immunosuppressed non-HIV-infected patients. The sensitivity of the PCR is here higher than direct examination (DE) of respiratory secretions because the infection is caused by a lower inoculum of Pneumocystis jirovecii (P. jirovecii). The objective of our retrospective study was to assess the contribution of quantitative PCR (qPCR) in the diagnosis of PCP. Patients and methods All patients hospitalized for PCP suspicion with a positive qPCR were included. Irrespective of the qPCR value, patients were initially classified into two groups (infection and colonization [PCP ruled out]) based on clinical, radiological, and microbiological data. Both groups were then compared based on the qPCR value. Results Between 2013 and 2016, 150 patients were included; 75% of them were not infected with HIV. The diagnosis of PCP was retained for 129 patients and rejected for 21 patients. The DE was negative in 60% of PCP cases. The median value of qPCR was 76,650 copies/mL among infected patients and 3220 copies/mL among colonized patients. The threshold corresponding to a specificity of 100% was 56,000 copies/mL. The optimal value to distinguish an infection from a colonization was 10,100 copies/mL. Conclusion Our study confirms the diagnostic value of the qPCR in immunosuppressed patients, especially when the DE is negative. When the qPCR is ˂ 56,000 copies/mL, the result should be interpreted based on the clinical context and paraclinical examinations.

The usage of left-ventricular-assist device (LVAD) is increasing in patients presenting with advanced heart failure. However, device-related infections are a challenge to recognize and to treat, with an important morbidity and mortality rate. The role of nuclear medicine imaging remains not well established for LVAD infections. The present study compared the accuracy of positron emission tomography/computed tomography with 18F-fludeoxyglucose (18F-FDG PET/CT) and radiolabeled leucocyte scintigraphy for the diagnosis of infections in patients supported with a continuous-flow LVAD. From a prospectively maintained database, we retrospectively analyzed the diagnostic performance of radiolabeled leucocyte scintigraphy and 18F-FDG PET/CT in 24 patients who had a LVAD with a suspected device-related infection. Both examinations were routinely performed in all patients. Infection was assessed by the International Society for Heart and Lung Transplantation criteria. Twenty-four patients were included: 15 had a specific VAD infection (5 cardiac-LVAD and 10 driveline), 6 had a VAD-related infection, while 3 patients had a non-VAD-related infection. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 95.2%, 66.7%, 95.2%, 66.7%, and 91.6%, respectively, for 18F-FDG-PET; and 71.4%, 100%, 100%, 33.3%, and 75%, respectively, for leucocyte scintigraphy. 18F-FDG PET/CT showed significantly higher sensitivity (P = 0.01) than leucocyte scintigraphy. 18F-FDG PET/CT and radiolabeled leucocyte scintigraphy single-photon emission computed tomography carry high performance in the diagnostic of LVAD infections. 18F-FDG PET/CT shows significantly higher sensitivity and could be proposed as first-line nuclear medicine procedure.

Background Pulmonary prosthetic valve and conduit infective endocarditis (PPVE) is a major issue in the growing congenital heart disease (CHD) population. Diagnosis is challenging and usual imaging tools are not always efficient nor validated in this specific population. Particularly, the diagnostic yield of 18F-fluorodeoxyglucose (18F-FDG) Positron Emission Tomography (PET)/Computed Tomography (CT) remains poorly studied in PPVE. Aims The Aim of this study was to assess the diagnostic performances of 18F-FDG PET/CT in CHD patients with PPVE suspicion. Methods A retrospective multicenter study was conducted in 8 French tertiary centers. Children and adult CHD patients who underwent a 18F-FDG PET/CT in the setting of PPVE suspicion between January 2010 and May 2020 were included. The cases are initially classified as definite, possible or rejected PPVE regarding the modified Duke criteria (DC) and finally by the Endocarditis Team consensus. The result of 18F-FDG PET/CT had been compared to final diagnosis consensus used as gold-standard in our study. Results Sixty-six cases of PPVE suspicion involving 59 patients (median age 23, 73% male) were included. Sensitivity, specificity, positive predictive value and negative predictive value of 18F-FDG PET/CT in PPVE suspicion were respectively: 79.1% (68.4–91.4), 72.7% (60.4–85.0), 91.9% (79.6–100) and 47.1% (34.8–59.4). 18F-FDG PET/CT findings would help to rightly reclassify 43% of possible PPVE to definite PPVE. Conclusion Using 18F-FDG PET/CT improves the diagnostic accuracy of the Duke Criteria in CHD patients with suspected PPVE. Its high positive predictive value could be helpful in routine to shorten diagnosis and treatment delays and improve clinical outcomes.

Introduction La pneumopathie a Pneumocystis jirovecii (PcP) est associee a un recours frequent aux soins intensifs (USI), a la ventilation mecanique et a un pronostic pejoratif. L’initiation precoce d’une corticotherapie adjuvante dans les formes severes de PcP permet une reduction significative de la mortalite chez les patients infectes par le virus de l’immunodeficience humaine (VIH), mais son benefice reste controverse chez les patients non infectes par le VIH (NVIH). Chez les patients hospitalises en USI, l’immunodepression et le recours a la corticotherapie au cours d’infection respiratoire severe comme la grippe est associee au risque de co-infections respiratoires ainsi qu’a la mortalite. L’objectif de cette etude etait d’evaluer l’epidemiologie et l’impact pronostique des co-infections respiratoires lors du diagnostic de PcP. Materiels et methodes Nous avons conduit une etude observationnelle retrospective, bicentrique, entre janvier 2011 et avril 2019, incluant tous les patients pour lesquels le diagnostic de PcP a ete etabli apres confirmation mycologique (examen direct positif et/ou qPCR positive) sur des prelevements respiratoires profonds (liquide d’aspiration tracheo-bronchique, lavage broncho-alveolaire (LBA)). La co-infection respiratoire etait definie par la detection d’un autre micro-organisme pathogene sur le meme prelevement que celui ayant conduit au diagnostic de PcP. Les analyses ont ete realisees sur la population globale puis sur les sous-groupes VIH et NVIH. Resultats A partir des 7 882 prelevements respiratoires analyses durant la periode de l’etude, 328 patients ont ete inclus. La moyenne d’âge etait de 56,7 ± 14,9 ans, 193 (58,8 %) etaient des hommes, 74 (22,6 %) etaient infectes par le VIH, le score SOFA moyen a l’admission etait de 3,5 ± 3,3, 168 (51,2 %) patients ont recu une corticotherapie adjuvante et la mortalite a J-90 etait de 25,3 %. Une co-infection respiratoire a ete mise en evidence chez 180 patients (54,9 %): 125 (38,1 %) co-infections virales dont 79 (24,1 %) a cytomegalovirus (CMV), 76 (23,2 %) co-infections bacteriennes et 36 (11 %) co-infections parasitaires ou fongiques. En analyse multivariee, la presence d’une co-infection respiratoire par le CMV (OR 3,44; 1,24-2,90; p = 0,02), de tumeur solide en cours de prise en charge (OR 11,8; 1,90-78; p = 0,008) et un score SOFA eleve a l’admission (OR 1,62; 1,34-2,05; p Conclusion La co-infection respiratoire par le CMV au diagnostic de PcP est independamment associee au risque de mortalite a J-90, en particulier chez les patients NVIH avec une corticotherapie adjuvante. Ces resultats suggerent que la recherche de co-infection respiratoire a CMV devrait etre systematiquement realisee au diagnostic de PcP dans le LBA, notamment avant d’envisager une corticotherapie adjuvante chez les patients NVIH. Des etudes interventionnelles prospectives prenant en compte la presence du CMV au diagnostic de PcP afin d’evaluer l’interet de la corticotherapie adjuvante et/ou du traitement anti-CMV sur le pronostic des patients NVIH semblent donc justifiees.

Introduction La cefazoline a ete montree comme etant une alternative efficace aux penicillines anti-staphylococciques (PAS) mais uniquement dans les bacteriemies a Staphylocoque dore sensible a la meticilline (SASM). Pourtant, les recommandations actuelles americaines et europeennes recommandent la cefazoline en alternative aux PAS dans l’endocardite infectieuse alors meme que cette molecule pourrait etre concernee par un effet inoculum. L’objectif de cette etude etait donc de comparer l’efficacite entre la cefazoline et les PAS dans les endocardites a SASM. Materiels et methodes Dans cette etude de cohorte bicentrique, tous les patients dont le diagnostic d’endocardite a SASM a ete retenu en reunion de concertation pluridisciplinaire endocardite entre juillet 2013 et decembre 2018 ont ete screenes. Les patients etaient inclus s’ils avaient recu soit un traitement par cefazoline, soit un traitement par PAS. Le critere de jugement principal etait la mortalite toute cause a 90 jours (J90). Les criteres de jugements secondaires etaient les emboles symptomatiques sous traitement, la rechute, la duree de la bacteriemie et les arrets de traitement pour effets indesirables. Resultats Dans cette etude, 225 patients ont ete inclus, 182 (72,0 %) dans le groupe PAS et 63 (28 %) dans le groupe cefazoline. La duree mediane de traitement etait la meme dans les deux groupes (32 jours). La mortalite globale a J90 etait de 28,4 % (64 sur 225 patients). Il n’y avait pas de difference de mortalite entre le groupe cefazoline et le groupe PAS (p = 0,91) en analyse multivariee. En revanche, l’âge (p Conclusion Nous n’avons pas retrouve de difference d’efficacite ou de tolerance entre cefazoline et penicilline anti-staphylococcique pour le traitement des endocardites a SASM. Les facteurs associes a une sur-mortalite ainsi que les facteurs protecteurs etaient ceux classiquement retrouves dans la litterature.

Rationale & Objective: The usefulness of measures of neutrophil gelatinase-associated lipocalin (NGAL) in urine or plasma obtained on clinical laboratory platforms for predicting acute kidney injury (AKI) and AKI requiring dialysis (AKI-D) has not been fully evaluated. We sought to quantitatively summarize published data to evaluate the value of urinary and plasma NGAL for kidney risk prediction. Study Design: Literature-based meta-analysis and individual-study-data meta-analysis of diagnostic studies following PRISMA-IPD guidelines. Setting & Study Populations: Studies of adults investigating AKI, severe AKI, and AKI-D in the setting of cardiac surgery, intensive care, or emergency department care using either urinary or plasma NGAL measured on clinical laboratory platforms. Selection Criteria for Studies: PubMed, Web of Science, Cochrane Library, Scopus, and congress abstracts ever published through February 2020 reporting diagnostic test studies of NGAL measured on clinical laboratory platforms to predict AKI. Data Extraction: Individual-study-data meta analysis was accomplished by giving authors data specifications tailored to their studies and requesting standardized patient-level data analysis. Analytical Approach: Individual-study-data meta analysis used a bivariate time-to-event model for interval-censored data from which discriminative ability (AUC) was characterized. NGAL cutoff concentrations at 95% sensitivity, 95% specificity, and optimal sensitivity and specificity were also estimated. Models incorporated as confounders the clinical setting and use versus nonuse of urine output as a criterion for AKI. A literature-based meta-analysis was also performed for all published studies including those for which the authors were unable to provide individual-study data analyses. Results: We included 52 observational studies involving 13,040 patients. We analyzed 30 data sets for the individual-study-data meta-analysis. For AKI, severe AKI, and AKI-D, numbers of events were 837, 304, and 103 for analyses of urinary NGAL, respectively; these values were 705, 271, and 178 for analyses of plasma NGAL. Discriminative performance was similar in both meta-analyses. Individual-study-data meta-analysis AUCs for urinary NGAL were 0.75 (95% CI, 0.73-0.76) and 0.80 (95% CI, 0.79-0.81) for severe AKI and AKI-D, respectively; for plasma NGAL, the corresponding AUCs were 0.80 (95% CI, 0.790.81) and 0.86 (95% CI, 0.84-0.8 6). Cutoff concentrations at 95% specificity for urinary NGAL were >580 ng/mL with 27% sensitivity for severe AKI and >589 ng/mL with 24% sensitivity for AKI-D. Corresponding cutoffs for plasma NGAL were >364 ng/mL with 44% sensitivity and >546 ng/mL with 26% sensitivity, respectively. Limitations: Practice variability in initiation of dialysis. Imperfect harmonization of data across studies. Conclusions: Urinary and plasma NGAL concentrations may identify patients at high risk for AKI in clinical research and practice. The cutoff concentrations reported in this study require prospective evaluation.

Glial fibrillary acidic protein is a recently identified rare cause of autoimmune encephalomyelitis, in which the cerebrospinal fluid shows lymphocytic pleocytosis accompanied by linear perivascular radial gadolinium enhancement in the brain. We report a 19-year-old man admitted to the intensive care unit with suspected viral meningoencephalitis. Magnetic resonance imaging showed mild encephalopathy with a reversible splenial lesion. He quickly developed a coma and acute respiratory failure. Glial fibrillary acidic protein antibodies and human parainfluenza virus were detected by cerebrospinal fluid exams. He was treated with intravenous immunoglobulin, methylprednisolone pulses, plasma exchange and then six infusions of cyclophosphamide plus two of rituximab, which resulted in a total recovery.

In the last decades, the number of cancer patients admitted in intensive care units (ICUs) for septic shock has dramatically increased. However, prognosis data remain scarce. To assess the 180-day mortality rate in cancer patients admitted to the ICU for septic shock, a 5-year prospective study was performed. All adult patients admitted for septic shock were included and categorized into the following two groups and four subgroups: cancer patients (solid tumor or hematological malignancy) and non-cancer patients (immunocompromised or not). Data were collected and compared between the groups. Upon early ICU admission, the decision to forgo life-sustaining therapy (DFLST) or not was made by consultation among hematologists, oncologists, and the patients or their relatives. During the study period, 496 patients were admitted for septic shock: 252 cancer patients (119 hematological malignancies and 133 solid tumors) and 244 non-cancer patients. A DFLST was made for 39% of the non-cancer patients and 52% of the cancer patients. The 180-day mortality rate among the cancer patients was 51% and 68% for those with hematological malignancies and solid cancers, respectively. The mortality rate among the non-cancer patients was 44%. In a multivariate analysis, the performance status, Charlson comorbidity index, simplified acute physiology score 2, sequential organ failure assessment score, and DFLST were independent predictors of 180-day mortality. Despite early admission to the ICU, the 180-day mortality rate due to septic shock was higher in cancer patients compared with non-cancer patients, due to excess mortality in the patients with solid tumors. The long-term prognosis of cancer patients with septic shock is modulated by their general state, severity of organ failure, and DFLST.

Resume Mieux connaitre la maladie de Gaucher (MG) et sa prise en charge permet au patient d’ameliorer sa qualite de vie. Pour atteindre cet objectif, il apparait essentiel de mettre a la disposition des malades et de leur entourage un dispositif educatif. Le programme national d’education therapeutique du patient (ETP) dedies aux adultes atteints de la MG de type 1, coordonne par un pharmacien et experimente en Aquitaine, est progressivement deploye sur l’ensemble du territoire.

We report a case of a 12 year old child with a ventricular septal defect (VSD) and right-sided MRSA endocarditis complicated by pulmonary septic emboli. The patients was treated successfully with daptomycin in combination with gentamicin and rifampin, followed by surgery to excise the vegetation and close the VSD.

Streptococcus species are important causes of infective endocarditis but species identification remains challenging. We report two cases of infective endocarditis due to Streptococcus tigurinus-like organisms, which were first identified by 16S ribosomal RNA gene sequence analysis and subsequently confirmed using phylogeny based on the analysis of the shetA gene encoding exfoliative toxin.

Objective: To determine the most appropriate indication for total resection (TR) or partial resection(PR) of infected aortic grafts.Methods: A meta-analysis was conducted on the rates of early/late mortality, amputations and reinfection. A meta-regression was performed with 8 variables: patient age, male prevalence, presence of prosthetic duodenal fistula (PDF), presence of virulent or nonvirulent organisms, urgency, omentoplasty and follow-up.Results: For TR and PR, the rates of early mortality and reinfection were 16.8% and 10.5%, 11% and 27% respectively.For TR, the rates of early mortality and reinfection for in situ reconstruction with allografts and veins were 23% and 10.7%, 10.5% and 2.8% respectively.For TR, urgency, male gender and omentoplasty all had a negative correlation with early mortality. Omentoplasty had a positive correlation with late mortality. Male gender, PDF and virulent organisms had a negative correlation with reinfection, whereas nonvirulent organisms had a positive correlation. Presence of PDF and follow-up had a negative correlation with amputation, whereas male gender had a positive correlation. For PR, no statistical correlation was analyzable except a negative correlation between PDF and reinfection.Conclusion: For TR, operative mortality increases in males, and in emergencies, so total removal of the infected aortic graft seems not advisable, and alternative interventions should be considered. With regard to the risk of reinfection, TR appears recommendable in the presence of nonvirulent infectious organisms, but there is increased risk in the presence of virulent organisms and PDF, and so other optimal options may be discussed.For PR results were not analyzable except for a negative correlation in the presence of PDF.

The usage of left-ventricular-assist device (LVAD) is increasing in patients presenting with advanced heart failure. However, device-related infections are a challenge to recognize and to treat, with an important morbidity and mortality rate. The role of nuclear medicine imaging remains not well established for LVAD infections. The present study compared the accuracy of positron emission tomography/computed tomography withFrom a prospectively maintained database, we retrospectively analyzed the diagnostic performance of radiolabeled leucocyte scintigraphy andTwenty-four patients were included: 15 had a specific VAD infection (5 cardiac-LVAD and 10 driveline), 6 had a VAD-related infection, while 3 patients had a non-VAD-related infection. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 95.2%, 66.7%, 95.2%, 66.7%, and 91.6%, respectively, for

Guidelines for preventing Pneumocystis pneumonia (PCP) in HIV patients are based on CD4 below 200/mm3. Such cut-off value is suggested to guide prophylaxis in non-HIV conditions (NHIV) especially in autoimmune and inflammatory diseases (AD). We aimed to determine if CD4 could be used to guide PCP prophylaxis in AD.CD4 and lymphocyte-count were retrospectively studied in patients diagnosed with PCP between January 2013 and February 2016.129 patients were included. The median CD4-count was 302/mm3 in AD, which was significantly higher than in HIV patients (19/mm3; p0.0001). Fifty percent (n=10) of AD patients had CD4 counts greater than 300/mm3.Prophylaxis for PCP cannot rely solely on CD4-count in NHIV patients especially in AD.

Introduction L’hemoculture est un examen cle pour le diagnostic positif d’endocardite infectieuse (EI). Afin de detecter certaines bacteries dites fastidieuses et d’eviter l’absence de documentation, il est d’usage de repeter les hemocultures (au moins 3 series) et de les conserver 15 a 21 jours. Cependant, les donnees objectives concernant le delai de positivite des hemocultures en cas d’EI manquent. Materiels et methodes Afin de determiner le delai de positivite des hemocultures au cours de l’EI, tous les patients ayant une EI documentee par hemoculture bacterienne et presentes en RCP ont ete prospectivement inclus. L’etude a ete menee dans un centre hospitalier universitaire entre 2013 et 2017. Resultats Durant l’etude, 441 EI ont ete presentees en RCP et 401 etaient documentees avec une bacterie (91 %), dont 380 par des hemocultures. Dans 21 cas, la documentation bacteriologique reposait sur une serologie ou une technique de biologie moleculaire. L’information concernant le delai de positivite etait disponible pour 237 patients (135 EI sur valve native et 102 sur valve prothetique) et 183 d’entre eux (77 %) ont eu 4 series aero-anaerobies ou plus d’hemocultures. Parmi les 988 series prelevees, 978 (99 %) etaient positives. Les principales bacteries documentees etaient des staphylocoques (41 %), des streptocoques (32 %) et des enterocoques (21 %). Le delai median de positivite de la premiere hemoculture etait de 11,4 heures [interquartile = 7,3h–16,7 h] et le delai maximum de 93 heures. Il n’existait pas de difference de delai de positivite entre les 123 EI communautaires et les 114 EI associees aux soins : 11,2 h versus 11,4 h. Le delai de pousse median etait de 9,9 h pour les EI a Staphylococcus aureus versus 18 h pour les staphylocoques a coagulase negative, 11 h pour les enterocoques et 10,4 h pour les streptocoques. En cas d’EI compliquee d’emboles extracardiaques, le delai de positivite median etait de 9,7 h en cas de S. aureus versus 12,3 h pour les autres bacteries. Conclusion En cas d’EI, notre etude montre que le delai median de positivite de la premiere hemoculture bacterienne est de l’ordre de 11 h et aucune hemoculture ne devient positive au-dela du 4e jour. Les bacteries a pousse lente sont identifiees par d’autres moyens diagnostiques. On peut donc s’interroger sur la necessite de multiplier et de conserver les hemocultures plus de 5 jours en cas de suspicion d’endocardite.

Introduction De precedentes etudes ont deja demontre une prevalence augmentee des gammapathies monoclonales (11,5 a 19 %) et un sur-risque de myelome multiple (risque relatif de 6 a 51) chez les patients presentant une maladie de Gaucher. L’objectif principal de cette etude etait d’evaluer l’incidence des hemopathies lymphoides malignes chez les patients de la cohorte francaise de la maladie de Gaucher presentant une gammapathie monoclonale associee a une maladie de Gaucher de type 1. Patients et methodes Nous avons realise une etude de cohorte nationale multicentrique retrospective (01/01/1980–31/12/2018), incluant les patients recenses dans le registre francais de la maladie de Gaucher presentant une gammapathie monoclonale associee a une maladie de Gaucher de type 1. Le critere de jugement principal etait l’incidence des hemopathies lymphoides malignes observees au cours du suivi, que nous avons compare a l’incidence connue de 1/100 patients-annees chez les patients presentant une gammapathie monoclonale dans la population generale. Le critere de jugement secondaire etait la mortalite en lien une hemopathie lymphoide maligne. Resultats Parmi les 502 patients du registre francais de la maladie de Gaucher, 57 presentant une gammapathie monoclonale ont ete inclus. Sur une duree de suivi totale de 822 patients-annees, 3 hemopathies lymphoides malignes (1 myelome multiple, 1 lymphome du MALT et 1 leucemie lymphoide chronique) sont survenues, soit une incidence de 0,365/100 patients-annees, statistiquement non-superieure a l’incidence de la population generale (p = 0,988). La mortalite en lien avec une hemopathie lymphoide maligne etait de 1 cas sur l’ensemble de la cohorte, soit une incidence de 0,122/100 patients-annees. Conclusion L’incidence des hemopathies lymphoides malignes chez les patients presentant une gammapathie monoclonale n’est pas superieure dans le cadre de la maladie de Gaucher de type 1 par rapport a la population generale.

Introduction The Bentall procedure is a cardiac surgery involving graft replacement of the aortic valve, aortic root and ascending aorta. Graft infection after Bentall's procedure (BGI) is infrequent but severe, and often difficult to diagnose and treat. Patients and Methods A retrospective cohort study was performed using the Bordeaux endocarditis database of adult patients admitted to the Bordeaux University Medical Hospital for BGI between 2008 and 2014. Published case reports were identified in the literature. Results We identified 10 BGI patients in the database and 13 in the literature. The majority of infections were late-onset (20/23) and occurred as a result of gram positive cocci bacterial infection (16/22). Detailed diagnoses of the described BGI were determined using echocardiography, computed tomography (CT) and positron emission tomography/CT (PET/CT). Labeled-leukocyte scintigraphy was not reported in any case. Prolonged antibiotic therapy and surgery were found to be the treatment of choice for BGI; however it was not always possible to perform a surgical intervention. Clinical relapses occurred even with a negative PET/CT, while PET/CT consistently positive for BGI occurred in the absence of clinical relapse. This suggests that the use of PET/CT for follow-up is questionable. Conclusion Diagnosis of BGI is difficult, due to the combination of clinical, biological, and radiological observations obtained through transesophageal echocardiography and CT. PET/CT is an alternative method to diagnosis BGI, but its impact on clinical management remains unclear. Current data suggests that if surgical replacement of the prosthesis is not possible, patients should be treated with prolonged antibiotic therapy.

Introduction La maladie de Gaucher (MG) est une maladie lysosomale autosomique recessive, due a un deficit de l’activite enzymatique en glucocerebrosidase, conduisant a l’accumulation de son substrat, le glucosylcedamide, dans les macrophages du foie, de la rate et de la moelle osseuse. Le type 1 (le plus frequent) et le type 3 (atteinte neurologique) peuvent etre traites, alors que le type 2 (pronostic tres sombre) ne beneficie pas de traitement. La MG se manifeste par une hepatomegalie, une splenomegalie une thrombopenie, une anemie et des evenements osseux [EO] (osteonecrose epiphysaire, infarctus osseux, fracture pathologique). Certains biomarqueurs sont eleves (chitotriosidase, CCL 18, ferritine). La MG beneficie de plusieurs traitements specifiques : enzyme de substitution (imiglucerase, velaglucerase, taliglucerase) ou inhibiteur de substrat (miglustat, eliglustat). La velaglucerase alfa (VPRIV ® , laboratoire Shire) est disponible en France depuis 2010. Nous decrivons ici l’evolution sous traitement de 89 patients francais ayant beneficie d’un traitement par velaglucerase. Patients et methodes Analyse du registre francais de la MG (RFMG) du Centre de reference des maladies lysosomales (CRML), labellise par le Comite des registres–maladies rares (Inserm, InVS) depuis 2009. Tous les patients francais enregistres dans le RFMG et ayant beneficie d’un traitement par velaglucerase dans leur suivi ont ete analyses (date d’analyse au 30.09.2016). L’analyse des marqueurs biologiques sous velaglucerase etait effectuee par modele lineaire mixte. Resultats Quatre-vingt-neuf patients ayant eu un traitement par velaglucerase ont ete identifies dans le RFMG. Au debut du traitement par velaglucerase, l’âge median etait de 47 ans, 87 patients avaient un type 1 et 2 un type 3 ; 45 % etaient des femmes, 28 % etaient splenectomises et 54 % avaient eu au moins un EO. Parmi ces 89 patients, 70 (79 %) avaient eu un autre traitement specifique de la maladie de Gaucher avant l’introduction de la velaglucerase. Une majorite de patients qui ont switches vers la velaglucerase (53/65 soit 80 %) l’ont ete en raison de la penurie d’imiglucerase survenue en 2009–2010. La duree mediane du suivi sous velaglucerase alfa etait de 31,9 mois (0 a 73). Aucune osteonecrose et deux infarctus osseux sans retentissement fonctionnelle sont survenus durant le traitement par velaglucerase alfa. L’hepatomegalie a ete retrouvee chez 17/26 patients (65 %) avant le debut de la velaglucerase et chez 18/41 patients (44 %) a la derniere evaluation ; la splenomegalie chez 15/22 (68 %) au debut du traitement et chez 17/34 (50 %) a la derniere evaluation. Sur la population complete, l’hemoglobine augmentait significativement sous traitement (+ 0,17 g/L chaque annee, p = 0,03), la ferritine baissait (−30 ng/L chaque annee, p = 0,04), comme la chitotriosidase (−477 nmol/h/mL chaque annee, p = 0,036). Le taux de plaquettes restait stable. Les evenements indesirables (EI) survenus sous traitement etaient tous peu severes (asthenie, troubles digestifs, malaise vagal, toux, palpitations), sauf une allergie importante chez un patient qui avait deja presente une allergie grave a l’imiglucerase. Sur la population de patients naifs (19 patients n’ayant pas beneficie de traitement avant velaglucerase), le taux de plaquettes augmentait de 23 000/L/an (sd 12 000). Conclusion L’analyse des donnees des patients sous velaglucerase du Registre francais de la maladie de Gaucher permet de conclure que ce traitement est efficace sur les parametres cliniques et biologiques. L’incidence d’evenements osseux sous velaglucerase est comparable a celle sous imiglucerase. Le traitement est bien tolere.

Introduction Les bacteriemies constituent une infection severe du sujet âge. La presentation clinique atypique frequente de ces infections peut retarder leur diagnostic et aggraver leur pronostic. L’objectif de ce travail etait de determiner les facteurs de risque de mortalite des bacteriemies du sujet âge, et les facteurs associes a une semiologie atypique. Materiels et methodes Une etude observationnelle prospective menee de 2016 a 2017, a inclus tout patient de plus de 75 ans hospitalise en service de geriatrie, medecine ou reanimation medicale presentant une bacteriemie, caracterisee par une hemoculture positive. Une clinique atypique correspondait a l’absence de temperature ≥ 38,3 °C ou Resultats Cent trente et un patients ont ete inclus (âge moyen : 85 ± 5,6 ans, 46,6 % de femmes). La mortalite a S1 etait de 9,2 % et a M3 de 41,4 %. En analyse multivariee, a S1, l’atypie semiologique tendait a etre associee au deces [odd ratio (OR) = 3,44, intervalle de confiance 95 % (IC) (0,82-14,49), p = 0,092] et l’infection par une bacterie a Gram negatif etait protectrice [OR = 0,08, IC95 % (0,01–0,41), p = 0,003]. A M3, l’atypie semiologique [OR = 3,97, IC95 % (1,34–11,77), p = 0,013], l’infection nosocomiale [OR = 5,69, IC95 % (2,04-15,87), p = 0,001], l’insuffisance cardiaque [OR = 4,79, IC 95 % (1,87-12,28), p = 0,001] et une neoplasie evolutive [OR = 3,20, IC95 % (1,13-9,06), p = 0,029] etaient associees a la mortalite. Les patients n’avaient pas retrouve leur niveau d’autonomie initial a 3 mois (score ADL a 2,9 vs 3,6, p = 0,052). Vingt pour cent (n = 27) des patients ont presente une semiologie atypique de la bacteriemie. Le diabete et les infections a S. aureus etaient les deux facteurs de risque de cette atypie identifies dans cette etude [OR = 2,46 (1,01–5,99), p = 0,048 et OR = 3,77 (1,14–12,41), p = 0,029, respectivement]. Conclusion Cette etude confirme le mauvais pronostic vital et fonctionnel des bacteriemies du sujet âge. La semiologie atypique est associee a une surmortalite. Des hemocultures devraient etre envisagees devant une symptomatologie brutale et inexpliquee chez un patient âge, notamment diabetique. La poursuite des inclusions permettra de determiner les facteurs de risque de deces des patients de profil clinique atypique pour mettre en place des strategies de prevention.

Introduction La prise en charge des endocardites infectieuses (EI) par une equipe medico-chirurgicale experte au moyen de reunions de concertation multidisciplinaire (RCP) se generalise. S’il semble acquis que cette organisation permet d’ameliorer le pronostic a court terme des patients, les donnees a long terme sont encore rares. Materiels et methodes Afin de mesurer la mortalite a un an des endocardites infectieuses, tous les patients hospitalises dans l’etablissement presentant une EI prise en charge par les referents de la RCP endocardite ont ete suivis prospectivement. L’etude observationnelle a ete menee dans un centre hospitalier universitaire entre 2013 et 2017. Resultats Durant l’etude, parmi les 704 patients presentes en RCP, 493 avaient une EI certaine ou possible et le devenir a 1 an etait connu pour 448 d’entre eux (4 perdus de vue et 41 suivis depuis moins de 1 an) : 254 EI sur valve native (57 %) et 194 sur valve prothetique (43 %). L’âge median des patients etaient de 69,3 ans (155 patients avaient plus de 75 ans) et 329 (73 %) etaient des hommes. Les EI associees aux soins (EIAS) representaient 47 % des cas. Un micro-organisme etait isole dans 92 % des cas (S. aureus = 24 %), 252 patients (56 %) presentaient un embole extracardiaque et 68 (15 %) etaient en insuffisance cardiaque. L’index median de comorbidite de Charlson (ICC) etait de 5,0. Deux cent seize patients (48 %) ont ete operes. Les taux de mortalite a 1 mois, 3 mois, 6 mois et 1 an etaient respectivement de 14,1 %, 19,0 %, 23,2 % et 27,7 %. L’ICC a l’inclusion des patients decedes a 1 an etait de 6,0 vs 4,0 pour les survivants. La mortalite a 1 an etait significativement plus elevee en cas d’EIAS (33 % vs 23 %), d’EI documentee a S. aureus (39 % vs 24 %) et de traitement medical exclusif (40 % vs 15 %) et d’insuffisance cardiaque (43 % vs 25 %). Conclusion Si la mise en place de RCP dediees a l’endocardite semble ameliorer le pronostic a court terme de l’EI, la mortalite a un an reste elevee car les patients sont de plus en plus âges et ont de lourdes comorbidites. Notre etude confirme que les facteurs pronostiques pejoratifs precoces demeurent a plus long terme et que le pronostic est meilleur en cas d’infection communautaire avec recours a la chirurgie.

Introduction Conformement aux preconisations du plan national d’alerte des antibiotiques, les referents de la RCP d’infectiologie d’un hopital universitaire se sont fixes pour objectif d’ameliorer la prescription des anti-infectieux de l’etablissement au moyen de programmes d’evaluation des pratiques professionnelles (EPP). Materiels et methodes Dans le cadre de la RCP d’infectiologie trois EPP destinees a evaluer, respectivement, les prescriptions de carbapenemes (CP), aminosides (AM) et fluoroquinolones (FQ) ont ete mises en place a partir de 2014. La methodologie est commune pour chacune de ces EPP. Elle repose sur trois phases successives : (1) audit des prescriptions durant deux mois (6 mois pour les CP) ; (2) sensibilisation des prescripteurs par les referents sous la forme de sessions de formations (diaporama + remise d’un guide synthetique) ; (3) nouvel audit des prescriptions durant deux mois. Le degre de conformite des prescriptions a ete analyse par un groupe de referents (medecin et pharmacien) et apprecie par un index d’adequation therapeutique (IAT) compose de six criteres (indication, molecule, posologie, duree, voie, association) pour les CP et les FQ. Les resultats de chaque EPP sont reevalues annuellement par la mesure de l’IAT et la surveillance de la consommation antibiotique. Resultats Concernant les CP, le nombre de prescriptions a baisse de 16 % entre les 2 periodes, avec une augmentation du recours a la desescalade de 61 %. Par ailleurs, le pourcentage de dossiers de CP presentes en RCP a augmente de 16 a 39 %. Dans le meme temps, l’IAT a diminue de 2,46 a 1,98 traduisant une amelioration de la qualite des prescriptions. Concernant les AM, le nombre de prescriptions a diminue de 28 % entre les 2 periodes. La posologie moyenne d’amikacine a augmente de 10 %. La concentration maximale moyenne cible etait atteinte dans 34 % des cas en periode 1 versus 41 % en periode 2. Concernant les FQ, le nombre de prescriptions a diminue de 52 % entre 2015 et 2017. L’IAT a diminue de 3,26 a 1,61 entre 2015 et 2016 puis s’est stabilise en 2017. Le logiciel CONSORES, mis en place en 2012, permet desormais de suivre les consommations d’antibiotiques en doses definies journalieres (DDJ) pour 1000 journees d’hospitalisation. Entre 2014 et 2017, les DDJ de FQ sont passees de 70 a 50, celles des AM de 24 a 6. Les DDJ des CP sont restees stables : 20 en 2014 et 22 en 2017. Conclusion Entre 2014 et 2017, la mise en place par la RCP d’infectiologie d’EPP dediees au bon usage des antibiotiques (AM, CP et FQ) a permis une amelioration qualitative durable des prescriptions. En parallele, les quantites consommees ont diminue. Le suivi annuel de l’IAT et des consommations d’antibiotiques contribue a perenniser les resultats obtenus.

Objective One of the objectives of the French national plan on antibiotics is to preserve antibiotic effectiveness. A group of infectious disease specialists of the University hospital of Bordeaux aimed to monitor the prescriptions of broad-spectrum antibiotics. Particular attention was paid to carbapenem (CBP) prescriptions given the increase in betalactamase- and carbapenemase-producing bacteria. Patients and methods We carried out a three-step Professional Practice Evaluation (PPE): evaluation of CBP prescriptions made at the hospital between January and June 2013; CBP prescription training for prescribers; and another evaluation of CBP prescriptions between January and June 2014. Results Although the number of admissions remained stable between the two evaluation periods, CBP prescriptions decreased by 16%. The mean treatment duration was stable (9.6 days). Physicians asked for the infectious disease specialist's advice for 82% of CBP prescriptions in 2013 and for 83% in 2014. The number of case patients discussed at the multidisciplinary staff meetings for approval of CBP prescriptions increased from 16% in 2013 to 39% in 2014. Antibiotic de-escalation increased by 61% between the two periods. Conclusion Professional Practice Evaluation, supervised by an infectious disease specialist, is a useful addition to weekly multidisciplinary staff meetings to improve CBP prescription.

To assess intracellular and plasma efavirenz concentrations in HIV-infected patients who switched to efavirenz-based highly active antiretroviral therapy (HAART) from successful protease inhibitor-based HAART.A total of 49 patients were included in this observational cohort study. At inclusion, all patients had plasma HIV-RNA levels50 copies/mL and switched to efavirenz combined with two nucleoside reverse transcriptase inhibitors. Intracellular and plasma concentrations were measured 12 h post-dose, 1 month (M1) and 6 months (M6) after starting efavirenz. Virological success (VS) was defined as plasma HIV-RNA level50 copies/mL within the first 12 months and remaining undetectable at the end of the follow-up.VS was documented in 48 patients for at least 12 months (range 12-78 months). High inter-patient variabilities of intracellular and plasma efavirenz concentrations were observed (coefficients of variation40%). At M1 and M6, respectively, median [Q1; Q3] intracellular efavirenz concentrations were 5300 [2830; 11 530] and 6790 [3870; 8790] ng/mL, median plasma efavirenz concentrations were 2050 [1600; 3100] and 2100 [1410; 2500] ng/mL. No correlation was found between intracellular and plasma concentrations. Plasma efavirenz levels exceeded the proposed threshold of 1000 ng/mL in 96% of patients from M1.For moderately pre-treated HIV-infected patients with few mutations who switched to efavirenz from previous successful HAART, the proposed plasma efficacy-threshold was reached without any dosage adaptation. VS was maintained beyond 12 months, despite high inter-patient and intra-patient variabilities of intracellular and plasma efavirenz concentrations.

Introduction Avec l’avenement de nouveaux traitements specifiques, le pronostic des patients d’onco-hematologique (POH) s’ameliore constamment. Dans le meme temps, leur admission en reanimation est plus frequente. Par ailleurs le pronostic du choc septique (CS) s’est nettement ameliore : qu’en est-il du pronostic du CS chez les POH ? Materiels et methodes Nous avons mene une etude prospective observationnelle dans une reanimation medicale de CHU entre janvier 2011 et decembre 2015 afin de decrire les caracteristiques demographiques, cliniques et pronostiques des patients adultes admis pour CS et ayant une affection maligne. Les donnees ont ete comparees a la population admise pour CS sans affection maligne. Resultats Parmi les 4228 patients admis durant le periode de l’etude, 591 avaient un CS et 266 (45 %) d’entre eux etaient pris en charge pour une affection maligne evolutive : 148 cancers solides et 118 hemopathies. L’âge median etait de 64 ans. L’origine des infections differait entre les deux groupes : respiratoire (27 %), intra-abdominale (26 %) ou liee a un catheter (14 %) dans la population des POH et respiratoire (38 %), intra-abdominale (27 %) ou urinaire (15 %) hors POH. Si le taux de documentation du sepsis etait superposable dans les deux groupes (64 % vs 61 %), la proportion de bacteriemies etait plus elevee chez les POH (47 % vs 32 %). La plupart des bacteries isolees etaient a Gram negatif (62,5 %) avec une plus forte proportion de bacteries non fermentaires en cas de malignite (16,7 % vs 7,6 %). Les POH qui etaient plus frequemment en aplasie (28 % vs 2 %), ils etaient plus rarement intubes (33 % vs 59 %) et hemofiltres (14 % vs 27 %). La mortalite hospitaliere etait superposable dans les deux groupes : 32 %. Elle etait significativement augmentee chez les POH en cas d’intubation ou d’hemofiltration. Conclusion L’epidemiologie du CS a change : les patients sont plus âges et jusqu’a 50 % d’entre eux presentent une pathologie maligne. Bien qu’il existe quelques differences quant a la presentation clinique et a la documentation microbiologique, le pronostic global du CS des POH est superposable a celui des autres patients. A condition d’une prise en charge precoce, peu invasive et concertee avec l’onco-hematologue, la presence d’une affection maligne ne doit plus etre un frein a l’admission en reanimation, y compris en cas de CS.