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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).

There is a Blood Commentary on this article in this issue., Key Points As a proof of concept, COVID-19 convalescent plasma represents an interesting approach in B-cell–depleted patients with protracted COVID-19.COVID-19 convalescent plasma induces a decrease in temperature and inflammatory parameters within 1 week associated with oxygen weaning., Anti-CD20 monoclonal antibodies are widely used for the treatment of hematological malignancies or autoimmune disease but may be responsible for a secondary humoral deficiency. In the context of COVID-19 infection, this may prevent the elicitation of a specific SARS-CoV-2 antibody response. We report a series of 17 consecutive patients with profound B-cell lymphopenia and prolonged COVID-19 symptoms, negative immunoglobulin G (IgG)-IgM SARS-CoV-2 serology, and positive RNAemia measured by digital polymerase chain reaction who were treated with 4 units of COVID-19 convalescent plasma. Within 48 hours of transfusion, all but 1 patient experienced an improvement of clinical symptoms. The inflammatory syndrome abated within a week. Only 1 patient who needed mechanical ventilation for severe COVID-19 disease died of bacterial pneumonia. SARS-CoV-2 RNAemia decreased to below the sensitivity threshold in all 9 evaluated patients. In 3 patients, virus-specific T-cell responses were analyzed using T-cell enzyme-linked immunospot assay before convalescent plasma transfusion. All showed a maintained SARS-CoV-2 T-cell response and poor cross-response to other coronaviruses. No adverse event was reported. Convalescent plasma with anti–SARS-CoV-2 antibodies appears to be a very promising approach in the context of protracted COVID-19 symptoms in patients unable to mount a specific humoral response to SARS-CoV-2., Visual Abstract

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

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.

International audience; OBJECTIVES: The aim of this study was to assess the diagnostic performances of (18)F-fluorodeoxyglucose ((18)F-FDG) positron emission tomography (PET)/computed tomography (CT) in congenital heart disease (CHD) patients with pulmonary prosthetic valve or conduit endocarditis (PPVE) suspicion. BACKGROUND: PPVE 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 of (18)F-FDG PET/CT remains poorly studied in PPVE. METHODS: A retrospective multicenter study was conducted in 8 French tertiary centers. Children and adult CHD patients who underwent (18)F-FDG PET/CT in the setting of PPVE suspicion between January 2010 and May 2020 were included. The cases were initially classified as definite, possible, or rejected PPVE regarding the modified Duke criteria and finally by the Endocarditis Team consensus. The result of (18)F-FDG PET/CT had been compared with final diagnosis consensus used as gold-standard in our study. RESULTS: A 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 of (18)F-FDG PET/CT in PPVE suspicion were respectively: 79.1% (95% CI: 68.4%-91.4%), 72.7% (95% CI: 60.4%-85.0%), 91.9% (95% CI: 79.6%-100.0%), and 47.1% (95% CI: 34.8%-59.4%). (18)F-FDG PET/CT findings would help to correctly reclassify 57% (4 of 7) of possible PPVE to definite PPVE. CONCLUSIONS: Using (18)F-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.

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 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 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.

International audience; This study aims to assess the efficacy and safety of convalescent plasma therapy (CPT) in COVID-19 critically ill patients with protracted severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNAemia. A retrospective cohort study was conducted in intensive care unit (ICU). All patients with severe COVID-19 pneumonia for whom RNAemia remained positive more than 14 days after onset of the infection were included and given CPT. The primary objective was to evaluate SARS-CoV-2 RNAemia 7 days (D7) after CPT. A total of 14 patients were included and they received a median CPT volume of 828 ml (range: 817-960). CPT was administered in a median time of 14 days after ICU admission. At D7, 13/14 patients had negative SARS-CoV-2 blood PCR and one patient had negative blood PCR 11 days after CPT. At D7 and at D14, the clinical status was improved in 7/14 and 11/14 patients, respectively. The 28-day mortality rate was 14%. No CPT-related adverse effects had been reported. CPT is safe and may be efficient in patients with protracted RNAemia admitted in ICU for severe COVID-19 pneumonia. Randomized controlled trials are needed to confirm these results.

Contexte La transfusion de plasma de donneurs convalescents (PDC) au cours de la COVID-19 est controversée. En France, hors essai clinique, elle est encadrée par un protocole à usage thérapeutique soumis à un avis multidisciplinaire (RCP) préalable. L’expérience de ce traitement en réanimation n’est pas décrite. Méthode Tous les patients admis dans une unité de réanimation d’un CHU pour un SDRA COVID-19 et ayant une PCR plasmatique SARS-CoV-2 positive au moins 10 jours après le début des symptômes ont reçu une transfusion de PDC après validation en RCP. L’objectif principal était d’évaluer la tolérance et la virémie 7 j après la transfusion (J7). Résultats Entre mai 2020 et avril 2021, 31 patients (27 hommes et 4 femmes, âge moyen = 69 ans) ont été inclus et ont reçu un volume médian de 836 mL de PDC sur 2 jours consécutifs. Tous présentaient au moins un facteur de risque de forme grave dont 15 une affection maligne évolutive et 14 avaient une sérologie SARS-CoV-2 négative à l’admission en réanimation. Les PDC ont été transfusés en moyenne 18 j après le début des symptômes et 8 j après l’admission en réanimation. À J7, 22/31 patients avaient une PCR plasmatique négative. Le délai médian de négativation de la PCR plasmatique était de 8 j. À J 7, le score de sévérité clinique OMS était stable pour 12/31 (39 %), en amélioration pour 14/31 (45 %) et détérioré pour 5/31 (16 %) patients. La mortalité à 28 jours était de 26 % (8/31 dont 3 dans les sept jours après PDC). Aucun évènement indésirable significatif lié à la transfusion n’a été rapporté. Conclusion Notre étude confirme la faisabilité de la transfusion de PDC en réanimation, notamment en cas d’immunodépression humorale.

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

International audience; PURPOSE: High-resolution free-breathing late gadolinium enhancement (HR-LGE) was shown valuable for the diagnosis of acute coronary syndromes with non-obstructed coronary arteries. The method may be useful to detect COVID-related myocardial injuries but is hampered by prolonged acquisition times. We aimed to introduce an accelerated HR-LGE technique for the diagnosis of COVID-related myocardial injuries. METHOD: An undersampled navigator-gated HR-LGE (acquired resolution of 1.25 mm(3)) sequence combined with advanced patch-based low-rank reconstruction was developed and validated in a phantom and in 23 patients with structural heart disease (test cohort; 15 men; 55 ± 16 years). Twenty patients with laboratory-confirmed COVID-19 infection associated with troponin rise (COVID cohort; 15 men; 46 ± 24 years) prospectively underwent cardiovascular magnetic resonance (CMR) with the proposed sequence in our center. Image sharpness, quality, signal intensity differences and diagnostic value of free-breathing HR-LGE were compared against conventional breath-held low-resolution LGE (LR-LGE, voxel size 1.8x1.4x6mm). RESULTS: Structures sharpness in the phantom showed no differences with the fully sampled image up to an undersampling factor of x3.8 (P > 0.5). In patients (N = 43), this acceleration allowed for acquisition times of 7min21s ± 1min12s at 1.25 mm(3) resolution. Compared with LR-LGE, HR-LGE showed higher image quality (P = 0.03) and comparable signal intensity differences (P > 0.5). In patients with structural heart disease, all LGE-positive segments on LR-LGE were also detected on HR-LGE (80/391) with 21 additional enhanced segments visible only on HR-LGE (101/391, P

COVID‐19 leads to mortality of several patients and the cytokine storm is reportedly critical in the patients. In order to reduce the cytokine storm, we would like to propose the IL6 receptor antagonist therapy for the COVID‐19 patients. Two humanized monoclonal antibodies are in clinical trial following IL6R antagonist therapies namely tocilizumab and sarilumab. However, researchers and physicians should look for more IL6 receptor antagonists for the therapy of cytokine storm syndrome SARS‐CoV‐2 infected persons to enhance the therapeutic options for cytokine storm. This article is protected by copyright. All rights reserved.

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: 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.

Gaucher disease (GD) is a rare lysosomal autosomal-recessive disorder due to deficiency of glucocerebrosidase, polyclonal gammopathy (PG) and/or monoclonal gammopathy (MG) can occur in this disease. We aimed to describe these immunoglobulin abnormalities in a large cohort of GD patients and to study the risk factors, clinical significance, and evolution. Data for patients enrolled in the French GD Registry were studied retrospectively. The risk factors of PG and/or MG developing and their association with clinical bone events and severe thrombocytopenia, two markers of GD severity, were assessed with multivariable Cox models and the effect of GD treatment on gammaglobulin levels with linear/logarithmic mixed models. Regression of MG and the occurrence of hematological malignancies were described. The 278 patients included (132 males, 47.5%) were followed up during a mean (SD) of 19 (14) years after GD diagnosis. PG occurred in 112/235 (47.7%) patients at GD diagnosis or during follow-up and MG in 59/187 (31.6%). Multivariable analysis retained age at GD diagnosis as the only independent risk factor for MG (&gt, 30 vs. &le, 30 years, HR 4.71, 95%CI [2.40&ndash, 9.27], p &lt, 0.001). Risk of bone events or severe thrombocytopenia was not significantly associated with PG or MG. During follow-up, non-Hodgkin lymphoma developed in five patients and multiple myeloma in one. MG was observed in almost one third of patients with GD. Immunoglobulin abnormalities were not associated with the disease severity. However, prolonged surveillance of patients with GD is needed because hematologic malignancies may occur.

International audience

In nonoperated prosthetic valve endocarditis (PVE), long-term outcome is largely unknown. We report the follow-up of 129 nonoperated patients with PVE alive at discharge. At 1 year, the mortality rate was 24%; relapses and reinfection were rare (5% each). Enterococcal PVE was associated with a higher risk of relapse.

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.

International audience; Patients with type 1 Gaucher disease (GD1) present thrombocytopenia, anemia, organomegaly, and bone complications. Most experts consider that the less aggressive forms do not require specific treatment. However, little is known about the disease course of these forms. The objective of this cross-sectional retrospective study was to compare the clinical, radiological, and laboratory characteristics of patients with less severe GD1 at diagnosis and at the last evaluation to identify features that might lead to potential complications. Non-splenectomized and never-treated patients (19 women and 17 men) were identified in the French Gaucher Disease Registry (FGDR). Their median age was 36.6 years (2.4–75.1), and their median follow-up was 7.8 years (0.4–32.4). Moreover, 38.7% were heterozygous for the GBA1 N370S variant, and 22.6% for the GBA1 L444P variant. From diagnosis to the last evaluation, GD1 did not worsen in 75% of these patients. Some parameters improved (fatigue and hemoglobin concentration), whereas platelet count and chitotriosidase level remained stable. In one patient (2.7%), Lewy body dementia was diagnosed at 46 years of age. Bone lesion onset was late and usually a single event in most patients. This analysis highlights the genotypic heterogeneity of this subgroup, in which disease could remain stable and even improve spontaneously. It also draws attention to the possible risk of Lewy body disease and late onset of bone complications, even if isolated, to be confirmed in larger series and with longer follow-up.

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.

Intravenous imiglucerase enzyme replacement therapy for Gaucher disease type 1 administered every 2 weeks is at variance with the imiglucerase plasma half-life of a few minutes. We hypothesized that studying the pharmacokinetics of imiglucerase in blood Gaucher disease type 1 monocytes would be more relevant for understanding enzyme replacement therapy responses. Glucocerebrosidase intra-monocyte activity was studied by flow cytometry. The pharmacokinetics of imiglucerase was analyzed using a population-pharmacokinetic model from a cohort of 31 patients with Gaucher disease type 1 who either started or were receiving long-term treatment with imiglucerase. A pharmacokinetic analysis of imiglucerase showed a two-compartment model with a high peak followed by a two-phase exponential decay (fast phase half-life: 0.36 days; slow phase half-life: 9.7 days) leading to a median 1.4-fold increase in glucocerebrosidase intra-monocyte activity from the pre-treatment activity (p = 0.04). In patients receiving long-term treatment, for whom the imiglucerase dose per infusion was chosen on the basis of disease aggressiveness/response, imiglucerase clearance correlated with the administered dose. However, the residual glucocerebrosidase intra-monocyte activity value was dose independent, suggesting that the maintenance of imiglucerase residual activity is patient specific. Endogenous pre-treatment glucocerebrosidase intra-monocyte activity was the most informative single parameter for distinguishing patients without (n = 10) and with a clinical indication (n = 17) for starting enzyme replacement therapy (area under the receiver operating characteristic curve: 0.912; 95% confidence interval 0.8–1; p

BACKGROUND: The absence of fever in bacteremia in patients who are older is known to delay diagnosis. Our objective was to determine whether atypical presentation was associated to mortality as a result of bacteremia in this patient cohort as well as possible factors associated with this atypical presentation. METHODS: We conducted an observational prospective study in 2 French university hospitals in 2016-2017 including patients ages >/=75 years with bacteremia. Atypical presentation was defined as the absence of a temperature >/=38.3 degrees C or

International audience

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.

Objective: To confirm the advantage of in situ reconstruction (ISR) over extra-anatomic reconstruction (EAR) for aortic graft infection and determine the most appropriate conduit including autogenous veins, cryopreserved allografts, and synthetic prosthesis (standard, rifampicin of silver polyesters). Methods: A meta-analysis was conducted with rate of mortality, graft occlusion, amputation, and reinfection. A meta-regression was performed with 4 factors: patients’ age, presence of prosthetic-duodenal fistula (PDF), virulent organisms, or nonvirulent organisms. Results: In situ reconstruction over EAR seems to favor all events. For the 5 conduits used for ISR, according to operative mortality, age of the patients looks to have a positive correlation only for silver polyester and no conduit present any advantage in the presence of PDF. Reinfection seems to be not significantly different for the 5 conduits, and only autogenous veins appear to have a positive correlation with infecting organisms. Conclusion: In situ reconstruction may be considered as first-line treatment. Our results suggest that silver polyesters appear to be most appropriate for older patients, and in order to limit reinfection, autogenous veins are probably the most suitable conduit.

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.

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.

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.