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BackgroundOsteomyelitis-complicating pressure ulcers are frequent among patients with spinal cord injuries (SCIs), and the optimal management is unknown. In our referral center, the current management is debridement and flap coverage surgeries, followed by a short antibiotic treatment. We aimed to evaluate patients’ outcomes a year after surgery.MethodsWe performed a quasi-experimental retrospective before/after study on SCI patients with presumed osteomyelitis associated with perineal pressure ulcers. We included all patients who underwent surgery with debridement and flap covering, followed by effective antibiotic treatment, between May 1, 2016, and October 30, 2020. The effective antimicrobial treatment duration included the 10 days leading up to January 1, 2018 (before period), and the 5 to 7 days after (after period). We also compared the efficacy of 5–7-day vs 10-day antibiotic treatment and performed uni- and multivariable analyses to identify factors associated with failure.ResultsOverall, 415 patients were included (77.6% male patients; mean age ± SD, 53.0 ± 14.4 years). Multidrug-resistant organisms (MDROs) were involved in 20.7% of cases. Favorable outcomes were recorded in 69.2% of cases: 117/179 (65.3%) in the 10-day treatment group vs 169/287 (71.9%) in the 5–7-day treatment group (P = .153). The only factor associated with failure in the multivariate analysis was a positive culture from suction drainage (odds ratio, 1.622; 95% CI, 1.005–2.617; P = .046). Effective treatment duration >7 days and intraoperative samples negative for MDROs were not associated with better outcomes (P = .153 and P = .241, respectively).ConclusionsA treatment strategy combining surgical debridement and flap covering, followed by 5 to 7 days of effective antibiotic treatment seems safe.

In our hospital, during COVID-19 pandemic, overall consumption of antibiotics increased during the three first surges, mainly due to ICU prescription However, antibiotic consumption decreased in the Infectious Diseases Department. Rates of ESBL Enterobacterales remained stable.

Le céfidérocol intraveineux commercialisé sous le nom de Fetcroja® est la première céphalosporine de type sidérophore mise sur le marché. Elle a été approuvée pour le traitement des infections sévère à Bacille Gram négatif (BGN) résistant lorsque les options thérapeutiques sont limitées selon l’HAS. En effet, in vitro, le céfidérocol est stable vis-à-vis des 4 types de β-lactamase de la classification d’Ambler, y compris les métallo-β-lactamases, et démontre une excellente activité vis-à-vis de la plupart des BGN, y compris les souches multi-résistantes. Dans divers essais randomisés réalisés en double aveugle, le céfiderocol a montré une non- infériorité par rapport à l'imipenème/cilastatine pour le traitement des infections urinaires compliquées, et versus le méropénème au cours des pneumonies associées aux soins. Au cours d'un essai s'intéressant uniquement aux pathogènes résistants aux carbapénèmes, le céfidérocol a montré une activité comparable au meilleur traitement disponible, mais un déséquilibre de mortalité dans le bras céfidérocol. Par ailleurs, le céfidérocol semble avoir une bonne tolérance et peu d'effets indésirables dans les essais randomisés. Le céfidérocol est donc une nouvelle molécule attractive étant donné son spectre en particulier sur les BGN multi-résistants et représente une nouvelle option thérapeutique dans les situations complexes.

Background . Ceftazidime/Avibactam (C/A) and Ceftolozane/Tazobactam (C/T) are two novel antibacterial agents with a known efficacy on Gram-negative bacteria (GNB). Objectives . We aimed to describe the efficacy and safety of surgical management combined with C/A or C/T treatment for bone and joint infections (BJI). Patients and Methods . We conducted an observational, bi-centric study of patients treated with C/A or C/T for a BJI between May 2016 and June 2019. Failure was defined as a need for an unplanned additional antibiotic treatment or orthopedic surgery or death due to the BJI until the patient's latest visit. Results . Overall, 15 patients were included. Nine patients were treated with C/A, mainly for polymicrobial BJI due to multidrug-resistant (MDR) bacteria (Enterobacteriaceae n=7). Six patients were male; median age was 66 years-old, and median Charlson comorbidity index (CCI) was 5. It was the first septic episode on the site in 3/9 patients. Cure rate was 7/9 (median follow-up: 272 days). Two patients showed C/A-related confusion. Five patients were treated with C/T, for BJI involving MDR-Pseudomonas aeruginosa. Four patients were male; median age was 53 years-old, and median-CCI was 2. All patients had previous septic episodes on infectious site. Cure rate was 3/5 (median follow-up: 350 days). One patient was successfully treated by C/T then C/A for multistage spondylodiscitis. Conclusion . In our experience, C/A and C/T were two effective and safe options, even as salvage treatment of BJI due to MDR GNB despite the absence of label, but more data are warranted.

Summary Background Shortening the duration of antibiotic therapy for patients admitted to hospital with community-acquired pneumonia should help reduce antibiotic consumption and thus bacterial resistance, adverse events, and related costs. We aimed to assess the need for an additional 5-day course of β-lactam therapy among patients with community-acquired pneumonia who were stable after 3 days of treatment. Methods We did this double-blind, randomised, placebo-controlled, non-inferiority trial (the Pneumonia Short Treatment [PTC]) in 16 centres in France. Adult patients (aged ≥18 years) admitted to hospital with moderately severe community-acquired pneumonia (defined as patients admitted to a non-critical care unit) and who met prespecified clinical stability criteria after 3 days of treatment with β-lactam therapy were randomly assigned (1:1) to receive β-lactam therapy (oral amoxicillin 1 g plus clavulanate 125 mg three times a day) or matched placebo for 5 extra days. Randomisation was done using a web-based system with permuted blocks with random sizes and stratified by randomisation site and Pneumonia Severity Index score. Participants, clinicians, and study staff were masked to treatment allocation. The primary outcome was cure 15 days after first antibiotic intake, defined by apyrexia (temperature ≤37·8°C), resolution or improvement of respiratory symptoms, and no additional antibiotic treatment for any cause. A non-inferiority margin of 10 percentage points was chosen. The primary outcome was assessed in all patients who were randomly assigned and received any treatment (intention-to-treat [ITT] population) and in all patients who received their assigned treatment (per-protocol population). Safety was assessed in the ITT population. This study is registered with ClinicalTrials.gov, NCT01963442, and is now complete. Findings Between Dec 19, 2013, and Feb 1, 2018, 706 patients were assessed for eligibility, and after 3 days of β-lactam treatment, 310 eligible patients were randomly assigned to receive either placebo (n=157) or β-lactam treatment (n=153). Seven patients withdrew consent before taking any study drug, five in the placebo group and two in the β-lactam group. In the ITT population, median age was 73·0 years (IQR 57·0–84·0) and 123 (41%) of 303 participants were female. In the ITT analysis, cure at day 15 occurred in 117 (77%) of 152 participants in the placebo group and 102 (68%) of 151 participants in the β-lactam group (between-group difference of 9·42%, 95% CI −0·38 to 20·04), indicating non-inferiority. In the per-protocol analysis, 113 (78%) of 145 participants in the placebo treatment group and 100 (68%) of 146 participants in the β-lactam treatment group were cured at day 15 (difference of 9·44% [95% CI −0·15 to 20·34]), indicating non-inferiority. Incidence of adverse events was similar between the treatment groups (22 [14%] of 152 in the placebo group and 29 [19%] of 151 in the β-lactam group). The most common adverse events were digestive disorders, reported in 17 (11%) of 152 patients in the placebo group and 28 (19%) of 151 patients in the β-lactam group. By day 30, three (2%) patients had died in the placebo group (one due to bacteraemia due to Staphylococcus aureus, one due to cardiogenic shock after acute pulmonary oedema, and one due to heart failure associated with acute renal failure) and two (1%) in the β-lactam group (due to pneumonia recurrence and possible acute pulmonary oedema). Interpretation Among patients admitted to hospital with community-acquired pneumonia who met clinical stability criteria, discontinuing β-lactam treatment after 3 days was non-inferior to 8 days of treatment. These findings could allow substantial reduction of antibiotic consumption. Funding French Ministry of Health.

Resume Introduction L’infection urinaire (IU) constitue la deuxieme cause d’infection bacterienne communautaire chez le sujet âge. Ce diagnostic est difficile car les symptomes sont souvent atypiques. Nous presentons les caracteristiques des patients ayant une IU parmi une population geriatrique (signes fonctionnels urinaires et/ou syndrome infectieux). Nous avons egalement evalue la sensibilite et la specificite de la bandelette urinaire (BU) pour le diagnostic d’IU dans cette population. Patients et methode Nous avons realise une etude observationnelle, prospective, monocentrique, d’avril 2017 a janvier 2018, incluant tous les patients hospitalises en geriatrie, presentant des signes fonctionnels urinaires et/ou un syndrome infectieux sans point d’appel, pour lesquels un examen cytobacteriologique des urines (ECBU) a ete demande. Une BU etait systematiquement realisee pour tous ces patients. Les caracteristiques cliniques et biologiques des patients ont ete etudiees selon le diagnostic definitif. En outre, les resultats des BU ont ete compares a ceux des ECBU en cas de diagnostic final d’IU. Resultats Au total, 165 patients ont ete inclus. Parmi eux, 67 (40,6 %) avaient une IU et 98 (59,4 %) avaient un autre diagnostic. Il y avait significativement plus de femmes ( p p La BU presentait une sensibilite elevee (92 %) et une VPN elevee (91 %) interessantes dans notre population. Conclusion En cas d’IU chez le sujet âge, peu de criteres sont discriminants avec une autre origine. Par ailleurs, une BU negative suggere l’absence d’IU en raison de sa bonne valeur predictive negative.

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.

Corynebacterium striatum is a ubiquitous colonizer of human skin and mucous membranes. It is increasingly involved in infections, especially with prosthetic devices or in immunocompromised individuals. Microbiological diagnosis is challenging and bacterial resistance is a major concern. We performed a retrospective study of monomicrobial bone and joint infections (BJI) due to C. striatum in two referral centers from April 2012 to July 2017. We collected the patients' clinical and microbiological characteristics and outcomes. We also performed a literature review of BJI due to C. striatum. We identified 12 cases (nine prosthetic joint infections, one osteosynthetic device infection, one non-union, and one arthritis) in 11 patients, five of which were immunocompromised. Microbiological diagnosis was performed with prolonged culture media. Ten out of 12 strains were susceptible to aminopenicillin, a drug class not recommended for testing by the EUCAST/CASFM guidelines, and 8/12 patients were treated with amoxicillin-rifampicin. The cure rate was 8/12, after a median follow-up period of 487.5 days (IQR 140.3-1348.5). Twelve cases of BJI due to C. striatum were previously reported. Among them, 5/12 patients were immunocompromised, 3/12 cases were acute BJI, and 2/12 were device-related infections. The diagnosis was performed by PCR in one case, and 10/12 patients were treated with glycolipopeptides, with a cure rate of 11/12. We report the largest cohort of monomicrobial BJI with C. striatum. Determination of aminopenicillin susceptibility is essential since it is frequently active in our experience, even in BJI. The cure rate of this infection seems high.

International audience; Background: Clostridioides difficile infection (CDI) is rising and increases patient healthcare costs due to extended hospitalisation, tests and medications. Management of CDI in French primary care is poorly reported. Objectives: To characterise patients suffering from CDI, managed in primary care and describe their clinical outcomes. Methods: Retrospective observational study based on survey data among 500 randomly selected General Practitioners (GPs) surveyed in France from September 2018 to April 2019. GPs were asked to complete a multiple-choice questionnaire for each reported patient presenting a CDI. Responses were analysed according to clinical characteristics. Treatment strategies were compared according to the outcome: recovery or recurrent infection. Results: Participation rate was 8.6% (n ¼ 43/500) with two incomplete questionnaires. Data from 41 patients with an actual diagnosis of CDI were analysed. Recovery was observed in 61% of patients with a confirmed diagnosis of CDI. In the recovery group, this was exclusively a primary episode, most patients (72%) had no comorbidities, were significantly younger (p ¼ 0.02) than the ones who relapsed and 92% were successfully treated with oral metronidazole. Duration of diarrhoea after antimicrobial treatment initiation was significantly shorter in the recovery group (48 h) (p ¼ 0.03). Cooperation with hospital specialists was reported in 28% of the recovery group versus 87.5% of the recurrent group (p ¼ 0.0003). Overall, GPs managed successfully 82.9% of cases without need of hospital admission. Conclusion: GPs provide relevant ambulatory care for mild primary episodes of CDI using oral metronidazole. Persistent diarrhoea despite an appropriate anti-Clostridiodes regimen should be interpreted as an early predictor of relapse.

Key Points Question What are the risk factors for treatment failure in patients with community-acquired pneumonia (CAP) who reached clinical stability after 3 days of β-lactam treatment? Findings In this secondary analysis of a randomized clinical trial that included 291 adults, only male sex and age were associated with failure in the multivariable analysis. These results were independent of antibiotic treatment duration and biomarker levels. Meaning In this study, among patients with CAP who reached clinical stability after 3 days of antibiotic treatment, male sex and age were associated with higher risk of failure, suggesting that these factors should be taken in account in the treatment of patients with the condition., Importance Failure of treatment is the most serious complication in community-acquired pneumonia (CAP). Objective To assess the potential risk factors for treatment failure in clinically stable patients with CAP. Design, Setting, and Participants This secondary analysis assesses data from a randomized clinical trial on CAP (Pneumonia Short Treatment [PTC] trial) conducted from December 19, 2013, to February 1, 2018. Data analysis was performed from July 18, 2019, to February 15, 2020. Patients hospitalized at 1 of 16 centers in France for moderately severe CAP who were clinically stable at day 3 of antibiotic treatment were included in the PTC trial and analyzed in the per-protocol trial population. Interventions Patients were randomly assigned (1:1) on day 3 of antibiotic treatment to receive β-lactam (amoxicillin-clavulanate [1 g/125 mg] 3 times daily) or placebo for 5 extra days. Main Outcomes and Measures The main outcome was failure at 15 days after first antibiotic intake, defined as a temperature greater than 37.9 °C and/or absence of resolution or improvement of respiratory symptoms and/or additional antibiotic treatment for any cause. The association among demographic characteristics, baseline clinical and biological variables available (ie, at the first day of β-lactam treatment), and treatment failure at day 15 among the per-protocol trial population was assessed by univariate and multivariable logistic regressions. Results Overall, 310 patients were included in the study; this secondary analysis comprised 291 patients (174 [59.8%] male; mean [SD] age, 69.6 [18.5] years). The failure rate was 26.8%. Male sex (odds ratio [OR], 1.74; 95% CI, 1.01-3.07), age per year (OR, 1.03; 95% CI, 1.01-1.05), Pneumonia Severe Index score (OR, 1.01; 95% CI, 1.00-1.02), the presence of chronic lung disease (OR, 1.85; 95% CI, 1.03-3.30), and creatinine clearance (OR, 0.99; 95% CI, 0.98-1.00) were significantly associated with failure in the univariate analysis. When the Pneumonia Severe Index score was excluded to avoid collinearity with age and sex in the regression model, only male sex (OR, 1.92; 95% CI, 1.08-3.49) and age (OR, 1.02; 95% CI, 1.00-1.05) were associated with failure in the multivariable analysis. Conclusions and Relevance In this secondary analysis of a randomized clinical trial, among patients with CAP who reached clinical stability after 3 days of antibiotic treatment, only male sex and age were associated with higher risk of failure, independent of antibiotic treatment duration and biomarker levels. Another randomized clinical trial is needed to evaluate the impact of treatment duration in populations at higher risk for treatment failure., This secondary analysis of a randomized clinical trial assesses treatment failure risk factors in patients with community-acquired pneumonia who reached clinical stability after 3 days of β-lactam treatment.

International audience; Objectives: Limited data have been reported regarding osteomyelitis due to carbapenemase-producing Enterobacteriaceae (CPE), including co-infections with extended-spectrum β-lactamase (ESBL)-producing micro-organisms.Methods: We conducted a retrospective study in a reference centre for bone and joint infections from 2011 to 2019 among patients infected with CPE.Results: Nine patients (mean age 46.8 ± 16.6 years), including three with infected implants, were identified. Infections were mostly polymicrobial (n = 8/9), including Staphylococcus aureus (n = 6/9). CPE were mainly OXA-48-type, associated with ESBL-producing Enterobacteriaceae (n = 8/9), of which 5/9 isolates were Klebsiella pneumoniae. Control of the infection was achieved in seven cases.Conclusions: CPE osteomyelitides are essentially polymicrobial and fluoroquinolone-resistant infections, highlighting the need for efficient surgery with implant removal.

Bloodstream infections (BSIs) among older patients are frequent with high rate of mortality. Infections with multidrug-resistant organisms (MDRO) are associated with higher mortality than with susceptible microorganisms. We aimed to evaluate the prevalence of MDRO infection during BSI in older population and the factors associated with unfavorable outcome. This study is a retrospective cohort of all BSI episodes occurring among older patients (> 65yo), from April 1, 2010, to December 31, 2016, in a French university hospital for geriatric medicine. A total of 255 BSI episodes were analyzed. Mean age was 86.3±6.5 years, and sex ratio (M/F) was 0.96. Main comorbidities were orthopedic device (26.7%), active neoplasia (24.3%), and diabetes mellitus (18.4%). Main primary sites of infection were urinary tract infections (56.9%), respiratory tract infections (10.6%), intra-abdominal infections (7.1%), and skin and soft tissue infections (4.7%). Main bacteria identified were Escherichia coli (45.1%), Staphylococcus aureus (14.1%), enterococci (10.7%), coagulase-negative staphylococci (CoNS) (5.5%), and streptococci (5.1%). MDROs were involved in 17.2% of BSI (gram-negative bacilli: 9.0%; CoNS: 4.3%; and methicillin-resistant S. aureus (MRSA): 3.9%). The main factor associated with MDRO BSI was colonization with MDRO (OR=6.29; 95%CI=2.9-14.32). Total mortality was 18.4% and significantly higher in case of initial severity (OR=3.83; 95%CI=1.75-8.38), healthcare-associated infection (OR=5.29; 95%CI=1.11-25.30), and MRSA BSI (OR=9.16; 95%CI=1.67-50.16). BSI due to MDRO is frequent in older population and is strongly associated with carriage of MDRO. Healthcare-associated BSI, severe episodes, and BSI due to MRSA are associated with unfavorable outcome. In these cases, a broad-spectrum antibiotic should be promptly initiated.

Objective To compare the impact of a care bundle including medication reconciliation at discharge by a pharmacist versus standard of care, on continuity of therapeutic changes between hospital and primary care and outcome of patients, within 1 month after discharge. Methods Randomised controlled trial in 120 adult patients with at least one chronic disease and three current medications before admission, hospitalised in an infectious disease department of a tertiary hospital and discharged home. Patients were randomly assigned (1:1) to receive a discharge care bundle including medication reconciliation, counselling session and documentation transfer to primary care physician (PCP) (intervention group) or standard of care (control group). Primary outcome was the proportion of in-hospital prescription changes, not maintained by the PCP, 1 month after discharge. Secondary outcome measures included the proportion of patients experiencing early PCP's consultation, hospital readmissions or adverse reactions within 1-month postdischarge and cost of discharge prescriptions. Results Baseline characteristics were comparable between the two groups. One month after discharge, the proportion of in-hospital prescription changes, not maintained by the PCP, was 11% in the intervention group versus 24% in the control group (P = .007). The median delay before PCP's consultation was longer in the intervention group (30.5 vs 19.5 days, P = .013), there were fewer patients readmitted to hospital (3.4% vs 20.7%, P = .009, odds ratio (OR) = 0.13 [0.02-0.53]) and fewer patients who suffered from adverse drug reaction (7.0% vs 22.8%, P = .04, OR = 0.26 [0.07-0.78]). Conclusion This care bundle resulted in the reduction of treatment changes between hospital discharge and primary care.

Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a current pandemic worldwide. This virus can reach all organs and disturbs the immune system, leading to a cytokine storm in severe forms. We aimed to report cutaneous features among coronavirus disease 2019 (COVID-19) hospitalized patients. Methods We performed a cross-sectional study on 1 given day among all patients hospitalized in acute care for COVID-19 and included all patients with cutaneous features. Follow-up 48 hours later was obtained. Results Among 59 adult patients hospitalized on the day of the study in an infectious diseases ward for SARS-CoV-2 infection who were confirmed by molecular assay and/or radiological findings (computed tomography scan), 40 were included. Several cutaneous manifestations were found: macular exanthema (80%), face edema (32%), livedo (13%), urticarial rash (8%), purpura (5%), oral lichenoid lesions (33%), and conjunctivitis (18%). Cutaneous biopsy was performed in 17 patients. Histological findings showed mast cell hyperplasia (100%), superficial perivascular infiltrate of lymphocytes (94%), and superficial edema (47%) consistent with capillary leak. Conclusions Various dermatological signs can be encountered during COVID-19. A macular rash was the most frequent. All cutaneous features could be related to a vascular leak process., This cross-sectional study showed that cutaneous features are various among hospitalized patients with COVID-19. Macular rash was the most frequent and could be predictive of worsening. They seem related to an immune system disturbance, leading to a vascular leak process.

Highlights • COVID-19 pneumonia is at risk of transfer in intensive care unit or death • Hydroxychloroquine+azithromycin seems to improve outcome of admitted patients • We report no major cardiac adverse event of this combination therapy, Introduction Interest of anti-infective agents in COVD-19 showed discrepant results. However, there is no evaluation about the impact in changes of practices on the prognosis over time. Methods Single center, retrospective study, conducted from March 5th to April 25th 2020, in adults hospitalized in a medicine ward for a COVID-19. Patient characteristics were compared between 2 periods (before/after March 19th) considering French guidelines issued by learned societies. Aim of the study was to evaluate how medical care impacted unfavorable outcome, namely admission in intensive care unit (ICU) and/or death. Results One hundred thirty-two patients were admitted, mean age was 59.0 ± 16.3 years, mean CRP level was 84.0±71.1 mg/L, 46% had a lymphocyte count

We report the case of a 67-year old man with a right knee prosthetic joint infection due to extensively drug-resistant Enterobacter hormaechei. The resistance phenotype was due to the overproduction of the intrinsic cephalosporinase (ACT-5) associated with the production of three acquired β-lactamases (CTX-M-15, TEM-1B and OXA-1), and a putative membrane decreased permeability. He was first treated with colistin-tigecyclin due to adverse drug reactions; treatment was switched to cefiderocol for a 12-week antibiotic duration, with a favorable outcome.

IntroductionHydroxychloroquine (HCQ) with or without azithromycin is currently still debated as a potential treatment for the COVID-19 epidemic. Some studies showed discrepant results. However, timing for the treatment initiation and its setting (in-hospital or out-patient) are not consistent across studies.MethodsMonocentric retrospective study conducted from 2th March to 17th April 2020, in adults hospitalized in a tertiary hospital for COVID-19. Patients characteristics were compared between groups depending on the therapy received (HCQ/azithromycin taken ≥ 48 hours or other treatment). Outcomes were evaluated from admission, by the need for intensive care unit (ICU) support and/or death. Univariate analyses were performed using non-parametric tests and confirmed by a multiple logistic regression using Pearson correlation test.ResultsAmong 132 patients admitted for COVID-19 in the medicine ward, 45 received HCQ/azithromycin ≥ 48 hours, with a favorable outcome in 91.1% of cases (OR=6.2, p=0.002) versus others regimen (n=87). Groups were comparable at the baseline in terms of age, sex, comorbidities, extend in thoracic imaging, and severity.Among patients that required to be transferred to ICU (n=27) (for mechanical ventilation), median delay for transfer was 2 days (IQR 1-3). We report only 1 patient that presented an adverse event (a prolonged QT interval on EKG) that required to discontinue HCQ.ConclusionThe present study suggests a potential interest of the combination therapy using HCQ/azithromycin for the treatment of COVID-19 in in-hospital patients.

International audience

Background Infections caused by multidrug-resistant organisms (MDRO) are emerging worldwide. Physicians are increasingly faced with the question of whether patients need empiric antibiotic treatment covering these pathogens. This question is especially essential among MDRO carriers. We aim to determine the occurrence of MDRO bacteraemia among bacteraemic patients colonized with MDRO, and the associated factors with MDRO bacteraemia among this population. Methods We performed a retrospective monocentric study among MDRO carriers hospitalized with bacteraemia between January 2013 and August 2016 in a French hospital. We compared characteristics of patients with MDRO and non-MDRO bacteraemia. Results Overall, 368 episodes of bacteraemia were reviewed; 98/368 (26.6%) occurred among MDRO carriers. Main colonizing bacteria were extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli (40/98; 40.8%), ESBL-producing Klebsiella pneumoniae (35/98; 35.7%); methicillin-resistant Staphylococcus aureus (26/98; 26.5%) and multidrug-resistant Pseudomonas aeruginosa (PA) (12/98; 12.2%). There was no significant difference considering population with MDRO bacteraemia vs. non-MDRO bacteraemia, except for immunosuppression [OR 2.86; p = 0.0207], severity of the episode [OR 3.13; p = 0.0232], carriage of PA [OR 5.24; p = 0.0395], and hospital-acquired infection [OR 2.49; p = 0.034]. In the multivariate analysis, factors significantly associated with MDRO bacteraemia among colonized patient were only immunosuppression [OR = 2.96; p = 0.0354] and the hospital-acquired origin of bacteraemia [OR = 2.62; p = 0.0427]. Conclusions According to our study, occurrence of bacteraemia due to MDRO among MDRO carriers was high. Factors associated with MDRO bacteraemia were severity of the episode and hospital-acquired origin of the bacteraemia. Thus, during bacteraemia among patients colonized with MDRO, if such characteristics are present, broad-spectrum antimicrobial treatment is recommended.

Background Recurrent urinary tract infections (R-UTIs) are the main cause of morbidity and hospitalizations in subjects with neurogenic bladder (NB) due to spinal cord injury (SCI). We evaluated the efficacy of weekly oral cyclic antibiotic (WOCA) prophylaxis (ie, the alternate weekly administration of 2 antibiotics) in preventing R-UTIs. Methods Randomized (1:1), open-label, superiority-controlled trial compared WOCA prophylaxis to no prophylaxis (control) for 6 months in patients with NB due to SCI, using clean intermittent self-catheterization, and suffering from R-UTIs. Primary outcome was incidence of symptomatic antibiotic-treated UTIs. Secondary outcomes were number of febrile UTIs, number of hospitalizations, WOCA tolerance, antibiotic consumption, number of negative urine cultures, and emergence of bacterial resistance in urinary, intestinal, and nasal microbiota. Results Forty-five patients were either allocated to the WOCA group (n = 23) or the control group (n = 22). Median (IQR) incidence of symptomatic antibiotic-treated UTIs was 1.0 (0.5–2.5) in the WOCA group versus 2.5 (1.2–4.0) (P = .0241) in the control group. No febrile UTIs were recorded in the WOCA group versus 9 (45.0%) (P < .001) in the control group. The median number of additional antibiotic treatment was 0.0 (IQR, 0.0–2.0) versus 3.0 (2.0–5.0) (P = .004) in the WOCA and control groups, respectively. Only few adverse events were reported. No impact on emergence of bacterial resistance was observed. Conclusions WOCA is efficient and well tolerated in preventing R-UTIs in SCI patients. In our study, we did not observe any emergence of antibiotic resistance in digestive and nasal microbiological cultures. Clinical Trials Registration NCT01388413.

Summary Background Carbapenem-resistant Enterobacteriaceae (CRE) and vancomycin-resistant enterococci (VRE) carriage are increasing worldwide. Faecal microbiota transplantation (FMT) appears to be an attractive option for decolonization. This study aimed to evaluate CRE vs VRE clearance by FMT among carriers. Methods A multi-centre trial was undertaken on patients with CRE or VRE digestive tract colonization who received FMT between January 2015 and April 2017. Adult patients with CRE or VRE colonization, confirmed by three consecutive rectal swabs at weekly intervals, including one in the week prior to FMT, were included in the study. Patients with immunosuppression or concomitant antibiotic prescription at the time of FMT were excluded. Successful decolonization was determined by at least two consecutive negative rectal swabs [polymerase chain reaction (PCR) and culture] on Days 7, 14, 21 and 28, and monthly for three months following FMT. Results Seventeen patients were included, with a median age of 73 years [interquartile range (IQR) 64.3–79.0]. Median duration of carriage of CRE or VRE before FMT was 62.5 days (IQR 57.0–77.5). One week after FMT, three of eight patients were free of CRE colonization and three of nine patients were free of VRE colonization. After three months, four of eight patients were free of CRE colonization and seven of eight patients were free of VRE colonization. Qualitative PCR results were concordant with culture. Six patients received antibiotics during follow-up, three in each group. No adverse events were reported. Conclusion CRE and VRE clearance rates were not significantly different in this study, possibly due to the small sample size, but a trend was observed. These data should be confirmed by larger cohorts and randomized trials.

Elderly patients are more susceptible to Clostridium difficile infections (CDIs). Despite existing guidelines, there is no specific treatment for CDI in geriatrics. Vancomycin is commonly used in the treatment of CDI. Teicoplanin is an alternative glycopeptide which recently received marketing authorization approval for CDI in Europe. Evaluate the potential interest of oral teicoplanin and assess whether such treatment could potentially become an alternative treatment in mild to severe CDIs in elderly patients. A prospective monocentric study was conducted over 10 months (from December 2015 to October 2016) in a geriatric unit (Sainte Perine, AP-HP, Paris, France). According to the remote infectious disease specialist, some hospitalized patients suffering from CDI and aged over 65 years received oral teicoplanin 200 mg twice a day (highest dose recommended). The clinical response to teicoplanin and relapses after treatment were evaluated. Patients were monitored up to 90 days after teicoplanin administration, and analyzed in non-responder imputation analysis. Eleven patients received teicoplanin among 19 CDIs during the study time period. In non-responder imputation analysis, 90.9% (n = 10) successfully responded to oral teicoplanin. The rate of relapse observed after a 90-day follow-up was 36.4%. Patients reported no drug-related adverse effects. Oral teicoplanin is a glycopeptide that could be proposed as an alternative to other recommended drugs for CDI. In our case series, teicoplanin seems to be an effective therapy as a first-line regimen for CDI in geriatrics. Such treatment has good acceptability in geriatrics, considering it can be taken orally twice a day.

Carbapenem-resistant Enterobacteriaceae (CRE) or vancomycin-resistant enterococci (VRE) carriage present a major public health challenge. Decolonization strategies are lacking. We aimed to evaluate the impact of faecal microbiota transplantation (FMT) on a cohort of patients with digestive tract colonization by CRE or VRE. Eight patients were included: six carrying CRE and two colonized by VRE. One month after FMT, two patients were free from CRE carriage, and another patient was free from VRE after three months. In our experience, this strategy is safe.

Introduction Comme les autres bacteries multiresistantes (BMR), les bacteries hautement resistantes emergentes (BHRe) sont un probleme majeur de sante publique. Leur presence augmente la difficulte de prise en charge des patients, en raison de la complexite logistique necessaire. Mais la meconnaissance, la mefiance potentielle du personnel soignant et leur impact sur la prise en charge ne sont pas bien connus. Nous les avons evalue et compare a ceux du portage d’une autre BMR. Materiels et methodes Nous avons realise une enquete a l’aide d’un questionnaire standardise, hetero-administre, comparant la connaissance de la definition d’une BHRe et d’une BMR, ainsi que le ressenti, l’apprehension et le stress des equipes pour la prise en charge. Cette enquete a ete realisee du 1er decembre 2019 au 10 janvier 2020, aupres du personnel soignant de deux services de medecine dont un comportant une unite dediee avec un personnel forme a la prise en charge des patients porteur de BHRe. Les resultats ont ete compares en fonction de l’appartenance a un des deux services. Resultats Au total, 68 questionnaires ont ete distribues, 60 ont ete restitues et analyses. La population analysee etait composee de 36 infirmieres diplomees d’Etat (IDE), 22 aides-soignantes (AS) et 2 agents. Sur l’ensemble de la population sondee, les resultats etaient les suivants : – connaissance de la definition microbiologique : 82 % ; – connaissance du mode de transmission : 38 % ; – frein a la prise en charge d’un patient porteur : 35 % ; – anxiete a prendre un patient porteur : 10 % ; – perception d’un danger pour le personnel du portage : 29 % ; – perception d’un danger pour les autres patients du portage : 32 %. Il n’existait pas de difference significative (p > 0,05) quand on comparait BHRe et BMR. Par contre, le portage d’une BHRe versus une BMR complique la prise en charge pour le personnel (p = 0,038 ; OR : 3,38). Enfin, le personnel d’un service sans unite dediee a la prise en charge de BHRe ne rapporte pas significativement plus de stress a la prise en charge d’un patient porteur de BHRe vs BMR (p = 0,78), mais va moins souvent voir un patient porteur de BHRe qu’un patient porteur de BMR (p = 0,009 ; OR 9,91). Conclusion Cette enquete declarative met en evidence que la presence d’une BHRe complique significativement la prise en charge des patients pour le personnel comparativement a une BMR. Le personnel travaillant dans des unites dediees a moins d’apprehension a voir les patients porteurs de BHRe que le personnel ne travaillant pas dans ces unites.

Retrospective cohort study. Our study aimed to describe the outcome of bloodstream infection (BSI) in spinal cord injury (SCI) patients and their associated risk factors for severity and mortality. A French University Hospital. We conducted a retrospective cohort study of all BSIs occurring in hospitalized SCI patients. We analyzed their outcome and risk factors especially the impact of multidrug-resistant organisms (MDROs). Overall, 318 BSIs occurring among 256 patients were included in the analysis. Mean age was 50.8 years and gender ratio (M/F) was 2.70, with a mean injury duration of 11.6 years. Severity and 30-day mortality of BSI episodes were, respectively, 43.4% and 7.9%. BSI severity was significantly more frequent when caused by respiratory tract infections (RTIs) (odds ratio (OR)=1.38; 95% confidence interval (CI): 1.13–1.44) and significantly lower when caused by urinary tract infections (UTIs) (OR=0.47; 95% CI: 0.28–0.76). BSI mortality was significantly higher when caused by RTIs (OR=3.08; 95% CI: 1.05–8.99), catheter-related bloodstream infections (OR=3.54; 95% CI: 1.36–9.18) or Pseudomonas aeruginosa infections (OR=3.79; 95% CI: 1.14–12.55). MDROs were responsible for 41.2% of all BSI. They have no impact on severity and mortality, whichever be the primary site of infection. In multivariate analysis, mortality was higher when BSI episodes were due to RTIs (OR=3.26; 95% CI: 1.29–8.22) and Pseudomonas aeruginosa infections (OR=3.53; 95% CI: 1.06–11.70), or when associated with immunosuppressive therapy (OR=2.57; 95% CI: 1.14–5.78) or initial severity signs (OR=1.68; 95% CI: 1.01–2.81). BSI occurring in SCI population were often severe but mortality remained low. MDROs were frequent but not associated with severity or mortality of BSI episodes. Risk factors associated with mortality were initial severe presentation, RTI, immunosuppressive therapy and BSI due to Pseudomonas aeruginosa.

Community-acquired pneumonia (CAP) is frequent and can be life-threatening. Streptococcus pneumoniae is the main bacteria involved, and is susceptible to penicillin A. Rapid microbiological diagnosis could then help reduce the antimicrobial spectrum. The pneumococcal urinary antigen (PUA) test is fast and easy to perform, but its impact on antimicrobial prescription and cost-effectiveness in emergency departments (ED) is not well known. We performed a pragmatic real life retrospective study in an adult ED to assess its usefulness: proportion of positive results, impact on antimicrobial prescriptions and cost-effectiveness. Over 3 years (from January 1st 2012 to December 31st 2014), 979 PUA tests were reutilized in our ED among 1224 patients who consulted for CAP; 51 (5.2%) were positive. Among them, 10 led to a modification of the antimicrobial treatment, but only 7 (14.3%) were in accordance with the results. The total cost of a PUA test is 27€. As only 7 PUA tests led to appropriate antimicrobial modification, we deemed that 972 had no impact, and the potential cost savings, if the test had not been used, would have been 26,244 € (972 × 27) during 3 years, that is 8748 € per year. Thus, it seems that the PUA test should not be generally used in the ED considering its low rate of positivity and the difficulties for physicians to adapt antibiotic treatment accordingly. This attitude change in utilization would lead to substantial cost savings.

Introduction Les manifestations cutanees observees chez les patients COVID-19 sont multiples et frequentes : engelures, exantheme, urticaire, purpura, eczema. Chez les patients recevant des antiinfectieux et presentant ces symptomes compatibles avec des reactions d’hypersensibilites retardees (HSR), le diagnostic de toxidermie est systematiquement evoque. Methodes A partir de la cohorte bicentrique des patients presentant des manifestations cutaneo-muqueuses au cours du COVID-19 nous decrirons la demarche collaborative entre les services de medecine et la pharmacie hospitaliere et l’etude de faisabilite des preparations magistrales de patch tests, prick-tests et tests IDR. Resultats Parmi la cohorte de 59 patients hospitalises pour une pneumonie COVID-19 en mars 2020, 68 % avait des atteintes cutanees (exanthemes dans 80 %) ; 23 des 40 patients presentant des manifestations cutanees (58 %) avaient recu au moins un antiinfectieux (hydroxychloroquine [HCQ], azithromycine [AZT], spiramycine [SPR], amoxicilline [AMX] et/ou ceftriaxone [CFX]). Une revue complete de la litterature a ete realisee et les PUI realisant ce type de tests ont ete contactees pour determiner les concentrations non irritantes, dilutions optimales, nature des diluants, verification de la texture, choix des controles positifs et negatifs, conditionnement le plus approprie et evaluation des moyens humains et materiels necessaires. Quinze fiches de fabrication ont ete redigees. La pharmacie a elabore des tests epicutanes doses a 30 % dans de la vaseline a partir des formes orales (HCQ, AZT) ; 10 % (lyophilistas) ou 30 % (solutions) dans vaseline pour les solutions injectables (AMX, CFX et SPR). Les prick-tests et les tests IDR en seringues ont ete prepares en conditions steriles, a partir des formes injectables (AMX, CFX et SPR). Les tests cutanes seront realises a 1 an de l’episode (mars 2021) : resultats a venir. Conclusion Ce travail a favorise le travail pluridisciplinaire entre les services. Les resultats des tests allergologiques permettront d’identifier les HSR allergiques qui contre-indiqueront la reintroduction des molecules et la meilleure comprehension des atteintes dermatologiques observees chez les patients atteints de COVID-19.

Introduction Lors de la premiere vague de COVID-19, les praticiens ont largement prescrit l’association hydroxychloroquine (HCQ) – azythromycine (AZM). Methodes Nous rapportons une serie de 3 cas de DRESS certains, selon le score REGISCAR, chez des patients atteints de pneumonies COVID-19 severes. Resultats Le premier patient a 58 ans, est diabetique, hypertendu et obese. Il presente a J20 du debut des symptomes de COVID-19 un exantheme maculo papuleux diffus, œdeme du visage, adenomegalies supra centimetriques et une hypereosinophilie a 0,74 G/L ; a J15 d’un traitement par ceftriaxone (CTX), AZM et HCQ. La deuxieme patiente a 76 ans, est diabetique, hypertendue et atteinte d’une SEP. Elle presente a 1 mois du debut de sa pneumonie COVID-19 ; et a 21 jours post-prises de CTX, AZM et HCQ une eruption cutanee severe compatible avec un DRESS. Elle a presente une hypereosinophilie concomitante a 0,65 G/L avant traitement par dermocorticoides. Le troisieme patient a 56 ans et aucune comorbidite. Il presente a J3 du debut des symptomes de COVID-19 un volumineux œdeme du visage et des lesions erythemateuses maculopapuleuses purpuriques ; a J8 d’un traitement antipaludeens et AINS. Pour chacun d’entre eux, la biopsie cutanee appuie le diagnostic de DRESS ; les PCR sanguines HHV6, EBV, CMV, VIH, VHB, VHC, parvovirus B19 sont negatives ; et l’evolution a ete lentement favorable avec un blanchiement complet de la peau en plus de 15 jours d’application de Clobetasol. Discussion Le DRESS syndrome est une toxidermie rare qui peut-etre fatale. Aucun cas de toxidermie type DRESS n’avait ete rapportee jusqu’a ce jour dans un contexte de COVID-19. Moins d’une dizaine de cas de DRESS ont ete rapportes dans la litterature avec l’un ou l’autre des traitements par HCQ ou AZM. Les reactivations virales sont classiquement decrites avec HHV6 ou d’autres herpes virus (EBV, CMV), mais aucune de ces replications virales classiques n’ont ete objectivees chez nos patients qui etaient atteints de formes actives severes d’infections par le SARS-CoV-2, probablement replicatif. L’implication du SARS-CoV-2 est supposee ici. Conclusion Il s’agit ici de la premiere serie de cas de DRESS certains chez des patients atteints de formes severes de COVID-19.

The use of antibiotics, as any other drug, is regulated by the terms of its marketing authorisation, notified in the Summary of Product Characteristics (SPC). If a prescription is not in accordance with the SPC, the physician prescribes off-label. There is very little literature regarding off-label use of antibiotics in adult healthcare facilities. A prospective monocentric study was conducted during 11 days from February to June 2015 in hospitalised patients from a tertiary teaching hospital with a high prevalence of multidrug-resistant organism colonisation to evaluate off-label use of antibiotics. Two independent experts assessed whether prescriptions complied with the latest guidelines in infectious diseases and whether off-label use of antibiotics was associated with an increased risk of adverse events. In total, 160 antibiotic prescriptions were analysed, of which 76 (47.5%) were off-label. Of the 76 off-label prescriptions, 50 (65.8%) were off-label regarding indications and 26 (34.2%) regarding doses. Nevertheless, 46/50 off-label indications (92.0%) and only 14/26 off-label doses (53.8%) were approved by experts, especially because of dose adjustment requirements. During follow-up, the rate of reported adverse events was not statistically different between patients with (n = 76) and without (n = 84) off-label prescriptions (P = 0.35). In a context of multidrug resistance and a lack of new drugs, high rates (47.5%) of antibiotic off-label use were observed in our hospital, but without an increased rate of adverse events. Moreover, 78.9% of off-label uses were in accordance with guidelines. Therefore, the SPC is not the warrant of an appropriate use of antibiotics.

Background In France, Carbapenem-Resistant Enterobacteriaceae (CRE) and Vancomycin-Resistant Enterococci (VRE) are considered as Extensively Drug-Resistant (XDR) bacteria. Their management requires reinforcement of hospital’s hygiene policies, and currently there is few consistent data concerning the spontaneous decolonization in XDR colonized patients. Our aim is to study the natural history of decolonization of XDR carriers over time in a hospital setting in a low prevalence country. Material and methods Retrospective multicenter study over 2 years (2015–2016) in 2 different tertiary care hospital sites and units having an agreement for permanent cohorting of such XDR carriers. We gathered the type of microorganisms, risk factors for colonization and rectal swabs from patient’s follow-up. We also evaluated patient care considering isolation precautions. Results We included 125 patients, aged 63+/−19y, including 72.8% of CRE (n = 91), 24.8% of VRE (n = 31) and 2.4% (n = 3) co-colonized with CRE and VRE. CRE were mainly E. coli (n = 54), K. pneumoniae (n = 51) and E. cloacae (n = 6). Mechanisms of resistance were mainly OXA-48 (n = 69), NDM-1 (n = 11), OXA-232 (n = 8) and KPC (n = 3). Prior antibiotic therapy was reported in 38.4% (n = 48) of cases. Conversely, 17.6% (n = 22) received antibiotics during follow-up. Spontaneous decolonization occurred within the first 30 days in 16.4% (n = 19/116) of cases and up to 48.2% after day-90 with a median follow-up of 96 days (0–974). We estimated that XDR carriage was associated with a larger care burden in 13.6% (n = 17) of cases, especially due to a prolongation of hospitalization of 32.5 days (15–300). Conclusions Our study shows that spontaneous decolonization is increasing over time (up to 48.2%). We can regret that only few patients underwent screening after 1 year, emphasizing the need for more monitoring and prospective studies.

Introduction Deux nouveaux antibiotiques associant une cephalosporine et un inhibiteur de betalactamase ont ete recemment mis sur le marche. Leur efficacite au cours des infections osteo-articulaires est mal connue. Materiels et methodes Etude retrospective monocentrique, de 05/2016 a 01/2019, des prescriptions de ceftolozane-tazobactam (C/T) et ceftazidime-avibactam (C/A) au cours des infections osteo-articulaire. Les patients ont ete identifies par la pharmacie et les dossiers medicaux revus avec une fiche standardisee de recueil incluant indication, caracteristiques cliniques, biologiques et microbiologiques, evolution, tolerance. Resultats Nous avons recense 10 prescriptions de C/T et 14 de C/A. L’âge median etait de 63,0 ans dans le groupe C/T et 64,0 ans (IQR 51,75–66,0) dans le groupe C/A (IQR 44,8–71,0), avec un sexe ratio (M/F) exclusivement masculin dans le groupe C/T et de 2,5 dans le groupe C/A. La duree d’hospitalisation etait de 48,0 jours dans le groupe C/T et de 95,5 jours dans le groupe C/A. Dans le groupe C/A, 13 patients ont beneficie d’une prise en charge medico-chirurgicale pour infection de prothese (3), arthrite (8), escarre avec osteite (3). Dans le groupe C/T, 9 patients ont beneficie d’une prise en charge medico-chirurgicale pour infection de materiel (2), arthrite (5), escarre (2), osteite (1). Les prelevements per-operatoires ont permis un diagnostic microbiologique dans 90 % des cas dans le groupe C/T et dans 92,9 % des cas dans le groupe C/A. Les prelevements etaient polymicrobiens dans 66 % des cas dans le groupe C/T et 85,7 % dans le groupe C/A. Le choix de l’antibiotherapie etait lie a la resistance microbiologique dans 80 % des cas dans le groupe C/T et dans 78,5 % des cas dans le groupe C/A. Dans le groupe C/A, les principales bacteries multiresistantes identifiees etaient : P.aeruginosa (5), K. pneumoniae BLSE (5), K.pneumoniae secretrice de carbapenemase (2), E.coli BLSE (2), E.cloacae BLSE (3), et A. baumanii (1). Dans le groupe C/T, il s’agissait de P. aeruginosa (7), K. pneumoniae BLSE (1), M.morganii (1), C. koseri (1). Dans le groupe C/A, l’evolution etait favorable pour 9 patients, 4 ont rechute et 1 est decede. Dans le groupe C/T, on note 7 guerisons, 2 rechutes et 1 deces. Une encephalopathie sous C/A a ete recensee. Conclusion Peu de donnees sont disponibles sur l’utilisation hors AMM de C/A et C/T dans les infections-osteo-articulaires. Notre experience recense des infections polymicrobiennes avec au moins un germe multi-resistant, principalement P.aeruginosa ou enterobacteries BLSE. Bien que s’agissant de patients multi-operes aux nombreuses comorbidites, l’utilisation de C/A et C/T a permis une reponse favorable lors de situations complexes.

Introduction Les recommandations concernant les infections urinaires ont ete recemment actualisees. Cependant, leur connaissance et leur diffusion chez les urologues ne sont pas bien connues. ous nous sommes interesses a l’application de ces recommandations devant une situation clinique simple de colique nephretique febrile, et avons mesure la proportion de reponses correctes globales et en fonction du statut du prescripteur au moyen d’une enquete de pratique. Materiels et methodes Enquete auto-administree par voie electronique. Tous les urologues inscrits aupres de l’Association francaise d’urologie (AFU) ont ete invites par e-mail a remplir un questionnaire en ligne (50 items) entre juillet et septembre 2017. Nous presentons les donnees recueillies. Resultats Le questionnaire a ete envoye a 1754 urologues et remplis par 868 (49,4 %), dont 403 reponses incompletes et 465 completes qui ont pu etre analysees. Au total, 58,8 % des urologues ont realise l’evaluation exacte du score qSOFA, 65,3 % ont repondu en accord avec les recommandations de prise en charge, a savoir l’association d’une derivation en urgence des urines et d’une antibiotherapie immediate. Concernant l’antibiotherapie probabiliste, 54,7 % des urologues ont choisi une bi-antibiotherapie. Celle-ci devait comporter une betalactamine et un aminoside. Une cephalosporine de 3e generation a ete choisie par 66,2 % des repondants et seuls 39,9 % y ont associe l’amikacine, pourtant recommandee y compris en cas d’insuffisance renale. Apres documentation microbiologique, 288 repondants (62,5 %) ont choisi l’antibiotique au spectre le plus etroit possible, a savoir l’amoxicilline, dont 43 (14,9 %) a la dose correcte de 2 g × 3/jour per os. Concernant la duree de traitement, seuls 20 repondants (4,3 %) ont choisi une reponse conforme aux recommandations, soit 10–14 jours. Parmi les urologues seniors la proportion de bonne reponse etait de 23,2 % bonnes reponses, parmi les urologues CCA-Assistants elle etait de 23,8 % bonnes reponses et parmi les internes de 24 ;4 % bonnes reponses. Au total, un seul participant, qui etait chef de clinique, a repondu correctement a toutes les questions. Conclusion Cette etude montre que les recommandations des societes savantes ne sont pas suffisamment appliquees, en outre les prescripteurs juniors sont plus au fait des recommandations que les seniors. Ceci souligne la necessite de diffuser les recommandations et de changer les pratiques en particulier chez les urologues seniors. Reste a definir le type d’intervention les plus efficaces et renforcer le role des equipes transversales d’infectiologie ainsi que promouvoir les outils digitaux comme l’application du CIAFU qui permet d’avoir acces aux recommandations.

Introduction La rifampicine est l’antibiotique de choix dans le traitement des infections osteo-articulaires (IOA) a bacteries sensibles. Elle doit etre prescrite en association avec un autre antibiotique. Cependant la posologie optimale n’est pas connue. Nous nous sommes interesses a l’efficacite et la tolerance de ce medicament en fonction de la dose prescrite chez les patients traites pour une IOA dans un centre de reference. Materiels et methodes Etude retrospective, monocentrique, realisee entre janvier 2017 et decembre 2018 sur l’ensemble des patients traites par rifampicine pour une IOA. Les donnees suivantes ont ete collectees : caracteristiques des patients (âge, sexe, poids), bacteries responsables, dose journaliere et duree du traitement par rifampicine, duree totale du traitement efficace (incluant l’antibiotherapie parenterale) et les antibiotique(s) associe(s). L’evolution des patients a 6 mois apres la fin du traitement ainsi que les effets indesirables attribuables a la rifampicine ont ete releves dans les dossiers patients informatises (Orbis®), Resultats Durant ces 2 annees, 127 patients ont ete traites par rifampicine par voie orale pour une IOA dont 81 (64 %) sur materiel. L’âge moyen etait de 55 ans et le sexe ratio de 1,5. Chez 107 patients (84 %), la bacterie identifiee etait un staphylocoque. La dose journaliere mediane de rifampicine etait de 12 mg/kg (IQR 10,5–13,9). L’antibiotique associe etait une fluoroquinolone dans 81,9 % des cas. La duree mediane de traitement efficace etait de 45 jours (IQR 45–49,5) et la duree mediane du traitement par rifampicine etait de 37 jours (IQR 31,5–42) avec un pourcentage median du temps sous rifampicine de 81,2 %. L’evolution etait evaluable pour 118 patients. Elle etait favorable dans 103 cas (87,3 %) et defavorable dans 15 cas (12,7 %). Parmi les patients traites par rifampicine a une posologie ≤ 12 mg/kg/jour (n = 65), 57 (87,7 %) ont eu une evolution favorable. Parmi ceux traites a une posologie > 12 mg/kg/jour (n = 53), 46 (86,8 %) ont eu une evolution favorable. Un ou plusieurs effets indesirables ont ete notifies chez 32 patients (25 %), principalement des troubles digestifs (nausees, vomissement et/ou diarrhee), des mycoses. Un patient a developpe une insuffisance renale. Ces effets ont entraine un arret de traitement par rifampicine chez 9 patients (7 %). La survenue d’effet indesirable a ete notifiee chez 15,3 % des patients avec une posologie ≤ 12 mg/kg, versus 30,2 % des patients avec une posologie > 12 mg/kg (p = 0,05, test Chi2). Conclusion Lorsque les bacteries sont sensibles, un traitement antibiotique post operatoire par la rifampicine en association, permet d’obtenir une evolution satisfaisante chez 87 % des patients, meme a faibles doses (10–12 mg/kg/jour). Des effets indesirables ont ete observes chez un quart des patients et ont entraine un arret de traitement chez 7 % d’entre eux notamment chez les patients traites par des doses plus elevees.

Introduction Les etablissements de sante doivent assurer la continuite du traitement medicamenteux, de l’admission jusqu’a la sortie, transfert inclus. La conciliation medicamenteuse (CM) peut etre un moyen pour y parvenir. Ce travail a pour but d’analyser l’impact clinique et financier de la conciliation medicamenteuse des prescriptions de sortie, associee a un entretien pharmaceutique. Materiels et methode Lors de leur sortie, les patients ayant au moins une pathologie chronique et rentrant a domicile, sont randomises pour beneficier ou non de la CM de leur ordonnance de sortie (etude Conciville 2016-A01628-43). Pour les patients randomises dans le groupe CM, un entretien pharmaceutique expliquant les modifications de l’ordonnance, est associe a la correction des eventuelles erreurs de prescription (erreurs medicamenteuses et/ou reglementaires). De fevrier 2018 a aout 2018, les criteres suivants ont ete recueillis : pour les patients concilies : les types de problemes medicamenteux, les interventions pharmaceutiques, le devenir des interventions et pour tous les patients (concilies a la sortie ou non) le cout des ordonnances de sortie (pour un mois de traitement calcule sur la base des tarifs CEPS). Resultats et discussion Au total, 40 patients ont ete inclus. L’âge moyen etait comparable : 66,8 ± 11,5 ans dans le groupe non concilie (n = 21) vs 69,0 ± 10,7 ans dans le groupe concilie (n = 19), le sexe ratio etait de 2,5 vs 2,2 respectivement. Au total lors de la conciliation. Dix-huit prescriptions de sortie sur 19 (94,7 %) comportaient au moins un probleme (erreur medicamenteuse ou probleme reglementaire). Sur 172 lignes de prescription analysees, 65 problemes ont ete identifies dont 54 concernaient des erreurs medicamenteuses, notamment des prescriptions sur une duree trop longue (n = 18), des indications non traitees (n = 6), un plan de prise non optimal (n = 6), des medicaments non indiques (n = 5). Le taux d’acceptation des interventions pharmaceutiques etait de 50/65 (77 %). Le cout moyen des ordonnances de sortie etait de 345,1 ± 356,5 € pour le groupe concilie vs 545,9 ± 619,5 € dans le groupe non concilie. Conclusion La CM a permis d’eviter certaines erreurs de prescription et a permis de reduire les couts de l’ordonnance de sortie. L’analyse de l’ensemble des donnees de l’etude est necessaire pour confirmer cette tendance.

Therapies - In Press.Proof corrected by the author Available online since vendredi 11 mars 2016

Scedosporium apiospermum is a ubiquitous filamentous fungus, commonly found in soil, sewage and polluted waters. It is rarely pathogenic but can cause a broad spectrum of clinical diseases, which can be localised or disseminate to distant organs. The disseminated form of the disease is mostly seen among immunocompromised patients. However, some rare cases of disseminated disease have been reported in immunocompetent individuals. Treatment of these infections is challenging because of their natural resistance to many antifungal agents. Here, we report the case of a 57-year-old immunocompetent patient diagnosed with femoral pseudarthrosis due to S. apiospermum, despite having no obvious clinical sign of infection. Previously, the patient had undergone four iterative femoral surgeries following a road traffic accident which occurred 20 years before. During its last surgery for pseudarthrosis, no clinical or biological signs of infection were present. Per operative samples tested positive for S. apiospermum. The patient was successfully treated with oral voriconazole during 6 months with an excellent tolerance. We also provide a review of literature on bone and joint infections due to Scedosporium spp. (S. apiospermum, Scedosporium boydii and Scedosporium aurantiacum), discussing the evolution of their management and outcome which seems to improve since the use of voriconazole.