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Objectives Establish recommendations for the management of UTIs in MS patients. Background Urinary tract infections (UTIs) are common during multiple sclerosis (MS) and are one of the most common comorbidities potentially responsible for deaths from urinary sepsis. Methods The recommendations attempt to answer three main questions about UTIs and MS. The French Group for Recommendations in MS (France4MS) did a systematic review of articles from PubMed and universities databases (01/1980–12/2019). The RAND/UCLA appropriateness method, which has been developed to synthesize the scientific literature and expert opinions on health care topics, was used for reaching a formal agreement. 26 MS experts worked on the full-text review and a group of 70 multidisciplinary health care specialists validated the final evaluation of summarized evidences. Results UTIs are not associated with an increased risk of relapse and permanent worsening of disability. Only febrile UTIs worsen transient disability through the Uhthoff phenomenon. Some immunosuppressive treatments increase the risk of UTIs in MS patients and require special attention especially in case of hypogammaglobulinemia. Experts recommend to treat UTIs in patients with MS, according to recommendations of the general population. Prevention of recurrent UTIs requires stabilization of the neurogenic bladder. In some cases, weekly oral cycling antibiotics can be proposed after specialist advice. Asymptomatic bacteriuria should not be screened for or treated systematically except in special cases (pregnancy and invasive urological procedures). Conclusion Physicians and patients should be aware of the updated recommendations for UTis and MS.

Lyme borreliosis is a zoonosis characterized by great clinical polymorphism. We report 2 cases in patients who presented ocular manifestations: one anterior uveitis in an adult, which resolved under treatment, and one posterior uveitis in a child, whose initial ophthalmologic examination already showed retinal fibrous scars including the macular area. Lyme disease is on the long list of causes that must be discussed in cases of uveitis. The diagnosis is based on a series of epidemiological, clinical, and biological arguments with Western Blot serological profile analysis. Treatment is based especially on intravenous antibiotics.

The supply of fosfomycin had to be carefully controlled over metropolitan France during 10 weeks because of a unique crisis in production. Three hundred and forty prescriptions were collected and re-examined by an expert committee. The main indications were osteoarthritis (27%), lung infections (21%), severe sepsis (12.5%), and urinary tract infections (11%). The main bacteria involved, often multidrug resistant, were Pseudomonas aeruginosa (40%) and methicillin-resistant Staphylococcus. A careful analysis of the antibiogram proved fosfomycin to be irreplaceable in 36% of the cases. This study confirms and specifies the interest of fosfomycin. To our knowledge, this study was a unique opportunity to collect such specific data from the whole of France over a two-month shortage period.

International audience; ObjectivesWe aimed to assess antibiotic prescriptions to identify potential targets for improvement.MethodsWe conducted a point prevalence survey (November 2010) of antibiotic use in 314 voluntary hospitals recruited by the French Infectious Diseases Society (SPILF) and the National Observatory for Epidemiology of Bacterial Resistance to Antimicrobials (ONERBA). Data were entered online, immediately analyzed and exported.ResultsThe prevalence of antibiotic use was 19.5% (9059/46,446patients). A higher prevalence was observed in the infectious disease (58.4%), hematology (58%), and intensive care (48.7%) units. The three most frequently used antibiotic classes were aminopenicillins (23.8%), fluoroquinolones (17.9%), and 3rd-generation cephalosporins (16.7%). A monotherapy was prescribed to 64% of patients. The reasons for the antibiotic prescription were written in the medical records of 74% of patients and 62% were consistent with the local guidelines.ConclusionOur results are similar to that of other studies. Various local targets for improvement have been identified to help hospitals define a better antibiotic stewardship.; ObjectifsÉvaluer les prescriptions antibiotiques afin de proposer des pistes d’amélioration.MéthodesNous avons réalisé une enquête de prévalence de l’antibiothérapie, en novembre 2010, dans 314 hôpitaux volontaires recrutés par les réseaux de la SPILF et de l’ONERBA. Les données étaient saisies en ligne avec une analyse instantanée et un export des données.RésultatsLa prévalence de l’antibiothérapie était de 19,5 % (9059/46 446patients). Elle était plus élevée en maladies infectieuses (58,4 %), hématologie (58 %) et réanimation (48,7 %). Les trois classes les plus fréquentes étaient les aminopénicillines (23,8 %), les fluoroquinolones (17,9 %) et les céphalosporines de 3e génération (16,7 %). Une monothérapie était utilisée dans 64 % des cas. Le motif de la prescription était noté dans le dossier médical dans 74 % des cas et était conforme aux recommandations locales dans 62 %.ConclusionsCes résultats sont similaires à ceux d’autres enquêtes. Des possibilités d’amélioration sur des critères locaux permettent aux établissements d’orienter leurs politiques d’amélioration de la prescription.

Resistance is one of failure's reasons. We tried, through clinical experience, to approach the magnitude and nature of the links, between phenotypically defined acquired resistance and clinical failure, in community acquired respiratory infections. An efficient resistance mecanism, able to suppress antibiotic action, is clearely associated to a risk of clinical failure (e.g. betalactamase secretion, target modification using methilation for macrolides, target mutation for fluoroquinoles). Resistance mecanism due to reduction of target affinity (pneumococcus and betalactams) progressively decreasing beta lactam activity depending on its expression, is at present time, not clearely associeted with clinical failure. Critical concentration, defining phenotypical resistance, is predictive of failure if it identifies a bacterial population owning an efficient resistance mecanism. It will not be predictive of failure if that concentration do not detect the resistance mecanism (e.g. parC mutation and levofloxacin) or if the link between antibiotic and resistant bacteria is not binary but depends also on pharmacokinetic parameters (pneumococcus and betalactam). Using resistance as a parametre for antibiotic choice, must integrate several elements: presence or not of a resistance mecanism, type and efficiency of the mecanism, links with clinical failure and antibiotic concentration, type and site of infection. Critical concentration is not allways the magic number that predict failure or success.

This review is the fruit of multidisciplinary discussions concerning the continuous administration of beta-lactams, with a special focus on cefepime. Pooling of the analyses and viewpoints of all members of the group, based on a review of the literature on this subject, has made it possible to test the hypothesis concerning the applicability of this method of administering cefepime. Cefepime is a cephalosporin for injection which exhibits a broader spectrum of activity than that of older, third-generation cephalosporins for injection (cefotaxime, ceftriaxone, ceftazidime). The specific activity of cefepime is based on its more rapid penetration (probably due to its zwitterionic structure, this molecule being both positively and negatively charged) through the outer membrane of Gram-negative bacteria, its greater affinity for penicillin-binding proteins, its weak affinity for beta-lactamases, and its stability versus certain beta-lactamases, particularly derepressed cephalosporinases. The stability of cefepime in various solutions intended for parenteral administration has been studied, and the results obtained demonstrated the good compatibility of cefepime with these different solutions. These results thus permit the administration of cefepime in a continuous infusion over a 24-h period, using two consecutive syringes.

Resume Nous avons analyse 33 osteites ou osteoarthrites pour lesquelles les prelevements ont isole une ou plusieurs bacteries anaerobies. Le diagnostic d'infection anaerobie a ete retenu si les anaerobies ont ete isoles de prelevements fiables peroperatoires ou d'au moins deux prelevements non fiables (fistule, prelevement a l'aiguille) et a la condition d'une concordance entre les differents resultats. Cent dix huit bacteries ont ete isolees des 33 patients dont 81 bacteries anerobies strictes, soit 2,39 bacteries par patient (dont Peptostreptococcus 20, Prevotella 16, Bacteroides 12, dont six groupe fragilis ), Propionibacterium acnes dix, Fusobacterium nucleatum huit. Vingt-quatre osteites etaient des infections mixtes (73 %), neuf (27 %) etaient exclusivement a anerobies, dont sept monomicrobiennes. Nous avons analyse les infections et la repartition des etiologies bacteriennes selon les localisations, le mode de contamination, les facteurs de risque.

Summary Background Resistance of HIV-1 to antiretroviral drugs is the main cause of antiretroviral-treatment failure. We assessed the transmission of drug-resistant variants among individuals with primary HIV-1 infection. Methods Population-based sequencing of the viral reverse-transcriptase and protease genes derived from plasma viral RNA was done in 82 consecutive individuals with documented primary HIV-1 infection from January, 1996, to July, 1998. Phenotypic resistance to protease inhibitors was assessed by recombinant virus assay in individuals with two or more mutations associated with resistance to protease inhibitors. Findings Zidovudine-resistance mutations were detected in seven (9%) of 82 individuals. Mutations associated with resistance to other reverse-transcriptase inhibitors (RTls) were detected in two individuals. Primary-resistance mutations associated with protease inhibitors (V82A, L90M) were detected in three (4%) of 70 individuals; two of these had also RTl-resistance mutations. Decreased sensitivity to three or four protease inhibitors was seen in three individuals, one of whom was infected with HIV-1 variants that harboured 12 mutations associated with resistance to multiple RTl and protease inhibitors. Interpretation To introduce the best antiretroviral treatment, resistance testing should be done in recently HIV-1-infected individuals.

Hepatitis E is caused by the Hepatitis E Virus (HEV), entericaly transmitted. In areas with poor sanitation, HEV is responsible for high endemicity and major outbreaks. In countries with high sanitary conditions, HEV is a zoonosis responsible for sporadic cases, and is encountered in travellers returning from endemic areas. The clinical manifestations are not distinguishable from that caused by other causes of acute viral hepatitis. Fulminant hepatitis are encountered in 1 to 4% of acute hepatitis E. Remarquably, mortality among pregnant women is very high. Diagnosis can be made by serological testing and eventually viral detection by PCR. HEV can cause chronic infection in immunocompromised patients. There is no specific therapy. There is no vaccine currently available.

International audience; OBJECTIVES: To evaluate the feasibility of a point prevalence survey for monitoring antibiotic use in a voluntary sample of French hospitals. METHODS: Demographic and medical data were collected for all inpatients. Additional characteristics regarding antimicrobial treatment, type of infection and microbiological results were collected only for patients receiving antimicrobials. RESULTS: Among 3964 patients in 38 hospitals, 343 (8.7%) received antimicrobial prophylaxis and 1276 (32.2%) antimicrobial therapy. The duration of surgical antimicrobial prophylaxis was >1 day in 41 out of 200 (21%) of the cases. Among patients with antimicrobial therapy, 959 (75.2%) received β-lactams (including 34.8% penicillins with β-lactam inhibitors, 22.1% third-generation cephalosporins and 7.8% carbapenems) and 301 (23.6%) received fluoroquinolones (50% orally). A total of 518 (40.6%) patients were treated with more than one drug and 345 (27.2%) were treated for >7 days. Patients treated for hospital-acquired infections (39.2%) were more likely to receive combinations (47.6% versus 34.4%, P < 0.01), carbapenems (14.4% versus 2.6%, P < 0.01), glycopeptides (14.4% versus 3.7%, P < 0.01) and antifungals (17% versus 5.3%, P < 0.01) for a longer duration (7.8 versus 6 days, P < 0.01). Fifty-six patients (4.4%) were treated for >7 days and did not have any microbiological sample drawn. The time allocated for the survey represented 18.3-25.0 h for 100 patients. CONCLUSIONS: The data provide directions for further interventions, such as better use of diagnostic tools, decreasing the treatment duration and the use of combinations. In addition, the survey shows that, although cumbersome, it is feasible to improve the representativeness of national data in European surveys.

Summary. Itraconazole, a new triazole antifungal agent, has marked in vitro activity against filamentous fungi, particularly Aspergillus. We studied three groups of patients suffering from aspergillosis (16 cases): six affected with aspergilloma, three with allergic bronchopulmonary aspergillosis and seven with invasive aspergillosis. The survey consisted in clinical, radiological, mycological and serological evaluations with respect to drug plasma levels. Itraconazole was given at a dosage of 200–400 mg day-1 for periods ranging from 14 to 488 days. Out of the 16 patients, nine responded to therapy (recovery or improvement) and one failed to respond. Three patients improved but experienced relapses and three others could not be evaluated because of liver function disorders, so that treatment had to be stopped prematurely. Zusammenfassung. Itraconazol, ein neues antimykotisches Triazol hat eine in vitro nachgewiesene Wirkung gegen Fadenpilze, im besonderen Aspergillus. Wir untersuchten 3 Patientengruppen, die an Aspergillose litten (16 Falle); 6 davon waren von einem Aspergillom betroffen, 3 Falle mit allergischer bronchopulmonarer Aspergillose und 7 Falle mit invasiver Aspergillose. Die Uberwachung bestand aus klinischen, radiologischen, mykologischen und serologischen Untersuchungen mit Berucksichtigung der Medikamentenspiegel im Plasma. Itraconazol wurde in einer Dosis von 200–400 mg/Tag fur die Dauer von 14–488 Tagen gegeben. Von 16 Patienten reagierten 9 mit Heilung oder Besserung, 1 Patient reagierte nicht auf die Therapie. Der Zustand von 3 weiteren Patienten bessertc sich, sie erlitten jedoch Ruckfalle. Drei andere Falle konnten wegen Storungen der Leberfunktion nicht berucksichtigt werden, so das die Behandlung in diesen Fallen sofort beendet werden muste.

Lyme borreliosis is a zoonosis characterized by great clinical polymorphism. We report 2 cases in patients who presented ocular manifestations: one anterior uveitis in an adult, which resolved under treatment, and one posterior uveitis in a child, whose initial ophthalmologic examination already showed retinal fibrous scars including the macular area. Lyme disease is on the long list of causes that must be discussed in cases of uveitis. The diagnosis is based on a series of epidemiological, clinical, and biological arguments with Western Blot serological profile analysis. Treatment is based especially on intravenous antibiotics.

The supply of fosfomycin had to be carefully controlled over metropolitan France during 10 weeks because of a unique crisis in production. Three hundred and forty prescriptions were collected and re-examined by an expert committee. The main indications were osteoarthritis (27%), lung infections (21%), severe sepsis (12.5%), and urinary tract infections (11%). The main bacteria involved, often multidrug resistant, were Pseudomonas aeruginosa (40%) and methicillin-resistant Staphylococcus. A careful analysis of the antibiogram proved fosfomycin to be irreplaceable in 36% of the cases. This study confirms and specifies the interest of fosfomycin. To our knowledge, this study was a unique opportunity to collect such specific data from the whole of France over a two-month shortage period.

Resistance is one of failure's reasons. We tried, through clinical experience, to approach the magnitude and nature of the links, between phenotypically defined acquired resistance and clinical failure, in community acquired respiratory infections. An efficient resistance mecanism, able to suppress antibiotic action, is clearely associated to a risk of clinical failure (e.g. betalactamase secretion, target modification using methilation for macrolides, target mutation for fluoroquinoles). Resistance mecanism due to reduction of target affinity (pneumococcus and betalactams) progressively decreasing beta lactam activity depending on its expression, is at present time, not clearely associeted with clinical failure. Critical concentration, defining phenotypical resistance, is predictive of failure if it identifies a bacterial population owning an efficient resistance mecanism. It will not be predictive of failure if that concentration do not detect the resistance mecanism (e.g. parC mutation and levofloxacin) or if the link between antibiotic and resistant bacteria is not binary but depends also on pharmacokinetic parameters (pneumococcus and betalactam). Using resistance as a parametre for antibiotic choice, must integrate several elements: presence or not of a resistance mecanism, type and efficiency of the mecanism, links with clinical failure and antibiotic concentration, type and site of infection. Critical concentration is not allways the magic number that predict failure or success.

Levofloxacine is a fluoroquinolone presenting good anti-pneumococcal activity, including against strains with reduced sensitivity to penicillin. Four randomized controlled studies have compared the efficacy of levofloxacine versus other antibiotics (amoxacillin-clavulanic acid, amoxicillin, ceftriaxone, ceftriaxone plus cefuroxime +/- erythromycin) for the treatment of acute community-acquired pneumonia in adults. Grouping the 1,738 analyzable patients in these four studies, a meta-analysis was performed on the sub-group of 275 patients with documented pneumococcal infection (86 with bacteriemia) in order to compare the efficacy of levofloxacine with that of the comparer antibiotics. The trials were homogeneous, allowing the meta-analysis. The overall rate of clinical success was 88.6% in the levofloxacine group and 86.7% in the comparer group. The interval of confidence for the difference in the rate of estimated clinical success was between -5.65% and +9.39%. Bacteriologically, the rate of eradication was 90.2% and 90.4% respectively with an interval of confidence for the difference between -7.83% and +7.36%. The results of this meta-analysis confirmed that the efficacy of levofloxacine for the treatment of acute community-acquired pneumococcal pneumonia is not inferior to that of the comparers; the interval of confidence for the difference in the estimated rate of success did not include the breaking point of non-inferiority (-10% set for the clinical studies) and included zero.

Pivmecillinam is a unique beta-lactam antimicrobial that has been used for the treatment of acute uncomplicated urinary infection for > 20 y. Since this agent was introduced, the quinolone antimicrobials have become widely used for the same indication. This study compared the efficacy of a 3-d regimen of pivmecillinam 400 mg b.i.d. with norfloxacin 400 mg b.i.d. Women aged between 18 and 65 y presenting with symptoms of acute cystitis of < 7 d duration were eligible for enrollment; 483 were randomized to receive pivmecillinam and 471 to receive norfloxacin. In each group, 30% of women had negative urine cultures prior to therapy. Bacteriologic cure at early post-therapy follow-up was achieved in 222/298 (75%) pivmecillinam patients and 276/302 (91%) norfloxacin patients [p < 0.001; 95% confidence interval (CI) 12.0-21.8]. Clinical cure/improvement at Day 4 following initiation of therapy was observed in 434/457 (95%) women who received pivmecillinam and 425/442 (96%) who received norfloxacin (p = 0.39; 95% CI 1.5-3.9). Early post-therapy (11 +/- 2 d) clinical cure was achieved in 360/437 women (82%) who received pivmecillinam and 381/433 (88%) who received norfloxacin (p = 0.019; 95% CI 0.9-10.3). In women aged < or = 50 y, early clinical cure rates were 294/351 (84%) for pivmecillinam and 299/340 (88%) for norfloxacin (p = 0.11; 95% CI 1.0-9.4). Adverse effects were similar for both regimens, and there was no evidence of the emergence of organisms of increasing resistance with therapy. Short-course therapy with norfloxacin was superior to that with pivmecillinam in terms of bacteriologic outcome, although differences in clinical outcome were less marked. In conclusion, short-course therapy with pivmecillinam is an effective empirical treatment for pre-menopausal women.

Introduction – objectifs La DDVG est associee a des troubles de la repartition des graisses en lien avec l’insulinoresistance. Nous avons etudie les liens entre DDVG et exposition aux ARV et au VIH. Materiels et methodes Etude prospective de 2008 a 2013 de 72 patients VIH+ avec lipodystophie, exces de poids ou anomalie du bilan lipidique sans symptomes cardio-vasculaires et traites par ARV. Parametres etudies : âge, BMI, tour de taille, TA, Antecedents (diabete, cardio vasculaire), tabagisme, coinfection VHC, glycemie, insulinemie, cholesterolemie, microalbuminurie, HOMA, duree d’evolution de l’infection VIH non traitee, types et durees des ARV, recherche d’atherome carotidien. La DDVG a ete recherchee par echographie cardiaque et doppler tissulaire. Resultats 1. 14/72 pts (19,4 %) avaient une DDVG 2. Les patients avec DDVG n’ont pas ete plus exposes aux ARV ou au VIH ( tab 1 ). Conclusion Dans cette population les pts ayant une DDVG n’ont pas ete plus exposes au VIH ou aux ARV que les patients sans DDVG. Les ARV ne sont pas dans cette cohorte lipoa/dystrophyque ou dyslipidemique, un facteur de risque de DDVG.

Introduction – objectifs Chez des patients (pts) ayant des infections osseuses ou des EI et traites par Avo, les concentrations ([C]) seriques d’A ont ete mesurees pour verifier l’adequation therapeutique. Materiels et methodes 19 pts (âge moyen 72,2 ans) ont ete inclus : 7 EI, 8 infections de protheses articulaires, 5 osteo-arthrites ( S. gallolyticus 3, S. agalactiae 4, S. aureus 5, S. pneumoniae 2, E. faecalis 1, S. dysgalactiae 1, autres 5) ont ete traitees par Avo 2 g/6 h ou 2 g/8 h apres au moins 10 j d’antibiotherapie IV. Les CMI a l’A variaient de 0,012 a 0,25 mg/l. Les taux seriques etaient mesures par chromatographie haute-performance en phase liquide 1 h apres la prise de 2 g (Cmax) et 6 ou 8 h apres la prise (Cmin). La Cmin cible a ete definie ≥ 10 mg/l, permettant une exposition therapeutique optimisee (t > CMI). Resultats [C] moyennes observees : Cmax 28,52 mg/l (SD ± 14,7), Cmin 18,3 mg/l (SD ± 15,3). Les Cmin etaient inferieures chez les 7 pts recevant 2 g/8 h (14,3 mg/l, SD ± 7,0) a celles des 12 pts recevant 2 g/6 h (20,5 mg/l, SD ± 18,3). Les Cmin differaient selon la fonction renale : 13,5 mg/l (SD ± 5,7) chez les pts avec fonction renale normale, 25,1 mg/l (SD ± 22) chez les pts avec fonction renale alteree (creatininemie moyenne 150 mg/l). 4/19 patients (21 %) avaient des Cmin ≤10 mg/l. Conclusion Chez 15/19 pts (79 %), les Cmin plasmatiques d’A etaient superieures a la concentration cible definie, permettant de traiter des infections difficiles dues a des bacteries ayant une CMI a l’A

Introduction – objectifs L’osteite du pied diabetique est une complication frequente. Des recommandations placent la biopsie osseuse comme element central diagnostic. L’objectif de cette etude est de comparer les differentes techniques de bacteriologie dans le diagnostic des osteites de pied diabetique. Materiels et methodes Etude prospective, non controlee monocentrique effectuee entre avril 2012 et fevrier 2014. Le diagnostic d’osteite etait retenu sur les criteres cliniques et d’imagerie. Les prelevements ont ete effectues par biopsie percutanee radio-guidee. Ces prelevements ont ete techniques sous PSM : – Mise en culture classique sur milieux enrichis (gelose au sang, gelose chocolat) et milieu d’enrichissement Schaedler semi-gelose. – Ensemencement d’un flacon Bactec Pediatrique. – Recherche de bacteries par amplification du gene codant pour l’ARN 16S. - Recherche du Staphylococcus aureus par PCR en temps reel. Resultats Vingt-sept biopsies ont ete effectuees. Seize biopsies ont ete documentees sur le plan microbiologique. Sur les 27 cultures classiques effectuees, 15 cultures ont ete positives dont une culture positive apres incubation prolongee. Le S taphylococcus aureus a ete mis en evidence a 9 reprises. Sur les 24 prelevements ensemences en flacon d’hemoculture, 12 ont ete positifs. Vingt-deux PCR 16S ont ete faites, 1 est positive mettant en evidence un Staphylococcus aureus , egalement retrouve sur les milieux de cultures. Vingt-cinq PCR Staphylococccus aureus ont ete effectuees, 7 sont positives sur des prelevements dont les milieux de cultures avaient mis en evidence un Staphylococcus aureus. Conclusion Dans notre etude, la biologie moleculaire n’apporte pas d’element diagnostic supplementaire aux milieux de cultures classiques.

OBJECTIVE: To assess the impact of primary HIV infection (PHI) on the spread of HIV and the temporal trends in transmission of HIV drug resistance between 1996 and 1999 in Switzerland. METHODS: Sequencing of the genes for reverse transcriptase (RT) and protease was performed for 197 individuals with documented PHI. Phylogenetic analyses were confronted with epidemiological data. RESULTS: Significant clustering was demonstrated for 29% of the RT sequences. All these cases occurred closely together in place and time; contact tracing demonstrated transmission at the time of PHI in 30% of them. Genotypic drug resistance was detected in 8.6% of PHI individuals in 1996, 14.6% in 1997, 8.8% in 1998 and 5.0% in 1999. Drug-resistant variants were identified in 11.3% of individuals infected by homosexual contacts, 6.1% by heterosexual contacts, 13% of intravenous drug users and more frequently in men (10.4%) than women (2.6%). Potential factors involved in the recent decrease of transmission of drug-resistant variants include increase of HIV non-B subtypes from 23% in 1996 to 35% in 1999 (only one non-B subtype had resistance mutations) and a steady increase of patients with undetectable viraemia as documented in Swiss HIV Cohort Study (10% in 1996 vs 53% in 1999). CONCLUSIONS: Phylogenetic and epidemiological analyses underline the impact of PHI in the spread of HIV. Moreover, this study indicates that drug resistance transmission may have decreased recently in Switzerland through the increased frequency of infection with HIV non-B subtypes and the steady increase of patients with undetectable viraemia.

LEVOFLOXACIN: A new anti-pneumococcal fluoroquinolone, levofloxacin, has received approval in France for the treatment of community-acquired pneumonia at the dose of 500 mg once or twice a day, depending on the severity of the disease, the germ susceptibility and the patient's weight. Levofloxacin has a powerful and rapid bactericidal activity, particularly against pneumococci, whatever the level of penicillin resistance. The pharmacokinetic properties of the compound allow once daily dosage. Pharmacodynamically, it has been clinically demonstrated that the most predictive parameter of efficacy is the Cmax/MIC ratio. PNEUMOCOCCAL PNEUMONIA: Because of the potential gravity of pneumococcal pneumonia, it might be preferrable to use levofloxacin at the dose of 500 mg twice daily. The efficacy of the two levofloxacin doses for the treatment of pneumococcal pneumonia was thus analyzed. Five clinical studies including 4 comparative trials, enrolling nearly 2,000 patients with community-acquired pneumonia were reported in the international approval document. Among these patients, 310 had documented pneumococcal pneumonia including 31% with bacteriemia. TASK FORCE REPORT: On the basis of available data, the level of proof is sufficient to prescribe levofloxacin at the dose of 500 mg once daily for the treatment of mild to moderately severe community-acquired pneumonia in ambulatory patients, including those with suspected pneumococcal pneumonia, with or without bacteriemia. It would be reasonable to propose the 500 mg twice daily dosage for severe community-acquired pneumonia warranting intensive care hospitalization in accordance with the criteria of the ERS Task Force Report. The well-founded rationale of this therapeutic strategy should be validated by the results of ongoing studies and by following the evolution of germ susceptibility to these new compounds.

Non AIDS-defining cancer would have increased in HIV-patients as suggested by numerous studies. Four cases of adenocarcinoma of unknown primary site with thoracic localization that occurred in HIV-infected patients are described.To date, there have been no published data about carcinomas of unknown primary site relating to HIV-infected patients; however, immunodepression could promote them. Carcinomas of unknown primary site account for 0.5 to 10% of all cancer in general population. Primary carcinoma is identified in approximately one third of the cases and often corresponds to lung cancer in case of sus-diaphragmatic metastasis, particularly in case of pleural metastasis. Lung cancer in HIV-infected patients affects mostly young men who smoke and are often intravenous drug addicts. Adenocarcinoma is the most common histological type of cancer.Further studies of lung cancer in HIV-infected patients will help evaluate their frequency. In case of increasing frequency, lung cancer should then be included in AIDS-defining cancers.

In a prospective, randomized, multicenter trial, the efficacy of penicillin plus ofloxacin was compared to that of amoxicillin-clavulanate plus erythromycin in the treatment of community-acquired pneumonia. One hundred seventeen hospitalized patients presenting with severe community-acquired pneumonia received either penicillin 3 x 10(6) U/6 h plus ofloxacin 200 mg twice daily (group A) or amoxicillin-clavulanate 1 g/6 h plus erythromycin 1 g/8 h (group B). Initial assessment included clinical examination, determination of simplified acute physiology score (SAPS), chest X-ray and evaluation of microbiological data obtained from blood, sputum and/or bronchoscopy. Follow-up was documented at 72 h and at 30 days. Both groups were comparable for age, sex, SAPS, chest X-ray, hypoxemia and microbiological data. The causative pathogen was identified in 54 cases (53%), Streptococcus pneumoniae being most frequent isolate (54.7%). All organisms cultured were susceptible to at least one of the antibiotics of each combination of the protocol, with the exception of two strains of Pseudomonas aeruginosa. A favorable outcome was observed in 76% of the patients, equally distributed between the two groups. After completion of therapy there were 12 clinical failures in each group (20.5%). Six patients in each group (10.3%) died of infection. Tolerance was similar for both regimens, apart from an increased rate of superficial thrombophlebitis in patients receiving intravenous erythromycin. The combination of penicillin with ofloxacin is as effective and as safe as a previously recommended regimen combining amoxicillin-clavulanate and erythromycin in treating patients with community-acquired pneumonia.

Objectif Examiner les prescriptions de fosfomycine (FOS), ses indications et son efficacite en periode de contingentement. Durant une periode de 10 semaines la production de FOS a ete interrompue, et sa delivrance contingentee. Les prescriptions ont ete revues par un comite d’experts. Ont ete etudie, 114 prescriptions concernant 46 femmes et 68 hommes, 86 % d’adultes et 14 % d’enfants. Les principales bacteries identifiees etaient Pseudomonas aeruginosa (Pa) (36 %), Staphylococcus aureus meticilline-resistant (SARM) (30 %), Escherichia coli (E. coli), et les bacteries du groupe KES (Klebsiella, Enterobacter, Serratia) ; 67,5 % des bacteries etaient multi-resistantes (BMR). D’apres l’analyse des antibiogrammes la FOS etait le seul antibiotique efficace dans 35 % des cas. Indications Total Germes responsables Antibiotiques associes Duree moyenne de traitement en jours Evolution Osteo arthritis 31 SARM : 9 C3G : 9 28 Favorable : 25 SARM : 3 GP : 8 Defavorable : 5 Pa : 5 Imipeneme : 4 NR : 1 E. coli : 5 KES : 5 FQ : 2 Infections pulmonaires 29 Pa : 20 Imipeneme : 5 11,5 Favorable: 21 SARM : 3 Colimycine : 5 Defavorable : 7 SCNMR : 1 C3G : 3 NR : 1 KES : 1 Autres : 5 Infections urinaires 14 Pa : 10 C3G : 6 9,9 Favorable: 14 E. coli : 2 Imipeneme : 2 SARM : 2 Colimycine : 1 FQ : 1 Sepsis 13 SCNMR : 5 GP:6 12,8 Favorable : 8 SARM : 2 C3G:2 Defavorable : 3 E. coli : 2 NR : 2 KES : 2 Autres:1 Infections neurologiques 8 SAMS2 : 2 C3G : 2 9,6 Favorable : 6 KES : 2 GP : 1 Defavorable : 1 SARM : 1 Meropeneme : 1 NR : 1 SCNMR : 1 NR : 4 E. coli :1 NR : 1 SCNMR : staphylocoque a coagulase negative meticilline resistants ; SAMS : Staphylococcus aureus meticilline sensibles ; C3G : cephalosporine 3e generation ; GP : Glycopeptides ; FQ : fluoroquinolones ; NR : non renseigne. 18 % des patients presentait une bacteriemie et 17 % un choc septique ; 46,5 % etait immunodeprime et 68 % hospitalise en unite de soins intensifs. L’evolution etait favorable dans 89,5 % des cas. Ces resultats suggerent l’efficacite de la FOS dans le traitement des infections severes y compris a BMR

Between 1952 and 1973, 138 patients with thyroïd carcinoma have been recorded. From the critical study of these cases, the pathological, etiological and clinical features have been studied. Different therapeutic modalities are evaluated from these cases. Surgery was always used when possible. A hemithyroïdectomy was realised most often. We stress that sterilisation was obtained by 131I treatment in plurifocal metastasis, particularly in pulmonary metastasis, only when the iodine uptake was sufficient. Survival has been evaluated according to the pathology: papillary and vesicular carcinomas have a good prognosis (the papillary and vesicular survival rate at 10 years reaches respectively: 65% and 64%). Anaplastic carcinomas have a bad prognosis (the survival rate at 5 years is 18%, at 10 years, 0%. These results are similar to those published by differents authors. At the opposite, trabecular carcinomas have a very short survival (8% at 5 years, 7% at 10 years) which is very unusual in well differentiated thyroïd carcinomas. It has to be isolated from the others.

L. monocytogenes meningo-encephalitis are still a therapeutic problem, with most of the time a poor prognosis. In vitro, cotrimoxazole has about the same bactericidal activity as the ampicillin-aminoglycoside combination. So we treated 8 patients with L. M. meningoencephalitis with cotrimoxazole alone, with a mean duration of treatment of 13 days. All patients recovered without sequellae from their infectious episode.

This study took place between February 1984 and February 1985 in 76 febrile neutropenic patients. We evaluated the whole mycological and serological results, in 91 febrile episodes. We separated two groups: group I (acute leukemia, chronic myeloïd leukemia, medullar aplasia, lymphomas) and group II (chronic lymphoïd leukemia, Hodgkin disease, myelomas, solid tumors). Patients were included in this study if they developed a temperature of 38.5 degrees C or greater and if they had less than five hundred neutrophils per mm3. They were treated with mono or bi-antibiotherapy. If the patient remained febrile more than 72 hours, an antifungal therapy was added (Amphotericin B IV). Through these weekly results, we conclude: the high frequency of digestive tract candidiasis in such patients; disseminated candidiasis occurs only in the first group patients with fungal digestive colonization; the overall response rate in this study was 77 per cent. This underlines the interest of empiric treatment with amphotericin B IV.

In a prospective study 128 community acquired pneumoniae were treated with a macrolide (josamycin) by oral route. Patients improved in 94 p. 100 (113). Complications were as following: 2 deaths, 2 sequels, 3 failures. Authors discuss macrolides effectiveness in acute pneumoniae, particularly pneumococcal ones. They conclude macrolides are a good choice in first intention in acute pneumoniae of adults.

Out of 66 febrile neutropenic patients, 33 were treated with a ceftazidime-vancomycin combination (group A) and 33 with a ticarcillin-vancomycin-amikacin combination (group B). There was no significant difference in satisfactory results between the two groups (group A 79 per cent, group B 88 per cent), and both regimens were equally active in all febrile episodes. Reversible side-effects (renal and cutaneous toxicity) were observed in 15 per cent of the cases. Two cases of superinfection and one case of resistance occurring during treatment were noted in group B patients. At a time when Gram-positive infections are increasingly frequent among febrile neutropenic patients, the ceftazidime-vancomycin combination seems to be as effective as the ticarcillin-vancomycin-amikacin triple drug combination.

Resume Deux patients ayant effectue un voyage en zone d'endemie palustre sans chimioprophylaxie ont presente un acces pernicieux severe avec complications viscerales. Associee a la quinine, une exsanguino-transfusion a ete effectuee afin de diminuer le taux d'infestation par le Plasmodium falciparum. L'amelioration a ete rapide et spectaculaire. L'exsanguino-transfusion doit etre discutee chaque fois que la parasitemie est superieure a 10 %.