Digital health for remote home monitoring of patients with COVID-19 requiring oxygen: a cohort study and literature review

Background

The clinical course and outcome of COVID-19 vary widely, from asymptomatic and mild to critical. Elderly patients and patients with comorbidities are at increased risk of respiratory failure and oxygen requirements. Due to the massive surge, the pandemic has created challenges for overwhelmed hospitals. Thus, the original home management of COVID-19 patients requiring oxygen and remote monitoring by a web app and a nurse at home were implemented in our center. We aimed to evaluate the outcome of patients with COVID-19 requiring oxygen who benefited from home remote monitoring management.

Methods

We performed a retrospective cohort study on all COVID-19 patients requiring oxygen (< 5 L/min) who consulted from October 2020 to April 2021 at our emergency department and were managed with home remote monitoring by a web app and an in-home nurse. We also carried out a literature review of studies on COVID-19 patients requiring oxygen with remote monitoring.

Results

We included 300 patients [184 (61.3%) male patients, median age 51 years]. The main comorbidities were cardiovascular disease (n = 117; 39.0%), diabetes mellitus (n = 72; 24.0%), and chronic respiratory disease (n = 32; 10.7%). Among the 28 (9.3%) patients readmitted to the hospital, 6 (1.9%) were hospitalized in the intensive care unit, and 3 (0.9%) died. In the multivariable analysis, risk factors for unplanned hospitalization were chronic respiratory failure (odds ratio (OR) =4.476, 95%CI 1.565-12.80), immunosuppression (OR = 3.736, 95%CI 1.208-11.552), and short delay between symptoms onset and start of telemonitoring (OR = 0.744, 95%CI 0.653-0.847). In the literature review, we identified seven other experiences of remote monitoring management. Mortality rate and unplanned hospitalization were low (maximum 1.9 and 12%, respectively).

Conclusion

Our study confirms the safety of home remote monitoring of patients with COVID-19 who require oxygen, as well as our literature review. However, patients with chronic respiratory failure and immunosuppression should be closely monitored.

Real-life impact of respiratory panel PCR assay on antibiotic prescription in geriatric acute care in the pre-COVID-19 era

OBJECTIVES

In this era of bacterial resistance, avoiding inappropriate use of antibiotic treatments is of major importance. Respiratory tract infections are frequent among older patients, and differentiating viral from bacterial infections is a challenge. The aim of our study was to evaluate the impact of recently available respiratory PCR testing on antimicrobial prescription in geriatric acute care.

METHODS

We performed a retrospective study, including all hospitalized geriatric patients who had had multiplex respiratory PCR testing prescribed from 1st October 2018 to 30th September 2019. The PCR test comprised a respiratory viral panel (RVP) and a respiratory bacterial panel (RBP). PCR testing could be prescribed at any time during hospitalization by geriatricians. Our primary endpoint was antibiotic prescription after viral multiplex PCR testing results.

RESULTS

All in all, 193 patients were included, 88 (45.6%) of whom had positive RVP, while none had positive RBP. Patients with positive RVP had significantly fewer antibiotic prescriptions following test results than patients with negative RVP (odds ratio (OR) 0.41, 95% confidence interval (CI) 0.22-0.77; p = 0.004). Among positive-RVP patients, factors associated with antibiotic continuation were presence of radiological infiltrate (OR 12.02, 95%CI 3.07-30.29), and detected Respiratory Syncytial Virus (OR 7.54, 95%CI 1.74-32.65). That said, discontinuation of antibiotic treatment seems safe.

CONCLUSION

In this population, the impact of viral detection by respiratory multiplex PCR on antibiotic therapy was low. It could be optimized by means of clearly formulated local guidelines, qualified staff and specific training by infectious disease specialists. Cost-effectiveness studies are necessary.

Pregnant women with mild COVID-19 followed in community setting by telemedicine, and factors associated with unfavorable outcome

OBJECTIVES

Few is known on pregnant women with mild COVID-19 managed in a community setting with a telemedicine solution, including their outcomes. The objective of this study is to evaluate the adverse fetal outcomes and hospitalization rates of pregnant COVID-19 outpatients who were monitored with the Covidom© telemedicine solution.

METHODS

A nested study was conducted on pregnant outpatients with confirmed COVID-19, who were managed with Covidom© between March and November 2020. The patients were required to complete a standard medical questionnaire on co-morbidities and symptoms at inclusion, and were then monitored daily for 30 days after symptom onset. Adverse fetal outcome was defined as a composite of preterm birth, low birthweight, or stillbirth, and was collected retrospectively through phone contact with a standardized questionnaire.

RESULTS

The study included 714 pregnant women, with a median age of 32.0 [29.0-35.0] and a median BMI of 23.8 [21.3-27.0]. The main comorbidities observed were smoking (53%), hypertension (19%). The most common symptoms were asthenia (45.6%), cough (40.3%) and headache (25.7%), as well as anosmia (28.4%) and agueusia (32.3%). Adverse fetal outcomes occurred in 64 (9%) cases, including 38 (5%) preterm births, 33 (5%) low birthweights, and 6 (1%) stillbirths. Hospitalization occurred in 102 (14%) cases and was associated with adverse fetal outcomes (OR 2.4, 95% CI 1.3-4.4).

CONCLUSIONS

Our study suggests that adverse fetal outcomes are rare in pregnant women with mild COVID-19 who are monitored at home with telemedicine. However, hospitalization for COVID-19 and pregnancy-induced hypertension are associated with a higher risk of adverse fetal outcome.

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

Background

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

Methods

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

Results

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

Conclusions

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

[Excess mortality in nursing homes during the first wave of the Covid-19 pandemic]

Overall mortality in France is 147 568 deaths since the first wave. Although accounting for nearly 20% of deaths in France, the excess mortality in long-term care facilities compared to previous years has not been fully studied. The Covid-19 pandemic has highlighted the vulnerability of residents in long-term care facilities, with highly dependent elderly patients being the most exposed to the risk of death, with deleterious effects linked to the effects of confinement, which in Ehpad has resulted in major isolation of residents and the appearance by care teams of cognitive disorders appearing or deteriorating in residents, as well as a significant loss of autonomy.

Real-life temocillin use in Greater Paris area, effectiveness and risk factors for failure in infections caused by ESBL-producing Enterobacterales: a multicentre retrospective study

Background

Temocillin is a β-lactam that is not hydrolysed by ESBLs.

Objectives

To describe the real-life use of temocillin, to assess its effectiveness in infections caused by ESBL-producing Enterobacterales, and to identify risk factors for treatment failure.

Methods

Retrospective multicentric study in eight tertiary care hospitals in the Greater Paris area, including patients who received at least one dose of temocillin for ESBL infections from 1 January to 31 December 2018. Failure was a composite criterion defined within 28 day follow-up by persistence or reappearance of signs of infection, and/or switch to suppressive antibiotic treatment and/or death from infection. A logistic regression with univariable and multivariable analysis was performed to identify risks associated with failure.

Results

Data on 130 infection episodes were collected; 113 were due to ESBL-producing Enterobacterales. Mean age was 65.2 ± 15.7 years and 68.1% patients were male. Indications were mostly urinary tract infections (UTIs) (85.8%), bloodstream infections (11.5%), respiratory tract infections (RTIs) (3.5%) and intra-abdominal infections (3.5%). Bacteria involved were Escherichia coli (49.6%), Klebsiella pneumoniae (44.2%) and Enterobacter cloacae (8.8%). Polymicrobial infections occurred in 23.0% of cases. Temocillin was mostly used in monotherapy (102/113, 90.3%). Failure was found in 13.3% of cases. Risk factors for failure in multivariable analysis were: RTI (aOR 23.3, 95% CI 1.5-358.2) and neurological disease (aOR 5.3, 95% CI 1.5-18.6).

Conclusions

The main use of temocillin was UTI due to ESBL-producing E. coli and K. pneumoniae, with a favourable clinical outcome. The main risk factor for failure was neurological disease.

Antibiotic Consumption and Bacterial Resistance Rates in Hospitalized COVID-19 Patients: A Retrospective Study During the 3 First Surges

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

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.

Arthritis Caused by Nannizziopsis obscura, France

Nannizziopsis spp., fungi responsible for emerging diseases, are rarely involved in human bone and joint infections. We present a rare case of septic arthritis with necrotizing cellulitis caused by N. obscura in a patient in France who had undergone kidney transplant. Rapid, aggressive medical and surgical management led to a favorable outcome.

Hyaluronic acid and chondroitin sulphate treatment for recurrent severe urinary tract infections due to multidrug-resistant gram-negative bacilli in a patient with multiple sclerosis: case report and literature review

Urinary tract infections (UTIs) are the most common bacterial infections in patients with neurogenic lower urinary tract dysfunction. Antibiotic options for prophylaxis or curative treatment in case of recurrent UTIs, especially due to multidrug-resistant organisms (MDRO), are scarce. We present the case of a 72-year-old man with neurogenic lower urinary tract dysfunction and history of frequent recurrent UTIs due to multiple MDROs who was successfully treated with hyaluronic acid (HA) and chondroitin sulfate (CS) bladder instillations. We also provide a literature review on the efficacy of HA-CS intravesical instillations for prevention of UTI among this population.

Gut microbiome signatures linked to HIV-1 reservoir size and viremia control

BACKGROUND

The potential role of the gut microbiome as a predictor of immune-mediated HIV-1 control in the absence of antiretroviral therapy (ART) is still unknown. In the BCN02 clinical trial, which combined the MVA.HIVconsv immunogen with the latency-reversing agent romidepsin in early-ART treated HIV-1 infected individuals, 23% (3/13) of participants showed sustained low-levels of plasma viremia during 32 weeks of a monitored ART pause (MAP). Here, we present a multi-omics analysis to identify compositional and functional gut microbiome patterns associated with HIV-1 control in the BCN02 trial.

RESULTS

Viremic controllers during the MAP (controllers) exhibited higher Bacteroidales/Clostridiales ratio and lower microbial gene richness before vaccination and throughout the study intervention when compared to non-controllers. Longitudinal assessment indicated that the gut microbiome of controllers was enriched in pro-inflammatory bacteria and depleted in butyrate-producing bacteria and methanogenic archaea. Functional profiling also showed that metabolic pathways related to fatty acid and lipid biosynthesis were significantly increased in controllers. Fecal metaproteome analyses confirmed that baseline functional differences were mainly driven by Clostridiales. Participants with high baseline Bacteroidales/Clostridiales ratio had increased pre-existing immune activation-related transcripts. The Bacteroidales/Clostridiales ratio as well as host immune-activation signatures inversely correlated with HIV-1 reservoir size.

CONCLUSIONS

The present proof-of-concept study suggests the Bacteroidales/Clostridiales ratio as a novel gut microbiome signature associated with HIV-1 reservoir size and immune-mediated viral control after ART interruption. Video abstract.

Factors Associated With Treatment Failure in Moderately Severe Community-Acquired Pneumonia: A Secondary Analysis of a Randomized Clinical Trial

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.

Time to resolution of respiratory and systemic coronavirus disease 2019 symptoms in community setting

Objectives

To assess the time to resolution of respiratory and systemic symptoms and their associated factors in outpatients during the coronavirus disease 2019 (COVID-19) pandemic.

Methods

Cohort study including adult outpatients, managed with Covidom, a telesurveillance solution, with RT-PCR-confirmed diagnosis, from 9 March 2020 until 23 February 2021. Follow up was 30 days after symptom onset.

Results

Among the 9667 patients included, mean age was 43.2 ± 14.0 years, and 67.5% were female (n = 6522). Median body mass index (BMI) was 25.0 kg/m² (interquartile range 22.1–28.8 kg/m²). Main co-morbidities were: hypertension (12.9%; n = 1247), asthma (11.0%; n = 1063) and diabetes mellitus (5.5%; n = 527). The most frequent symptom during follow up was dyspnoea (65.1%; n = 6296), followed by tachypnoea (49.9%; n = 4821), shivers (45.6%; n = 4410) and fever (36.7%; n = 3550). Median times to resolution of systemic and respiratory symptoms were 3 days (95% CI 2−4 days) and 7 days (95% CI 6−8 days), respectively. Ultimately, 17.2% (95% CI 15.7%−18.8%) still presented respiratory symptoms at day 30. Longer time to respiratory symptom resolution was associated with older age, increased BMI, chronic obstructive pulmonary disease, coronary artery disease, asthma and heart failure. Regarding systemic symptoms, coronary artery disease, asthma, age above 40 years and elevated BMI were associated with longer time to resolution.

Conclusions

Time to symptom resolution among outpatients with COVID-19 seemed shorter for systemic than respiratory symptoms. Prolonged respiratory symptoms were common at day 30. Risk factors associated with later resolution included age, and cardiovascular and pulmonary diseases.

Surmortalité dans les maisons de retraite pendant la pandémie de COVID-19

Introduction

La maladie à coronavirus (COVID-19) est associée à un faible taux de mortalité global d’environ 2 % dans la population générale. La gravité et la mortalité du COVID-19 varient largement en fonction de plusieurs facteurs de risque tels que l’âge, la présence d’une insuffisance respiratoire chronique, l’immunosuppression et les facteurs de risque cardiovasculaires. La pandémie de COVID-19 a mis en évidence la vulnérabilité des résidents des établissements de soins de longue durée (ESLD), les patients âgés très dépendants étant les plus exposés au risque de décès. Cependant, la surmortalité en maison de retraite par rapport aux années précédentes n’a pas été entièrement étudiée. Nous avons cherché à comparer le taux de mortalité par semaine dans un réseau national français de maisons de retraite en 2020 aux taux de mortalité des années précédentes.

Matériels et méthodes

Une étude de cohorte rétrospective multicentrique a été réalisée auprès d’un réseau national de 28 maisons de retraite, également réparties en France, sur une période allant du 1^er septembre 2017 au 31 novembre 2020. Les données ont été extraites d’une base de données centralisée (Netvie), où la mortalité toutes causes du réseau était rapportée chaque semaine, avec le sexe et l’âge des participants.

Résultats

Au cours de la période d’étude, un total de 4029 résidents de maisons de soins infirmiers ont été identifiés ; parmi eux, 1972 (48,9 %) étaient décédés. Au cours des périodes 2017, 2018, 2019 et 2020, 4599, 4946, 5268 et 4722 résidents (p > 0,05) vivaient dans les maisons de soins infirmiers de l’étude, et 2238 (48,7 %), 2568 (51,9 %), 2561 (48,6 %) et 2679 (56,7 %) étaient décédés, respectivement. L’âge médian de l’ensemble de la cohorte était de 89,0 [intervalle interquartile (IQR) : 84,0–93,0] ans, et l’âge médian de la population décédée était de 90,0 [IQR : 85,0–94,0] ans. Le rapport des sexes (M/F) dans l’ensemble de la cohorte et dans la population décédée était de 0,39 et 0,44, respectivement. Nous avons remarqué une augmentation du taux de mortalité jusqu’à 9,1 % durant les semaines 13 à 16 de 2020 par rapport à un taux de mortalité de 1,7 % en 2018 (p < 10⁻⁵) et de 1,7 % en 2019 (p < 10⁻⁵) durant la même période. Au cours des semaines 13 à 16 de 2018, 2019 et 2020, l’âge médian de tous les résidents était de 90,0 [IQR : 85,0–94,0], 89,0 [IQR : 84,0–93,0] et 89,0 [IQR : 83,0–93,0], tandis que l’âge médian des résidents décédés était de 89,0 [IQR : 86,0–96,0], 91,0 [IQR : 88,0–95,0] et 89,0 [IQR : 84,0–93,8], respectivement. Au cours de ces semaines, le sex-ratio (M/F) dans l’ensemble de la cohorte était de 0,33 en 2018, 0,36 en 2019 et 0,36 en 2020. Parmi la population décédée, le sex-ratio était de 0,17 en 2018, 0,29 en 2019 et 0,55 en 2020.

Conclusion

Ainsi, nous pouvons conclure que la mortalité a été multipliée par plus de 5 lors de la première vague de la pandémie de COVID-19 dans les maisons de retraite, sans différence concernant le sex-ratio et l’âge avec la population décédée des années précédentes. Plusieurs rapports ont mis l’accent sur la mortalité élevée chez les personnes âgées, notamment dans les ESLD mais peu de données sont disponibles sur les maisons de retraite. Le personnel, les résidents et les proches doivent rester vigilants pour prévenir l’introduction et la propagation du SRAS-CoV-2 dans leurs établissements.

Rôle de la pharmacie dans l’investigation allergologique des patients ayant présenté un exanthème en cours d’hospitalisation pour COVID-19

Introduction

Les manifestations cutanées observées chez les patients COVID-19 sont multiples et fréquentes : engelures, exanthème, urticaire, purpura, eczéma. Chez les patients recevant des antiinfectieux et présentant ces symptômes compatibles avec des réactions d’hypersensibilités retardées (HSR), le diagnostic de toxidermie est systématiquement évoqué.

Méthodes

À partir de la cohorte bicentrique des patients présentant des manifestations cutanéo-muqueuses au cours du COVID-19 nous décrirons la démarche collaborative entre les services de médecine et la pharmacie hospitalière et l’étude de faisabilité des préparations magistrales de patch tests, prick-tests et tests IDR.

Résultats

Parmi la cohorte de 59 patients hospitalisés pour une pneumonie COVID-19 en mars 2020, 68 % avait des atteintes cutanées (exanthèmes dans 80 %) ; 23 des 40 patients présentant des manifestations cutanées (58 %) avaient reçu au moins un antiinfectieux (hydroxychloroquine [HCQ], azithromycine [AZT], spiramycine [SPR], amoxicilline [AMX] et/ou ceftriaxone [CFX]). Une revue complète de la littérature a été réalisée et les PUI réalisant ce type de tests ont été contactées pour déterminer les concentrations non irritantes, dilutions optimales, nature des diluants, vérification de la texture, choix des contrôles positifs et négatifs, conditionnement le plus approprié et évaluation des moyens humains et matériels nécessaires. Quinze fiches de fabrication ont été rédigées. La pharmacie a élaboré des tests épicutanés dosés à 30 % dans de la vaseline à 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 été préparés en conditions stériles, à partir des formes injectables (AMX, CFX et SPR). Les tests cutanés seront réalisés à 1 an de l’épisode (mars 2021) : résultats à venir.

Conclusion

Ce travail a favorisé le travail pluridisciplinaire entre les services. Les résultats des tests allergologiques permettront d’identifier les HSR allergiques qui contre-indiqueront la réintroduction des molécules et la meilleure compréhension des atteintes dermatologiques observées chez les patients atteints de COVID-19.

Première série de cas de DRESS syndrome au cours d’une pneumonie sévère COVID-19

Introduction

Lors de la première vague de COVID-19, les praticiens ont largement prescrit l’association hydroxychloroquine (HCQ) – azythromycine (AZM).

Méthodes

Nous rapportons une série de 3 cas de DRESS certains, selon le score REGISCAR, chez des patients atteints de pneumonies COVID-19 sévères.

Résultats

Le premier patient a 58 ans, est diabétique, hypertendu et obèse. Il présente à J20 du début des symptômes de COVID-19 un exanthème maculo papuleux diffus, œdème du visage, adénomégalies supra centimétriques et une hyperéosinophilie à 0,74 G/L ; à J15 d’un traitement par ceftriaxone (CTX), AZM et HCQ. La deuxième patiente a 76 ans, est diabétique, hypertendue et atteinte d’une SEP. Elle présente à 1 mois du début de sa pneumonie COVID-19 ; et à 21 jours post-prises de CTX, AZM et HCQ une éruption cutanée sévère compatible avec un DRESS. Elle a présenté une hyperéosinophilie concomitante à 0,65 G/L avant traitement par dermocorticoides. Le troisième patient a 56 ans et aucune comorbidité. Il présente à J3 du début des symptômes de COVID-19 un volumineux œdème du visage et des lésions érythémateuses maculopapuleuses purpuriques ; à J8 d’un traitement antipaludéens et AINS. Pour chacun d’entre eux, la biopsie cutanée appuie le diagnostic de DRESS ; les PCR sanguines HHV6, EBV, CMV, VIH, VHB, VHC, parvovirus B19 sont négatives ; et l’évolution a été 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-être fatale. Aucun cas de toxidermie type DRESS n’avait été rapportée jusqu’à ce jour dans un contexte de COVID-19. Moins d’une dizaine de cas de DRESS ont été rapportés dans la littérature avec l’un ou l’autre des traitements par HCQ ou AZM. Les réactivations virales sont classiquement décrites avec HHV6 ou d’autres herpes virus (EBV, CMV), mais aucune de ces réplications virales classiques n’ont été objectivées chez nos patients qui étaient atteints de formes actives sévères d’infections par le SARS-CoV-2, probablement réplicatif. L’implication du SARS-CoV-2 est supposée ici.

Conclusion

Il s’agit ici de la première série de cas de DRESS certains chez des patients atteints de formes sévères de COVID-19.

Treatment of bone and joint infections by ceftazidime/avibactam and ceftolozane/tazobactam: a cohort study

OBJECTIVES

Ceftazidime/avibactam (C/A) and ceftolozane/tazobactam (C/T) are two novel antibacterials with known efficacy against Gram-negative bacteria (GNB). We aimed to describe the efficacy and safety of surgical management combined with C/A or C/T treatment for bone and joint infections (BJIs).

METHODS

We conducted an observational, bicentric study of patients treated with C/A or C/T for a BJI between May 2016 and June 2019. Failure was defined as the need for unplanned additional antibiotic treatment or orthopaedic surgery, or death due to the BJI up to 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, the median age was 66 years and the median Charlson comorbidity index (CCI) was 5. It was the first septic episode at the site in 3/9 patients. The 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, the median age was 53 years and the median CCI was 2. All patients had previous septic episodes at the infection site. The 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 are two effective and safe options, even as salvage treatment for BJI due to MDR-GNB despite the absence of label, however more data are warranted.

Weekly Sequential Antibioprophylaxis for Recurrent Urinary Tract Infections Among Patients With Neurogenic Bladder: A Randomized Controlled Trial

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.

Discontinuing β-lactam treatment after 3 days for patients with community-acquired pneumonia in non-critical care wards (PTC): a double-blind, randomised, placebo-controlled, non-inferiority trial

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.

Bloodstream infections in older population: epidemiology, outcome, and impact of multidrug resistance

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.

Susceptibility Testing Is Key for the Success of Cefiderocol Treatment: A Retrospective Cohort Study

Cefiderocol is a novel siderophore cephalosporin, which has proven in vitro activity against carbapenem-resistant (CR) Gram-negative pathogens and stability towards all carbapenemases. The aim of this study was to describe the first cases of prescriptions and the efficacy of cefiderocol for compassionate use in the 2 months following its access in France. We performed a national retrospective study of all patients who received at least one dose of cefiderocol from 2 November 2018 to 5 November 2019. We collected clinical characteristics and outcome through a standard questionnaire. Bacterial isolates from 12 patients were centralized and analyzed in the French National Reference Center for Antimicrobial Resistance, and sequenced using Illumina technology. Finally, 13 patients from 7 French university hospitals were included in the study. The main type of infection treated by cefiderocol was respiratory tract infections (RTI, n = 10). The targeted bacteria were Pseudomonas aeruginosa (n = 12), including carbapenemase-producing P. aeruginosa (n = 9), Acinetobacter baumannii (n = 2), Klebsiella pneumoniae (n = 1), and Enterobacter hormaechei (n = 1). Overall, of the 12 patients whose samples were analyzed, 5 P. aeruginosa strains were not susceptible to cefiderocol (4 categorized as resistant and 1 as intermediate) according to Clinical and Laboratory Standards Institute (CLSI) breakpoints. If considering susceptible strains, the cure rate was 6/7, while being 0/5 among not-susceptible strains. This study underlines the necessity to test strains in adequate conditions.

Actinomycetoma Caused by Actinomadura mexicana, A Neglected Entity in the Caribbean

Mycetoma is a chronic infection that is slow to develop and heal. It can be caused by fungi (eumycetoma) or bacteria (actinomycetoma). We describe a case of actinomycetoma caused by Actinomadura mexicana in the Caribbean region.

Clinical Cutaneous Features of Patients Infected With SARS-CoV-2 Hospitalized for Pneumonia: A Cross-sectional Study

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.

Development of pancreatic injuries in the course of COVID-19

BACKGROUND AND STUDY AIMS

To investigate the clinical and laboratory characteristics of the cases with high lipase levels in the course of COVID-19.

PATIENTS AND METHODS

Hospital records of all cases, where lipase levels were measured, and the reverse transcriptase-polymerase chain reaction test due to SARS-CoV-2 was found positive, were retrospectively investigated. Of 127 COVID-19 patients tested for lipase, 20 (15.7%) had serum lipase levels above the upper laboratory limit. The patient group with the "high lipase level" was created from these subjects, and the rest constituted the "control" group.

RESULTS

While body mass index (BMI) levels were higher in the high lipase group, (p=0.014), the number of those with pre-existing diabetes mellitus (DM) was also found higher in the high lipase group than the controls (p=0.002). The history of DM was detected to increase the risk of developing high lipase level 4.63 times higher. Only two patients were diagnosed with acute pancreatitis (AP). While oxygen saturations on admission (p=0.019) and discharge (p=0.011) were lower in the high lipase group than the controls, amylase (p<0.001), C-reactive protein (CRP) (p=0.002) and D-dimer (p=0.004) levels were found higher. In addition, more patients required the treatment in intensive care unit in the high lipase group, compared to the controls (p=0.027). Accordingly, time of hospital stay became also prolonged (p=0.003).

CONCLUSIONS

Pancreatic injuries or even AP may develop during SARS-CoV-2 infection, especially in those with pre-existing DM. Monitoring of pancreatic enzymes is important in COVID-19 patients, especially with pre-existing DM.

Compassionate Use of Cefiderocol to Treat a Case of Prosthetic Joint Infection Due to Extensively Drug-Resistant Enterobacter hormaechei

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.

Predictive factors for positive disco-vertebral biopsy culture in pyogenic vertebral osteomyelitis, and impact of fluoroscopic versus scanographic guidance

Background

The aims of this study were to identify the predictive factors for microbiological diagnosis through disco-vertebral biopsy (DVB) in patients with pyogenic vertebral osteomyelitis (PVO) and negative blood cultures, and compare the performance of DVB under fluoroscopic versus scanographic guidance.

Methods

We performed a cohort study comparing positive and negative DVB among patients with PVO. All cases of PVO undergoing a DVB for microbiological diagnosis in our center were retrospectively reviewed. Infections due to Mycobacterium tuberculosis, infections on foreign device, and non-septic diseases were excluded. Anamnestic, clinical, biological, microbiological, as well as radiological data were collected from medical charts thanks to a standardized data set.

Results

A total of 111 patients were screened; 88 patients were included. Microbiological cultures were positive in 53/88 (60.2%) patients. A thickening of the paravertebral tissue ≥10 mm on magnetic resonance imaging (MRI) in axial MR scans was a predictive factor of DVB microbiological positivity (52.4% vs. 13.3%; p = 0.006; OR = 5.4). Overall, 51 DVB were performed under fluoroscopic guidance and 37 under scanographic guidance. Considering lumbar DVB, 25/36 (69.4%) of cases yielded positive results under fluoroscopic guidance versus 5/15 (33.3%) under scanographic guidance (p = 0.02; OR = 4.4). No adverse event linked to DVB was notified.

Conclusion

Every patient with PVO and negative blood cultures should undergo a DVB. A thickening of the paravertebral tissue ≥10 mm on MRI is associated with a higher rate of positive DVB culture. A lumbar DVB under fluoroscopic guidance is more sensitive than under scanographic guidance to identify the micro-organism involved.

[Nasopharyngeal carriage of SARS-CoV-2 among health personnel with symptoms suggestive of COVID-19 in a University Hospital in the Paris suburbs]

Introduction

Une consultation dédiée aux professionnels de santé symptomatiques a été ouverte au début de l'épidémie de COVID-19, afin de répondre aux besoins spécifiques de cette population. L'objectif de ce travail était d'estimer la fréquence du portage nasopharyngé du SARS-Cov-2 chez les personnels de santé symptomatiques suspects de COVID-19, et de déterminer les facteurs associés à ce portage.

Méthodes

Étude descriptive des caractéristiques cliniques et épidémiologiques des consultants, conduite du 5 mars au 17 avril 2020. Le recueil des données cliniques et des résultats du test RT-PCR a été conduit à l'aide de formulaires standardisés.

Résultats

Des 522 consultants, 308 exerçaient à l'Hôpital et 214 à l'extérieur. Ils avaient des formes bénignes de COVID-19 et des signes cliniques non spécifiques à l'exception de l'agueusie/anosmie, significativement plus fréquente chez ceux avec RT-PCR positive. Le taux de positivité de la RT-PCR était globalement de 38 %, sans différence significative selon la profession, supérieur chez les consultants extérieurs (47 % versus 31 %). À l'hôpital, ce taux était significativement moindre pour les personnels symptomatiques des secteurs de soins, comparé aux personnels des plateaux techniques et laboratoires (24 %, versus 45 %, p = 0,006 et 54 %, p < 0,001, respectivement), mais ne différait pas entre personnels des unités COVID et des autres secteurs de soins (30 % versus 28 %). Parmi les consultants extérieurs, les taux de positivité des personnels des EHPAD et des libéraux (53 % et 55 % respectivement) étaient plus du double de celui du personnel soignant hospitalier (24 %, p < 0,001).

Conclusions

Ces données confirment l'impact fort du COVID-19 sur les professionnels de santé. Les taux de positivité plus élevés chez les professionnels symptomatiques exerçant en dehors de l'hôpital, comparativement à ceux exerçant à l'hôpital, pourraient s'expliquer en partie par une pénurie en équipements de protection et par des difficultés d'accès au diagnostic virologique, qui étaient plus importants en dehors de l'hôpital quand l'épidémie a commencé.

French national cohort of first use of dalbavancin: A high proportion of off-label use

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.

Urinary tract infections in patients with neurogenic bladder

Urinary tract infections (UTIs) in patients with neurogenic bladder are a major public health issue due to their high incidence and major consequences. Despite their frequency and potential severity, their physiopathology and management are poorly known. We provide a narrative literature review on the epidemiology, physiopathology, diagnostic criteria, microbiology, antimicrobial management, and prevention. UTIs among patients with neurogenic bladder are associated with high morbidity and healthcare utilization. Risk factors for UTI among this population are: indwelling catheter, urinary stasis, high bladder pressure, and bladder stones. Their diagnosis is a major challenge as clinical signs are often non-specific and rare. A urinary sample should be analyzed in appropriate conditions before any antibiotic prescription. According to most guidelines, a bacterial threshold≥103CFU/ml associated with symptoms is acceptable to define UTI in patients with neurogenic bladder. The management of acute symptomatic UTI is not evidence-based. A management with a single agent and a short antibiotic treatment of 10 days or less seems effective. Antibiotic selection should be based on the patient's resistance patterns. Asymptomatic bacteriuria should not be treated to avoid the emergence of bacterial resistance. Regarding preventive measures, use of clean intermittent catheterization, intravesical botulinum toxin injection, and prevention using antibiotic cycling are effective. Bacterial interference is promising but randomized controlled trials are needed. Large ongoing cohorts and randomized controlled trials should soon provide more evidence-based data.

Veillonella parvula spondylodiscitis

OBJECTIVES

Veillonella parvula is an anaerobic Gram-negative coccus rarely involved in bone and joint infections.

PATIENTS AND METHOD

We report the case of a Veillonella parvula vertebral osteomyelitis (VO) in a female patient without any risk factor.

RESULTS

The 35-year-old patient was immunocompetent and presented with Veillonella parvula VO. She was admitted to hospital for inflammatory lower back pain. The discovertebral sample was positive for Veillonella parvula. Literature data on Veillonella VO is scarce. Reported cases usually occurred in immunocompromised patients. Diagnosis delay can be up to four months. Patients are usually afebrile. Outcome with antimicrobial treatment alone is favorable in half of cases. Other patients must undergo surgery.

CONCLUSIONS

Veillonella VO may occur in immunocompetent patients and have a clinical spectrum of mechanical lower back pain.

Cabozantinib for the treatment of patients with metastatic non-clear cell renal cell carcinoma: A retrospective analysis

BACKGROUND

Cabozantinib prolongs overall survival (OS) and progression-free survival (PFS) in patients with metastatic clear cell renal cell carcinoma (RCC) that progressed on first-line vascular endothelial growth factor receptor-tyrosine kinase inhibitor (VEGFR-TKI). The role of cabozantinib has not been established in non-clear cell renal cell carcinoma (nccRCC).

METHODS

This is a retrospective study of 30 patients with nccRCC who received cabozantinib from January 2013 to January 2017. Information collected included baseline characteristics, toxicity, dose reductions, PFS and OS. A fellowship trained abdominal radiologist, blinded to patient history and clinical data, assessed radiographic response using RECIST, v1.1.

RESULTS

With a median follow-up of 20.6 months (95% confidence interval [CI]: 11.4-28.8), median PFS was 8.6 months (95% CI: 6.1-14.7), and median OS was 25.4 months (95% CI: 15.5-35.4). Of the 28 patients with measurable disease, 4 had partial responses (2 papillary, 1 chromophobe and 1 unclassified RCC), 18 had stable disease (64.2%) and 6 had progressive disease (21.4%), resulting in a 14.3% objective response rate and a 78.6% disease control rate. Two patients with papillary RCC who had experienced disease progression on savolitinib achieved durable partial response and stable disease, respectively, following treatment with cabozantinib. Of the 21 patients who started cabozantinib at 60 mg/d, 12 (57.1%) required dose reduction due to toxicity.

CONCLUSION

In this retrospective study, cabozantinib produced a clinically meaningful benefit in patients with metastatic nccRCC, the majority of whom had disease progression on prior VEGFR-TKIs. Prospective trials of cabozantinib in nccRCC are warranted.

Factors associated with bacteraemia due to multidrug-resistant organisms among bacteraemic patients with multidrug-resistant organism carriage: a case control study

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.

The effects of smoking cessation on visceral adiposity index levels

Background

: Known to cause important metabolic disturbances, weight gain becomes a major health problem after smoking cessation. Visceral adiposity index (VAI) is becoming increasingly popular in the detection of cardiometabolic risks in several disorders and general population. Here, we aimed to investigate the effects of quitting smoking on VAI levels.

Materials and Methods

: Of 350 participants included into the cigarette cessation program, 70 (20%) completed the study and were enrolled into the analyses. VAI levels were calculated at the baseline and 3^rd month after cigarette cessation.

Results

: Thirty-eight (54.3%) out of 70 participants were male. While the mean age was found as 42 ± 1.0 years, mean starting age of smoking was found to be 16.87 ± 0.45 years, and mean smoking time was 23.07 ± 1.18 years. While VAI levels were found higher in men at the baseline, VAI levels were found similar in both genders at the end of the study. Higher VAI levels were found in those smoking >20 cigarettes/day, compared to those smoking ≤20 cigarettes/day. Although weight, waist circumference, body mass index (BMI), and high-density lipoprotein cholesterol levels increased, VAI levels were found to decrease significantly at the 3^rd month. In subgroup analyses, VAI levels were seen to decrease significantly only in men (P = 0.005). Furthermore, VAI levels were found to decrease (P < 0.001) in those with BMI ≥25 kg/m², whereas no significant change was observed in those with BMI <25 kg/m².

Conclusions

Although body weight increases significantly after quitting smoking, VAI levels, an indicator of cardiovascular risks, decrease significantly, especially in men or obese patients.

Clearance of carbapenem-resistant Enterobacteriaceae vs vancomycin-resistant enterococci carriage after faecal microbiota transplant: a prospective comparative study

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.

Case of femoral pseudarthrosis due to Scedosporium apiospermum in an immunocompetent patient with successful conservative treatment and review of literature

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.

Cost effectiveness of pneumococcal urinary antigen in Emergency Department: a pragmatic real-life study

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.