Lyme snap: A feasibility study of on-line declarations of erythema migrans in a rural area of France

The incidence of Lyme borreliosis remains a matter of debate, but it can be estimated using the incidence of erythema migrans (EM), which is pathognomonic of the first phase. The aim of this prospective pilot study was to assess the feasibility of the on-line declaration of EM in rural areas where the incidence of Lyme borreliosis was previously estimated at 85 per 100,000 inhabitants per year. The study was limited to a rural area (Les Combrailles, Auvergne) of approximately 52,800 inhabitants and was preceded by an information campaign for the inhabitants and the healthcare professionals. Patients who sent a photo of the suspected EM by email or MMS message between April 2017 and April 2018 and who accepted to answer a questionnaire were included in the study. Two physicians then evaluated the quality of the photographs and the probability of EM. In parallel, the number of EM seen by physicians and pharmacists in the area over the given period was recorded. Out of the 113 emails and MMS messages received, 73 people were outside of the trial area or period and 9 did not complete the questionnaire. The photos of the remaining 31 people were analysed. The median age was 51.5 years old ([38-58] IQR) and 18 (58%) were women. Seven people (25%) stated that they did not have a smartphone and in 9 cases (29%) the photo was sent by a third party. The quality of the photos was considered very good in 22 (71%) cases, good in 7 (23%) cases, and average in 2 (6%) cases. The probability of EM was determined to be strong or possible in 12 (38%) cases, i.e. an estimated incidence of 22.7 per 100,000 inhabitants. Over the study period, 40 physicians and 20 pharmacists were contacted on a monthly basis. A median of 5 physicians [3;7] and 4 pharmacists [3 ;7] answered each month for a total of 18 and 36 declared EM respectively. The EM (strong probability/possible) collected by on-line declaration and those declared by healthcare professionals were all sent between April and October 2017. The total time spent on the information campaign and collection has been estimated at 265 h (divided between 10 people) for an overall cost of 10,669 Euros. The incidence of EM recorded by on-line self-declaration in our study seems to be lower than in previous studies, the under-reporting was probably linked to the low use of new technologies in the rural areas. Increasing the human resources and finances appears difficult to achieve in practice over a longer time period but the development of an application for the automatic recognition of EM could be one method for a more exhaustive collection in the long term and at lower cost.

Outbreak of Colonization and Infection With Vancomycin-ResistantEnterococcus faeciumin a French University Hospital

An outbreak of infection with vancomycin-resistantEnterococcus faeciumoccurred at Hôtel-Dieu Hospital (Clermont-Ferrand, France). A case-control study was performed in the infectious diseases and hematology units of the hospital. Urinary catheter use (odds ratio [OR], 12 [95% confidence interval {CI}, 1.5-90];P<.02), prior exposure to a third-generation cephalosporin (OR, 22 [95% CI, 3-152];P= .002), and prior exposure to antianaerobials (OR, 11 [95% CI, 1.5-88];P<.02) were independently predictive of vancomycin-resistantEnterococcus faeciumcarriage.

Varicella outbreak in Sudanese refugees from Calais

We describe an outbreak of varicella in 31 Sudanese refugees (all except one were male, mean age: 26 ± 1), from the Calais migrant camp and sheltered in a French transit area. The attack rate was 39%. Adults are scantly immunized against varicella zoster virus in East Africa and may be exposed to epidemics once in France.

Landscape and climatic characteristics associated with human alveolar echinococcosis in France, 1982 to 2007

Binary file ES_Abstracts_Final_ECDC.txt matches

[Current events in vaccination]

The annual meeting of the Infectious Disease Society of America (IDSA) ; which brought together nearly 5000 participants from over 80 countries in Vancouver, Canada, October 21 to 24, 2010 ; provided a review of the influenza (H1N1) 2009 pandemic, evaluated vaccination programmes and presented new vaccines under development. With 12,500 deaths in the United States in 2009-2010, the influenza (H1N1) 2009 pandemic was actually less deadly than the seasonal flu. But it essentially hit the young, and the toll calculated in years of life lost is high. The monovalent vaccines, whether live attenuated or inactivated with or without adjuvants, were well tolerated in toddlers, children, adults and pregnant women. In order to protect infants against pertussis, family members are urged to get their booster shots. The introduction of the 13-valent Pneumococcal conjugated vaccine in the beginning of 2010 may solve - but for how long ? - the problem of serotype replacement, responsible for the re-increasing incidence of invasive Pneumococcal infections observed in countries that had introduced the 7-valent vaccine. The efficacy of a rotavirus vaccine has been confirmed, with a reduction in hospitalization in the United States and a reduction in gastroenteritis-related deaths in Mexico. In the United States, vaccination of pre-adolescents against human papillomavirus (HPV) has not resulted in any specific undesirable effects. Routine vaccination against chicken pox, recommended since 1995, has not had an impact on the evolution of the incidence of shingles. Vaccination against shingles, recommended in the United States for subjects 60 years and over, shows an effectiveness of 55 %, according to a cohort study (Kaiser Permanente, Southern California). Although some propose the development of personalized vaccines according to individual genetic characteristics, the priority remains with increasing vaccine coverage, not only in infants but also in adults and the elderly. Vaccine calendars that cover a whole lifetime should be promoted, since the vaccination of adults and seniors is a determining factor of good health at all ages.

[Prognostic value of the LRINEC score (Laboratory Risk Indicator for Necrotizing Fasciitis) in soft tissue infections: a prospective study at Clermont-Ferrand University hospital]

BACKGROUND

The LRINEC score was developed in a retrospective study in order to distinguish necrotizing fasciitis from severe soft tissue infections using laboratory data.

AIM

To evaluate the prognostic value of the LRINEC score in infectious cellulitis.

PATIENTS AND METHODS

A prospective study was performed at the departments of infectious diseases and dermatology of the Clermont-Ferrand University Hospital. The three evaluation criteria were: time from initiation of antibiotics to regression of erythema, duration of fever and occurrence of complications (abscess, surgery, septic shock, necrotizing fasciitis, death, transfer to intensive care). Potential predictive variables were: LRINEC score>6 at admission, comorbidities, local appearance, clinical presentation and soft tissue ultrasound results.

RESULTS

Fifty patients were included. The rate of complications was higher for patients with a LRINEC score>6 (54%) than for patients with a score<6 (12%, P=0.008). However, a LRINEC score>6 on admission was not significantly associated with increased duration of erythema or of fever. Prior lymphoedema was associated with a better prognosis.

DISCUSSION

The LRINEC score may be a useful tool for the detection of complicated forms of soft tissue infections. Patients with a LRINEC score>6 on admission should be carefully evaluated (hospitalization, surgical assessment, close monitoring).

Vaccination in adults with auto-immune disease and/or drug related immune deficiency: results of the GEVACCIM Delphi survey

INTRODUCTION

There are insufficient data regarding the efficacy and safety of vaccination in patients with auto-immune disease (AID) and/or drug-related immune deficiency (DRID). The objective of this study was to obtain professional agreement on vaccine practices in these patients.

METHODS

A Delphi survey was carried out with physicians recognised for their expertise in vaccinology and/or the caring for adult patients with AID and/or DRID. For each proposed vaccination practice, the experts' opinion and level of agreement were evaluated.

RESULTS

The proposals relating to patients with AID specified: the absence of risk of AID relapse following vaccination; the possibility of administering live virus vaccines (LVV) to patients not receiving immunosuppressants; the pertinence of determining protective antibody titre before vaccination; the absence of need for specific monitoring following the vaccination. The proposals relating to patients with DRID specified that a 3-6 month delay is needed between the end of these treatments and the vaccination with LVV. There is no contraindication to administering LVV in patients receiving systemic corticosteroids prescribed for less than two weeks, regardless of their dose, or at a daily dose not exceeding 10mg of prednisone, if this involves prolonged treatment. Out of 14 proposals, the level of agreement between the experts was "very good" for eleven, and "good" for the remaining three.

CONCLUSION

Proposals for vaccine practices in patients with AID and/or DRID should aid with decision-making in daily medical practice and provide better vaccine coverage for these patients.

Impact of rapid enterovirus molecular diagnosis on the management of infants, children, and adults with aseptic meningitis

Enteroviruses (EV) are the main etiological agents of aseptic meningitis. Diagnosis is made by detecting the genome using RT-PCR. The aim of the study was to evaluate the impact of a positive diagnosis on the management of infants, children, and adults. During 2005, 442 patients were admitted to hospital with suspected meningitis. Clinical and laboratory data and initial treatment were recorded for all patients with enteroviral meningitis. The turnaround time of tests and the length of hospital stay were analyzed. The results showed that EV-PCR detected EV in 69 patients (16%), 23% (16/69) were adults. About 18% of CSF samples had no pleocytosis. After positive PCR results, 63% of children were discharged immediately (mean 2 hr 30 min) and 95% within 24 hr. Infants and adults were discharged later (after 1.8 and 2 days, respectively). The use of antibiotics was significantly lower in children than in infants and adults. The PCR results allowed discontinuation of antibiotics in 50-60% of all patients treated. Patients received acyclovir in 16% of cases (7% children vs. 50% adults) and 23% (11% vs. 69%) underwent a CT scan. Clinical data were compared between patients whose positive EV-PCR results were available within 24 hr (n = 32) and those whose results were available > 24 hr after collection of CSF (n = 14). Duration of antibiotic treatment (difference: 2.3 days; P = 0.05) was reduced between the two groups. No statistical difference in the length of stay was observed. The EV-PCR assay should be performed daily in hospital laboratory practice and considered as part of the initial management of meningitis.

[Potential nosocomial disseminated infection due to Nocardia asteroides after a prosthesis insertion in an immunocompetent patient]

Nocardia infections are rare and usually occurred in immunocompromised patients with systemic dissemination from a lung infection. We report a case of an immunocompetent patient in whom Nocardia asteroides had cause psoas and cerebral abcess without pulmonary infection, a short period after a hip prosthesis insertion. The clinical history is highly suggestive of a hospital-acquired infection.

Hepatitis B in Moroccan health care workers

AIM

To evaluate knowledge and perception of hepatitis B, including prevention, among Moroccan health care workers (HCWs) and to estimate seroprevalence of hepatitis B and vaccine coverage (VC).

METHODS

Four hundred and twenty HCWs were randomly selected and stratified by site: 120 in Rabat, 140 in Taza and 160 in Témara-Skhirat. The study included an anonymous questionnaire about knowledge of hepatitis B and its prevention and a serological survey. Oral statements and vaccine registers were used to analyse the VC of the HCWs. Serological testing and VC were analysed according to the occupational exposure.

RESULTS

Participation rates in the questionnaire and serological tests were 68% (285/420) and 66% (276/420), respectively. Fifteen (5%) HCWs had a history of hepatitis B. All HCWs considered that hepatitis B virus (HBV) infection may be acquired through blood exposure. Vaccination was acknowledged as a necessary means against HBV transmission by 276 (98%) HCWs. Forty-two per cent HCWs had no HBV serological markers. The prevalence of hepatitis B surface antigen was 1%. The mean prevalence of hepatitis B core antibody (anti-HBc) was 28% and was significantly higher (P < 0.05) among nursing auxiliaries (57%), nurses (30%), medical physicians (31%) and midwives (25%) than among laboratory technicians (13%). According to the vaccination registers (available in two sites), VC (> or =3 doses) was 55%. VC was 75% among midwives, 61% among nurses, 53% among nursing auxiliaries and 38% among medical staff. Of the fully vaccinated HCWs without anti-HBc, 51% had serological evidence of protection.

CONCLUSION

HBV vaccines should be more readily available for Moroccan HCWs by reinforcing current vaccination programmes.

[Thromboembolic events at the time of highly active antiretroviral therapies against human immunodeficiency virus]

PURPOSE

Vein thrombosis risk and pulmonary embolism seem to be more important among human immunodeficiency virus (HIV) infected patients.

METHOD

We performed a retrospective study including 780 HIV positive patients followed-up between January 2000 and June 2005 at the University Hospital of Clermont-Ferrand.

RESULTS

Among the 780 HIV-infected patients, six cases of thromboembolic events were identified including, four with pulmonary embolism. All the patients were receiving lopinavir/ritonavir combination.

CONCLUSION

Although uncommon, pulmonary embolism occurs more frequently among HIV positive patients than in general population. Clinicians must remain aware about the possibility of the occurrence of a thromboembolic event especially during the first few months after introduction of the antiretroviral therapy.

[Kawasaki disease is also a disease of adults: report of six cases]

Kawasaki disease is an inflammatory arterial disease of unknown cause usually affecting young children, the principal complication of which is coronary artery aneurysm. Early treatment with immunoglobulins and aspirin prevents this complication. The diagnosis requires expert clinical criteria and, in atypical forms, a more recent decisional diagnostic tree has to be used. The authors report 6 cases of adult Kawasaki disease. As in the other sixty or so cases in the literature, hepatic forms were the commonest (5/6). Only three of the six cases met the classical clinical criteria and the diagnosis was made by the decisional tree or after coronary complications in the oldest subject. The five treated patients progressed favourably after a course of immunoglobulins. Echocardiography detected 100% of children with coronary disease but it was more difficult in adults in whom new non-invasive methods of coronary imaging (fast CT and MRI) and stress testing should complete the investigations. The association of prolonged pyrexia, clinical criteria and a biological inflammatory syndrome should, after exclusion of the differential diagnoses, suggest a diagnosis of Kawasaki disease in the adult as in the child. The possibility of coronary disease, even though extremely rare, should be recognised by the cardiologist and lead to diagnostic and therapeutic managements as aggressive as in children.

Safety and immunogenicity of subcutaneous or intramuscular administration of a monovalent inactivated vaccine against Leptospira interrogans serogroup Icterohaemorrhagiae in healthy volunteers

The safety and immunogenicity of a monovalent inactivated vaccine against Leptospira interrogans serogroup Icterohaemorrhagiae was evaluated in 84 volunteers according to the route of administration, i.e., subcutaneous (SC) or intramuscular (IM), in a double-blind randomised trial. The volunteers were randomised into four groups: SC vaccine; IM vaccine; SC placebo; and IM placebo. Primary vaccination comprised two injections on day 0 and day 14, with a booster after 6 months. A second booster was given 30 months after primary vaccination. Local reactions within 1 h of injections were rare, with no difference between vaccine groups. Local reactions within 3 h were more frequent after the second, third and fourth SC injections than after IM injections. Systemic reactions never occurred within 1 h of vaccination and were rare within 3 days; the rates were comparable for the different vaccine groups. Evolution of the antibody responses, as assessed by microscopic agglutination tests and specific IgG and IgM ELISAs, were similar for both injection routes. IgG seroconversion rates after the first booster were 97% (95% CI 80-100%) for the SC vaccine group, and 96% (95% CI 80-100%) for the IM vaccine group, and both reached 100% for IgG after the second booster. The safety and immunogenicity of the anti-leptospiral vaccine were both good. Monitoring of antibody levels established that a booster dose triggered a strong antibody response in fully vaccinated subjects at 30 months after primary vaccination.

[Should presumptive meningoencephalitis treatment in adults be active against Mycoplasma pneumoniae?]

INTRODUCTION

Meningoencephalitis is the most common central nervous system complication caused by Mycoplasma pneumoniae. Its frequency is probably underestimated.

OBJECTIVE

The study's aim was to determine the retrospectively incidence of M. pneumoniae meningoencephalitis among other cases of encephalitis diagnosed in infectiology, neurology and ICU at the Clermont-Ferrand University hospital in 2004 and 2005.

DESIGN

A case of meningoencephalitis was defined by encephalopathy (altered level of consciousness and/or change in personality), with one or more of the following symptoms: fever, seizure, focal neurological findings, meningitis, electroencephalography or neuroimaging findings consistent with encephalitis. Tumor and hematoma diagnosed by scan were excluded. M. pneumoniae was considered as a possible cause when patients had positive serological test (IgM Elisa) and/or positive PCR results for the CSF.

RESULTS

Four (8.3%) patients among 48 cases of encephalitis could have been caused by M. pneumoniae. All except one convulsed initially. Pneumopathy was found in two patients. All received a specific treatment later. Antibiotics seemed to influence evolution in only two patients. These 4 cases appeared during an epidemic between November 2004 and August 2005: 48 hospitalized adults had positive serological test for M. pneumoniae in 2005 and 15 in 2004, whereas the number of tests was the same in 2004 and in 2005.

CONCLUSIONS

M. pneumoniae should be investigated as a cause of meningoencephalitis if initial tests are negative, if patients have respiratory symptoms and in case of epidemic. Presumptive treatment of meningoencephalitis should include an antibiotic active against M. pneumoniae.

Cryptococcose neuroméningée révélée par une baisse de l'acuité visuelle chez un patient atteint de neurosarcoïdose et porteur d'une dérivation ventriculoatriale

INTRODUCTION

HIV infection is the main cause of cryptococcal neuromeningitis but other diseases may be associated with this infection.

CASE REPORT

We report a case of cryptococcal neuromeningitis in a patient with sarcoidosis and ventriculoatrial shunting. The patient was successfully treated by effective therapy without device withdrawal.

CONCLUSION

The relationship between cryptococcosis and sarcoïdosis has been already described and may be not fortuitous. However it remains a very rare complication of sarcoidosis. Because of its potential severity (mortality rate of 40%), the diagnosis of cryptococcosis should be evoked as a differential diagnosis of neuro-sarcoidosis.

Lymphomes non hodgkiniens et hodgkiniens et infection VIH : fréquence, pronostic et reconstitution immune sous trithérapie antirétrovirale ; CHU de Clermont-Ferrand, 1991–2003

OBJECTIVES

The authors had for aim to identify cases of non Hodgkin's (NHL) and Hodgkin's (HL) lymphomas in HIV1-infected patients to assess 1) their incidence, before and after 1996, 2) the clinical features and outcome under treatment together with the survival rate of the patients, 3) the immune reconstitution of lymphoma-free patients under HAART.

PATIENTS AND METHODS

A retrospective study was made of HIV1-infected patients managed at the Clermont-Ferrand University Hospital from 1991 to 2003 for the diagnosis and treatment of HIV1-related lymphomas.

RESULTS

Forty-one patients were included: 35 NHL and 6 HL giving a cumulative incidence rate estimate from 2.4% between 1991 and 1996 to 3.4% between 1997 and 2003 while other opportunistic diseases were decreasing. A high proportion of aggressive and disseminated disease was observed among NHL cases. Complete remission was achieved in 17 (49%) and 5 (83%) NHL and HL cases respectively. The mean survival was 109+/-54 months and was correlated with CD4 cell count at lymphoma diagnosis (univariate analysis). Among responding patients, 5 died: 3 from opportunistic infections, 1 commited suicide, and 1 from hepatic carcinoma. For responding patients, the mean increase of CD4 cell count under HAART was 58/mm3 over a 2 year-period and 192/mm3 over a 5 year-period of follow-up.

CONCLUSIONS

The incidence of lymphomas in HIV-infected patients has not decreased since the introduction of HAART. The immune status assessed by CD4 cell count on diagnosis is correlated with survival. Immune restoration in lymphoma-free patients under HAART is poor.

Infections associées à des évènements thrombotiques sévères avec présence d'anticorps antiphospholipides

The authors present 2 cases of infections in which the presence of antiphospholipid antibodies (APL), anticardiolipin and anti-beta2-GP1, was associated to the occurrence of significant thrombotic events: 1) a 55-year-old male patient whose serology (indirect immunofluorescence) revealed Coxiella burnetii infection (phase 2 antigens) with IgG at 1,600 and IgM at 50 (significant titer: IgG>or=200 and IgM>or=50); 2) and a 20-year-old male patient with a CMV infection confirmed by serology (IgG: 44 U/ml, significant threshold 6, IgM: 2.1 U/ml, significant threshold 0.9).

A new European perspective of influenza pandemic planning with a particular focus on the role of mammalian cell culture vaccines

Sixteen EU scientists and doctors were interviewed about pandemic planning using psychometric methods applied to a scientific problem for the first time. Criticism was aimed at countries which have no plan whatsoever, the majority of nations. Many such countries have not invested in scientific infrastructure and public health. Amongst the 15 or so published pandemic plans a lack of detail was identified. Of particular need was investment into avian virus vaccine stocks (H1-15), prepared licenses of vaccine and pre purchase and agreed distribution, investment into stocks of antivirals, antibiotics and masks. Most but not all members of the group predicted a global outbreak within 5 years, most probably starting in SE Asia. However it was recognised that a pandemic could start anywhere in the world which had juxtaposition of young people, chickens, ducks and pigs. Mammalian cell culture production using wild type virus with the production factory at category III levels of security was exemplified. Antivirals would be essential to ameliorate the first wave of infection although significant quantities of cell grown vaccine could be produced if, as in 1918, 1957 and 1968 there is a long period between the first virus isolation and person to person spread. The wider scientific community is more energised than previously for very serious preparations to be in place way before the outbreak begins as this is a major public health problem, completely dwarfing concerns about bioterrorism.

Comportement et conditions de travail exposant au sang : analyse des pratiques dans trois établissements de soins du Maroc

OBJECTIVE

As in other countries, Moroccan health-care workers are exposed to occupational blood exposure (OBE) hazards. The purpose of this study was to estimate the occupational safety and hygiene conditions determining the OBE risk for health-care workers. WORKERS AND METHODS: In March 2000, a multicentric study was carried out in Morocco on 420 health-care workers, with an anonymous questionnaire. The study included health-care workers in the Taza and Temara hospitals and health centers, as well as in a Rabat public medical analysis laboratory.

RESULTS

The participation rate was 67.8% (285/420). The population was mainly female (61%) with a mean age of 41.4 years (+/-7 years). Health-care workers answered that: occupational hygiene and safety were inadequate (55.1%); wearing single-use gloves was rare (34.5%); resheathing used needles was frequent (74.5%); safe containers were often missing (67%). In 1999, the annual average incidence of OBE was 1.5 (+/-4.3) per capita. If we consider the whole career of health-care workers, the incidence reached about 14.3+/-28.1 per capita. The absence of post-exposure chemoprophylaxis was the rule.

CONCLUSION

The study shows that there is a need to improve occupational hygiene and safety conditions for Moroccan health-care workers in order to reduce OBE hazards.

[Prevention and infection in adults patients with hyposplenism]

People with asplenia are at risk for infections due to many causative agents, mainly Streptococcus pneumoniae. Among adults, splenectomy is the most frequent etiology of hyposplenism followed with chronic hematological and connective diseases. Physiopathology of the immunologic impairment due to hyposplenia is multifactorial. Physicians and even patients must be aware of overwhelming sepsis occurring on these conditions. The prognosis of these life-threatening infections is related to the precocity of the treatment onset. These infections, mainly due to S. pneumoniae (50-90% of cases) could be prevented with appropriate precautions. Patients presenting with asplenia must be largely vaccinated against these infectious agents: S. pneumoniae, Haemophilus influenzae b, and possibly Neisseiria meningitidis. Oral phenoxymethylpenicillin seems to be the simplest chemoprophylaxis (despite the global increase of pneumococcal strains with reduced susceptibility). Duration of treatment following splenectomy is discussed: The French medicine agency (AFSSAPS) recommends a 2-year treatment after surgery and for patients having functional hyposplenism (persistency of Howell-Jolly bodies) and/or associated immunodeficiency. Despite these prevention policies, the patient must be informed of the risk of very severe infection.

[Regional variations of adult population vaccinal status]

OBJECTIVE

The authors had for aim to study the regional variations of vaccination coverage in adult population.

METHODS

Cross-sectional epidemiological study, including a representative sample of 2122 general practitioners and analyzed according to eight French regions.

RESULTS

Six thousand two hundred sixty-nine patients, 44 +/- 15 old, were included in the study. 90.5% of the patients were vaccinated against diphtheria, 94.4% against tetanus, and 92.6% against poliomyelitis. No difference between regions was noted but the rate of patients with up to date vaccination strongly differed, ranging from 54.8% (Paris/Ile de France) to 64.3% (South West) for diphtheria, from 60.4% (Paris/Ile de France) to 73% (South West) for tetanus, and from 58.8% (Paris/Ile de France) to 69.8% (South West) for poliomyelitis. Vaccination coverage against measles, parotiditis, hepatitis A and B, typhoid fever, yellow fever also significantly differed between regions and the only ones evenly distributed were vaccination against tuberculosis, meningococcus, and pneumococcus.

CONCLUSION

These results show insufficient vaccination coverage against diphtheria, tetanus, and poliomyelitis in all regions and show other important variations in vaccination coverage between regions, especially for hepatitis A and B.

[Asplenia and hyposplenism]

FROM ASPLENIA TO SEVERE INFECTION: The most serious consequence of asplenia due to absence of the spleen, its resection or its functional failure is the risk of severe infection. RAPIDLY PROGRESSIVE SEPTICEMIA: It is estimated that the risk of death due to septicemia is 200 times higher in splectomized patients than in patients with a spleen. Death occurs within several days or even hours in most of the patients due to overwhelming post-splenectomy infection (OPSI). The bacteria causing OPSI are predominantly pneumococci (50-80% of identified infections) as well as meningococci, Haemophilus sp, and other capsulated bacteria. IMPORTANCE OF AGE: The risk of infection is even greater if asplenia began early in life, either because of rapidly progressive congenital hemotological disease or splenectomy during infancy or early childhood. According to Holdsworth, infectious morbidity in subjects splenectomized before the age of 16 years is 4.4%, mortality reaches 2.2%. In adults, morbidity is 0.9% and mortality 0.8%. PREVENTION OF RECURRENCE: Furthermore, in an asplenic subject or in a patient with a chronic disease threatening the spleen, the development of infectious episodes is an expression of evolving immunodepression, calling for preventive measures against recurrence. Anti-pneumococcal vaccination and antibiotic prophylaxis using penicillin V considerably reduces the incidence of pneumococcal infection in splenectomized subjects.

[Antibiotic prophylaxis in splenectomized adults]

SIGNIFICANT INCIDENCE OF SPLENECTOMY: Asplenism concerns a significant number of subjects: in France 6,000 to 9,000 patients undergo splenectomy annually. More than half of these patients are adults.

NECESSARY PREVENTION

An asplenic adult is exposed to serious infections, predominantly caused by pneumococci but also by other encapsulated bacteria. Antibiotic prophylaxis is necessary and must be included in the overall management scheme in patients undergoing planned splenectomy.

IN CLINICAL PRACTICE

In France the official recommendation for antibiotic prophylaxis in the asplenic patient is Oracilline (Penicilline V) administered continuously for at least 2 years following splenectomy in adults and for at least 5 years following splenectomy in children. This prophylactic measure must be included in an overall program designed to prevent infections in asplenic patients.

[Alveolar echinococcosis of the liver. Mass ultrasound screening in the Haut Cantal area]

OBJECTIVE

Mass systematic screening for alveolar echinococcosis (AE) of the liver in the Haut Cantal endemic area.

MATERIAL AND METHODS

Targeted population was composed of the members of the Mutualité Sociale Agricole of the area, from 16 to 65 years old. 2077 notifications were sent, corresponding to 20% of the population of this area, defined by a triangle between Egliseneuve d'Entraigues, Riom ès Montagne and Saint Flour. Two screening tests were performed: Elisa serology test and liver ultrasound examination.

RESULTS

Participation levels were relatively low-ultrasound: 18.92%, serology: 17%. Among 350 liver examinations, 2 suspicions of AE were found: CT and serology confirmed the diagnosis in the first symptomatic patient; CT and biopsy confirmed the diagnosis in the other asymptomatic patient in whom serology was normal.

CONCLUSION

Ultrasound screening showed at least a 0.57% prevalence of AE, i.e., 2 cases out of 350. This low rate however confirms that Haut Cantal is an endemic area, but with a lower incidence rate than in other endemic areas.

Cat scratch disease with lymphadenitis, vertebral osteomyelitis, and spleen abscesses

In this report we describe a 30-year old male patient with vertebral osteomyelitis and spleen abscesses with cat scratch disease. The diagnosis was made on the basis of molecular detection of Bartonella henselae either on lymph node biopsies or on bone biopsy, histology of the lymph node, serology using either our in-house microimmunofluorescence assay or a commercial kit (Focus Technologies). Immunofluorescent detection was also performed directly on slide appositions using a monoclonal antibody. Treatment consisted of administration of antibiotics with rapid clinical improvement and a stabilization of skeletal lesions on the magnetic resonance imaging performed three months later. Twenty two other cases of this unusual manifestation associated with cat scratch disease have been reported in the literature and are reviewed here. Our case represents the second case of osteomyelitis associated with cat scratch disease in which B. henselae has been specifically identified as the etiological agent using several direct and indirect methods.

Triple Nucleoside Combination Zidovudine/Lamivudine/Abacavir versus Zidovudine/Lamivudine/Nelfinavir as First-Line Therapy in HIV-1-Infected Adults: A Randomized Trial

Objective

To compare the efficacy and safety of a triple nucleoside combination to a protease inhibitor-containing triple regimen as first-line antiretroviral therapy (ART) in HIV-1-infected patients.

Design

Open-label study in HIV-1-infected ART-naive adults, randomized to receive either Combivir® (lamivudine 150 mg/zidovudine 300 mg twice daily) + abacavir (300 mg twice daily), or Combivir® + nelfinavir (750 mg every 8 h) for 48 weeks. Plasma HIV-1 RNA, CD4 cell count and adverse events were assessed at baseline and weeks 4, 8, 16, 24, 32, 40 and 48.

Results

195 subjects (131 men, 64 women), median age 34 years, were randomized: 98 received combivir/abacavir and 97 combivir/nelfinavir. Baseline median plasma HIV-1 RNA was 4.2 log10 copies/ml [Interquartile range (IQR): 3.7-4.5.2] and 4.1 log10 copies/ml (IQR: 3.8–4.6), respectively. Baseline median CD4 cell count was 387 cells/mm3 (IQR: 194–501) and 449 cells/mm3 (IQR: 334–605), respectively. Nine patients (3 vs 6, respectively) did not start treatment or did not have any available efficacy data. At week 48, using the intent to treat analysis (switch/missing equals failure), plasma HIV-1 RNA was <50 copies/ml in 54/95 (57%) and 53/91 (58%) of subjects, respectively. Median CD4 increase was +110 and +120 cells/mm3, respectively. Possible hypersensitivity reactions to abacavir were reported in four subjects (4%).

Conclusion

The triple nucleoside combination combivir/abacavir is well tolerated as a first-line ART regimen in HIV-1-infected adults, with comparable antiviral activity to a nelfinavir-containing regimen at week 48.

[A collective malarial infestation during a humanitarian mission in west Africa]

Four truck drivers involved in a humanitarian mission across the Sahara towards Mali fell ill 15 days after their return. Plasmodium falciparum malaria (thankfully, non pernicious) was diagnosed with 3 to 4 days delay. The four drivers had been treated with chloroquine and proguanil but the dosage may have been insufficient with regard to their body weight (average weight = 110 kg). These 4 travelers had all slept outside (in Tintane, near Kiffa in Mauritania), without any anti-vectorial protection, whereas their other 8 companions (none of whom caught malaria) had slept in their vehicles. The evolution of the 4 cases was favourable despite the difficulties involved in urgently obtaining sufficient amounts of quinine for treatment. How can these cases be explained in relation to prophylactic treatment of associated chloroquine and proguanil? One explanation might be resistance of the P. falciparum strain. We were unable to study this possibility. The high incidence and similitude of cases points towards a hypothesis of resistance both to proguanil and chloroquine. Resistance to chloroquine, as has been formally ascertained in Mauritania, reinforces such a conviction. And yet prophylaxis does not prevent pernicious malaria. This clinical form of the disease, with P. falciparum primo-invasion occurring under rigorous chemoprophylaxis is characteristic of a partially resistant strain. The most reasonable explanation besides "chance" is that we are dealing here with a partially resistant strain of Plasmodium falciparum which is thus also partially sensitive to--in this case highly effective--therapeutic treatment. Indeed, chloroquino-resistant strains are more sensitive to mefloquine and halofantrine. Another explanation might be under-dosage of Savarine with relation to the body weight of these 4 patients. We should be aware of adapting more rigorously the posology of prescribed prophylaxis. But above all, this outbreak should remind us that we should recommend to travelers and drivers planning a trip to Sub-Saharan Africa to take with them anti-vectorial protective gear. Finally, the observation of these cases indicates once more the difficulty in France of establishing a proper diagnosis in face of malaria. Health personnel must systematically call to mind malaria in face of thrombopenia or fever following a sojourn in an endemic area even when chemoprophylaxis has been correctly followed.

Vaccination campaign following an increase in incidence of serogroup C meningococcal diseases in the department of Puy-de-Dôme (France)

In the department of Puy-de-Dôme, France, 17 cases of invasive meningococcal disease C were notified between March 2001 and the first week of 2002. Among the 15 confirmed cases, 11 (73%) were serogroup C, 2 (13%) serogroup B, and 2 could not be identified. The rapid increase in the number of cases in a period of low endemicity for the rest of the country and the severity of the disease (case fatality ratio 27%, purpura fulminans 64%) led the health authorities to initiate a vaccination campaign targeting children and young adults from 2 months up to 20 years living in a limited area of the department. Around 80,000 people were immunised between 16/01/02 and 09/02/02. More than half of the 1390 immediate side effects were headache and dizziness. As of mid-March, no further case of meningococcal disease has been notified since 6 January.

Hospitalization decision for ambulatory patients with community-acquired pneumonia: a prospective study with general practitioners in France

BACKGROUND

We designed a prospective study in the Puy-de-Dĵme region of France to identify factors associated with a hospitalization decision by general practitioners (GPs) for patients with community-acquired pneumonia (CAP).

PATIENTS AND METHODS

95 voluntary GPs were recruited to report over the period (February 1993 to March 1994) patients diagnosed with CAP defined as acute onset of fever associated with focal pulmonary crackles and/or radiological changes consistent with a pulmonary infection in patients over 3 years of age, living in the community.

RESULTS

37 of the 175 CAP patients (21.4%) were hospitalized. Univariate analysis showed that the hospitalization decision was related to age > 65 years, retirement, history of cardiovascular disease, other extrapulmonary chronic disease, chest auscultation findings, tachypnea at rest and altered mental status. Multivariate analysis identified four variables associated with hospitalization: living alone at home (OR = 3.75), history of cardiovascular disease (OR = 2.54), other chronic medical conditions excluding pulmonary diseases (OR = 4.28) and tachypnea at rest (OR = 3.33). The hospitalization decision by GPs for patients with CAP takes into account social conditions, co-morbid conditions of the patients and the seventy of CAP.