Cotrimoxazole for community-acquired urinary tract infections leads to more adverse effects than fluoroquinolones

BACKGROUND

For several years, we applied an internal guideline for community-acquired urinary tract infections (cUTI), targeting the reduction of fluoroquinolone use (FQ) and thereby favouring cotrimoxazole (CTM) prescription. Our aim was to report adverse effects (AE) and outcome for patients presenting with cUTI and treated with these compounds.

METHODS

This cohort study was based on the dashboard of our department, bringing together 28 parameters for all patients, including diagnosis, microbiological data, antibiotic therapy, AE, length of hospital stay (LHS) and outcome. We included all patients with cUTI due to Enterobacteriaeae treated with CTM or FQ, and compared these 2 groups on in-hospital AE, LHS, and unfavourable outcome defined as intensive care requirement or death.

RESULTS

From June 2008 to June 2019, 640 cUTI due to Enterobacteriaeae were observed, among which 295 (46%) treated with CTM and 345 (54%) with a FQ. There were 25 AE (3.9%): 17 (5.7%) in the CTM group, and 8 (2.3%) in the FQ group (P=0.025). Adverse effects were associated with increased LHS compared to patients without AE: 11±6 vs. 7±4 days respectively, P<0.001, 11.4±6.2 days in the CTM group vs. 9.2±5.8 in the FQ group (relative LHS increase of 73.5% and 29.5%, respectively). Unfavorable outcome occurred for 1 patient (0.3%) in the CTM group, and 5 (1.4%) in the FQ group, P=0.297.

CONCLUSION

Favouring cotrimoxazole for cUTI due to Enterobacteriaceae was associated compared to FQ with more AE and prolonged LHS. A cost-effectiveness analysis to validate such therapeutic strategy is warranted.

Efficacy and safety of clindamycin-based treatment for bone and joint infections: a cohort study

Clindamycin has high bioavailability together with good diffusion in bone tissue and could represent an alternative antibiotic compound for the treatment of bone and joint infections (BJIs). However, data regarding the efficacy and safety of clindamycin for BJIs are limited. A monocentric cohort study based on our medical dashboard, which prospectively recorded 28 characteristics for all hospitalized patients since July 2005, was performed. BJIs were selected, and then, all mono-microbial BJI managed with clindamycin-based therapy were included. Remission was defined as the absence of clinical and/or microbiological relapse after treatment. The duration of follow-up without relapse was determined retrospectively using computerized medical records. For 10 years, 196 BJIs, of which 80 (41%) were device-associated infections, were treated with clindamycin-based therapy. The bacterial causative agent was Staphylococcus aureus in 130 cases (66%), coagulase-negative staphylococci in 29 cases (15%), streptococci in 31 cases (16%) and other bacteria in 6 cases (3%). When used in combination therapy, clindamycin was mainly paired with fluoroquinolones (31%) or rifampin (27%). The mean duration of clindamycin treatment was 7.4 ± 3.2 weeks (range, 1-24). An AE was recorded for 9 (4.5%) patients. Remission was recorded for 111 (57%) patients, with a mean duration of clinical follow-up of 28 ± 24 months. Treatment failure occurred in 22 (11%) patients, 50 patients (25%) were lost to follow-up, and 8 (4%) required long-term suppressive therapy. Among the assessable patients, clindamycin-based therapy was efficient in 111/133 cases (83%) and thus represents a reliable and safe alternative treatment option.

Direct-acting antiviral treatment against hepatitis C virus infection in HIV-Infected patients - "En route for eradication"?

OBJECTIVES

Direct-Acting Antivirals (DAAs) opened a new era in HCV treatment. We report the impact of HCV treatment in French HIV-HCV coinfected patients.

METHODS

All HIV-HCV patients from the Dat'AIDS cohort followed between 2012 and 2015 were included. HCV status was defined yearly as naive, spontaneous cure, sustained virological response (SVR12), failure or reinfection.

RESULTS

Among 32,945 HIV-infected patients, 15.2% were positive for anti-HCV antibodies. From 2012 to 2015, HCV incidence rate increased from 0.35%PY to 0.69%PY in MSM, while median incidence was 0.08%PY in other patients. Median reinfection rate was 2.56%PY in MSM and 0.22%PY in other patients. HCV treatment initiation rate rose from 8.2% in 2012 to 29.6% (48.0% in pre-treated patients vs 22.6% in naïve patients). SVR12 rate increased from 68.7% to 95.2%. By the end of 2015, 62.7% of the patients were cured either spontaneously or following SVR.

CONCLUSIONS

HCV treatment dramatically increased in HIV-HCV patients in France from 2012 to 2015 resulting in HCV cure in nearly two-thirds of the patients in this cohort. Combined with a declining HCV prevalence, the prevalence of active HCV infection among HIV patients will drastically decrease in the forthcoming years.

Medical table: A major tool for antimicrobial stewardship policy

Infectious diseases are unpredictable, with heterogeneous clinical presentations, diverse pathogens, and various susceptibility rates to anti-infective agents. These features lead to a wide variety of clinical practices, which in turn strongly limits their evaluation. We have been using a medical table since 2005 to monitor the medical activity in our department. The observation of heterogeneous therapeutic practices led to drafting up our own antibiotic guidelines and to implementing a continuous evaluation of their observance and impact on morbidity and mortality associated with infectious diseases, including adverse effects of antibiotics, duration of hospital stay, use of intensive care, and deaths. The 10-year analysis of medical practices using the medical table is based on more than 10,000 hospitalizations. It shows simplified antibiotic therapies and a reduction in infection-related morbidity and mortality. The medical table is a major tool for antimicrobial stewardship, leading to constant benefits for patients.

Antimicrobial stewardship policy: time to revisit the strategy?

Recent data indicate that both the overall numbers of antibiotic prescription and the frequency of multidrug-resistant bacteria are increasing significantly. These threatening features are observed, despite national antimicrobial stewardship (AMS) policies aimed at decreasing antibiotic use. AMS should also focus on the initial steps leading to antibiotic prescription. Physicians and their patients should benefit from the structured clinical pathways, the latter being adapted to regional epidemiological data and resources. Continuous evaluation of these predefined clinical paths through a computerized medical dashboard will allow a critical review and finally the optimization of medical practices. These innovative behavioural approaches for clinicians will supply precise information on the relationship among the diagnosis, therapeutics and outcome. This changing environment will carry out the adapted therapeutic procedures, and appropriate antibiotic use will inherently improve.

[The French Society of EEG and Clinical Neurophysiology is 40 years old]

The historical reminder of the foundation of the French EEG Society and the changes which have occurred during its operation show the worry of the Society for a better efficiency all along this last fourty years. A general survey of the scientific activities disclose the contribution of the society in the papers first published in the Revue Neurologique, and, after 1971, in the Revue d'EEG et de Neurophysiologie clinique de Langue française. The French participation in other clinical neurophysiological or scientific meetings in France and abroad is underlined by the important role it has played in the life of the International Federation for EEG Societies. Training of specialized doctors and technicians in the domain of the functional exploration of the nervous system has been a standing preoccupation of the Society, with the teaching of the so-called "Attestation d'EEG" in French universities and the training of technical personnel in specialized schools.

Clobazam in therapy-resistant patients with partial epilepsy: a double-blind placebo-controlled crossover study

Clobazam was compared with placebo as antiepileptic adjunct medication in 129 therapy-resistant epileptic patients who were mainly suffering from complex partial seizures. The study was performed in five European countries according to a double-blind crossover design lasting 7 months. Two treatment periods of 3 months (1 month adjustment and 2 months maintenance medication) were separated by one medication switch-over month. The difference in seizure reduction between clobazam and placebo was significant (p less than 0.05). Nineteen percent of patients receiving clobazam became seizure-free during the maintenance dose period. In contrast, freedom from seizures was not observed in any placebo patient. Electroencephalogram (EEG) signs, mood ratings, and global impressions also indicated therapeutic effects of clobazam in epilepsy. The most frequent adverse reactions to clobazam were drowsiness and dizziness. However, the sedative effects of clobazam seemed to be less pronounced in comparison with other benzodiazepines. The study gives evidence of the therapeutic value of clobazam as adjunct medication in therapy-resistant partial seizures. The use of clobazam as monotherapy and long-term treatment, as well as the particular seizure response pattern to clobazam, has to be further investigated.

[Changes in the semeiology of epileptic seizures after status epilepticus: apropos of 65 cases]

In 65 patients with status epilepticus, we compared the clinical expression of isolated seizures and of status seizures. In 22 patients there was no relationship between status and isolated seizures. In addition the number of partial status is greater than that of partial seizures. In 9 patients, the type of seizures was modified after the status. From these results, status epilepticus seems to favor the eruption of secondary epileptogenic focuses, generally transitory.

[Treatment of partial motor status epilepticus in adults with intravenous diphenylhydantoin (DPH). Prospective study of 50 cases]

Fifty adult patients with partial motor status epilepticus were treated with a single intravenous (i.v.) injection of diphenylhydantoin (DPH), 20 mg/kg body weight at a rate of 1 mg/kg/min. Seizures were controlled in 32 patients (64%) during the injection or within the following hour; in 13 of them previous (i.v.) injections out of benzodiazepines had been ineffective. DPH was effective in 10 patients of 11 with a previous history of epileptic seizures and without problems of consciousness during their epileptic status. In contrast, 13 failures out of 18 concern occasional status in patients deeply comatose because of head trauma, neurosurgical operation or intracerebral hemorrhage. Total plasmatic levels of DPH, when measured 24 h after the injection, were found between 38 mumol/l in all patients, and were in the range of 40 mumol/l-100 mumol/l in 77% of cases. Adverse effects were: pain at the injection site (6 cases), horizontal nystagmus during injection (5 cases), transient cerebellar symptoms (3 cases). This study confirms that single loading doses of DPH can maintain DPH plasmatic levels within the therapeutic range during 24 h, with minor or transient side effects, provided that cardiovascular contra-indications are respected.

[Status epilepticus in adult epileptics followed in a neurologic hospital]

One or several status were observed in 90 chronic adult epileptics. Partial status, especially motor and of similar type, is rare in the clinical course of usual partial epilepsy. Generalized status, chiefly petit mal (PM) status, appears in more severe generalized epilepsies. Partial status epilepticus is observed in motor attacks and rarely in partial complex epilepsies, although the latter are more frequent. In 40% of cases the aetiology is unknown. Delay of the first status is variable, from 2 to 30 years. Status does not make previous epilepsy worse. Generalized status, mainly PM status, appears in patients with absences and generalized attacks, sometimes some decades after the beginning of the disease. In half of the cases PM status are frequent but are sometimes the only expression of the epilepsy.

[Contribution of visual evoked potentials (VEP) to neurology]

It is widely admitted that visual evoked potentials (VEPs) are clinically useful for diagnostic purposes in multiple sclerosis (MS). Delayed P100 component to pattern shift stimulation indicates a dissemination of the demyelinating process when routine ophthalmological investigations are normal. The delay of P100 may be observed early in the course of the disease following an attack of optic neuritis (ON); in the absence of previous ON the P100 latency may appear later after the onset. The P100 latency exceptionally returns to normal values. Compared with somatosensory or brain-stem auditory evoked potentials VEPs are the most efficient for the detection of silent lesions in MS. Longitudinal studies demonstrate that the percentage of MS patients with abnormal VEPs increases with time during the course of the disease. Delayed P100 component may also be recorded in patients with heredodegenerative or toxic optic neuropathies, but the clinical context is very different. The detection of bitemporal visual field defects with VEPs is more uncertain. In patients with cortical blindness VEPs may persist. When compared with usual campimetric investigations, VEPs do not represent a simple and reliable means of investigating lateral homonymous hemianopsia.

Neural generators of N18 and P14 far-field somatosensory evoked potentials studied in patients with lesion of thalamus or thalamo-cortical radiations

Somatosensory evoked potentials (SEPs) to electrical stimulation of the right or left median nerve were studied in 4 patients with hemianesthesia and a severe thalamic or suprathalamic vascular lesion on one side. The SEPs were recorded with a non-cephalic reference. The normal side of each patient served as his or her own control. The lesion consistently abolished the parietal N20-P27-P45 and the prerolandic P22-N30 SEP components. It did not significantly affect the P9-P11-P14 positive far fields, nor the widespread bilateral N18 SEP component. This allowed N18 features to be studied without interference from cortical components. It is proposed that N18 reflects several deeply located generators in brain stem and/or thalamus whereas N20 represents the earliest cortical response of the contralateral post-central receiving areas.

Astereognosis and dissociated loss of frontal or parietal components of somatosensory evoked potentials in hemispheric lesions. Detailed correlations with clinical signs and computerized tomographic scanning

Detailed clinical sensory and motor signs were correlated case by case with somatosensory evoked potentials (SEP) in 22 selected patients with a single circumscribed hemisphere lesion. The lesions collectively mapped out a variety of cerebral sites from the anterior frontal to the posterior parietal regions. SEPs were averaged from 8 standard scalp sites with an earlobe reference electrode, so that parietal N20-P27-P45 were differentiated from prerolandic P22-N30 SEP components. SEP wave forms to stimulation on the unaffected side served as the patient's own control. A complete parietal lesion produced contralateral hemianaesthesia without upper motor neuron signs and eliminated the parietal N20-P27-P45 while the prerolandic P22-N30 persisted at usual latencies. The neural generators for the N20 and the P22 components are thus distinct. It is also proposed that direct, short latency pathways convey somatosensory inputs to the motor cortex, independently of connections via parietal areas 2 and 5. Enhancement of P22-N30 after chronic parietal lesions suggests collateral reinnervation by residual inputs after partial deafferentiation of prerolandic cortex. Small postcentral lesions produced astereognosis (with preserved tactile and deep sensation) and reduced or eliminated the N20 and P27 SEP components, but did not affect the P22-N30 components. Precentral lesions with severe hemiplegia (but not prefrontal lesions) eliminated the prerolandic P22-N30 SEP components and did not alter the parietal N20-P27-P45 components. The data are pertinent to the understanding of the pathophysiology of somatosensory deficits and for the diagnostic use of SEPs in cerebral lesions.

Dissociation of early SEP components in unilateral traumatic section of the lower medulla

Spinal and scalp early SEPs were recorded, using a noncephalic reference electrode, in a patient with a traumatic cervicomedullary lesion causing unilateral loss of position sense. Cervical N11 and N13 and scalp-recorded far-field P14 SEPs were clearly dissociated following stimulation of the affected side. The findings suggest that the P14 component is generated above the foramen magnum, whereas the cervical N13 has a spinal generator.

[Aspects of early somatosensory and auditory evoked potentials in neurologic comas and brain death]

Following stimulation of the median nerve at the wrist, SEPs, BAEPs and EEG activity were recorded during the same session in 20 comatose patients (13 head injuries, 6 comas of vascular origin, 1 anoxic coma). Patients were classified according to clinical data. In traumatic comas with clinically preserved brain stem reflexes (5 patients), BAEPs were all present, with preserved cervical N14 and scalp recorded P15 SEPs; the parietal N20 SEP was either present on both sides or unilaterally absent in case of hemispheric, possibly EEG silent, traumatic lesion. In comas with a reactive EEG and absent brain stem reflexes (8 patients), N14 and P15 SEPs were present when the parietal N20 component was absent on both sides. In these patients various aspects of BAEPs were observed, but in most cases (7 out of 8) either the BAEPs were completely absent or only peaks I or I and II were present. In brain-dead patients (7 cases) the cervical N14 was recorded in all cases, the P15 SEP was inconstant and the parietal N20 component was constantly abolished on both sides; in most cases (5 out of 7) all the BAEPs were absent. The practical use of evoked responses for the survey of comatose patients is discussed.

[Epilepsy beginning between 18 and 39 years of age (author's transl)]

The frequency of primary generalized epilepsies is less than 20% of the epilepsies which begin between the ages of 18 and 39. Clinical seizures are rare, apart from myoclonus. A favourable outcome is observed in 70% of the patients. Seizures of frontal origin (absences and secondary generalized aversive seizures) are frequent in this group and difficult to control with anticonvulsant drugs, as are all other kinds of partial seizures with or without secondary generalization. Rarely, an epileptic state, most often of partial character, is the first ictal manifestation of epilepsy. Head trauma is the most frequent aetiology, followed by cerebral tumours and chronic alcoholic intoxication. The aetiology of epilepsy beginning in this class of ages remains unknown in nearly 50% of cases. The CT scan tends to reduce the frequency of cases of unknown origin.

[Short-latency somatosensory evoked potentials (SEPs) in dyssynergia cerebellaris myoclonica (author's transl)]

Short-latency SEPs following stimulation of the median nerve at the wrist have been studied in 6 patients suffering from dyssynergia cerebellaris myoclonica (DCM). Cervical N14 and scalp-recorded P15 potentials were found to be normal in patients with appropriate recording conditions. The N20 potential, usually recorded in normals in the parietal region contralateral to the stimulated side, was recorded only in 3 cases out of 6. When present, the N20 potential was found to be normal in latency, amplitude and topography. These data suggest that the electrophysiological events related with information processing at the subcortical levels of the lemniscal pathways (N14, P15) are unmodified in DCM, and lend substance to the hypothesis of a cortical long-loop reflex responsible for the triggering of intention myoclonus in these patients.

The origins of short-latency somatosensory evoked potentials in humans

Short-latency somatosensory evoked potentials (SEPs) to median nerve stimulation were studied in three patients with well-localized lesions of the lemniscal pathways. In two patients who had focal thalamic vascular lesions, the early scalp-recorded P15 far-field potential was unaltered while later SEP components were absent. In the third patient, operated on for astrocytoma of the dorsal medulla and right dorsal funiculus, the P15 potential was absent but the earlier negative potentials recorded from the neck persisted whichever side was stimulated. The data suggest a subthalamic origin for the scalp-recorded P15 far-field potential.

[Use of intravenous phenytoin in treatment of partial status epilepticus (author's transl)]

Twenty-two patients with partial status epilepticus were treated with phenytoin (DPH) intravenously (mean daily dose: 18,6 +/- 7,3 mg/kg). Benzodiazepines had been administered unsuccessfully in 18 cases before DPH. Seizures were stopped in 14 cases (less than 2 hours after the end of the initial dose in 13 cases). Failures were usually encountered in patients with severe brain damages. Adverse effects were observed in two patients: choreo-athetosic movements in one case with DPH plasma levels lower than 15 mg/l, cerebellar signs in the second patient whose DPH plasma level was 28 mg/l. As previously suggested by Cranford and al., the authors recommend a single slow intravenous infusion of 20 mg/kg (at a rate not exceeding 1 mg/kg/mn). The determination of DPH plasma concentrations demonstrated that with this procedure effective plasma levels are obtained during the 24 hours following the IV injection. In case of failure or of adverse effects determination of DPH plasma levels may be useful for adjusting the daily DPH dose.

[Value of visual evoked potentials in multiple sclerosis (MS). Comparative study of results obtained by light flash and checkerboard reversal stimulation]

Evoked visual potentials were studied in 12 subjects diagnosed or suspected of having MS. A comparison was made between these subjects and results obtained with single eye stimulation using a flash of light (101 subjects) or by using a reversible checker-board pattern (58 subjects). Reversible checker-board pattern simulation showed pathological unilateral or bilateral increase in the latency of the main positive spike in the response of 80% of the verified MS cases and 50% of the probable or possible MS cases. These percentages were 25% lower when flashes of light were used as stimulation. 58% of those patients who have never presented ophtalmological symptoms have abnormal latency in responses invoked by the reversible checker-board pattern, as opposed to 20% using flashes of light for stimulation. Study of E.V.P. in normal subjects indicates that the better results obtained with reversible checker-board stimulation can be attributed to greater reproductibility of the response. Analysis of the overall morphology of the responses significantly increases E.V.P. examination efficiency when using flashes of light as stimulation. However, in our series, it does not change the results obtained by only calculating the latency of response to reversal of a checker-board pattern.

[Significance of epileptic seizures occurring during the first week of traumatic coma (author's transl)]

Clinically evident epileptic seizures were observed in 145 patients during the first week of traumatic coma. They frequently occurred during the first day in young subjects in reactive coma, and were often isolated attacks. When ssen at a later stage they are more common in adults with non-reactive coma. The partial or generalised nature of the seizures, the depth of the coma, and the chronological order in which the seizures appear have no bearing on the etiology; the only positive finding was that recurrent seizures were more frequent in patients with intracranial hematoma (18,6% of the patients). The early appearance of seizures does not worsen the prognosis of reactive coma or non-reactive coma in young people. Critical discharges without clinical manifestations were present in 37 patients with traumatic coma during the first week. The average age of these injured patients was higher, and the prognosis for non-reactive coma worse in this group. The comatous state does not modify the clinical aspects or the etiological significance of these early post-traumatic discharges.

Transient hyperkinesia after a single intravenous perfusion of diphenylhydantoin. Report of a case associated with nontoxic plasma levels of diphenylhydantoin

Transient hyperkinesia was observed in a 16-year-old epileptic and mentally retarded patient after a single intravenous perfusion of diphenylhydantoin (DPH). No clinical signs of DPH intoxication were associated with the movement disorder. Repeated plasma anticonvulsant level determinations never showed toxic concentrations of DPH. Since a few spontaneous episodes of hyperkinesia had been observed before, the DPH intravenous perfusion could have unmasked a preexisting latent movement disorder in our patient. However, neuroradiological investigations failed to demonstrate the existence of any anatomical damage of the basal ganglia, and HVA as well as 5-HIAA levels measured in the CSF with the probenecid technique were within the normal range 2 months after cessation of hyperkinesia. HVA and 5-HIAA levels have also been measured in the CSF during the period with hyperkinesia; the results are discussed with reference to previously published data concerning cerebral monoamine metabolism in drug-treated epileptic patients.