[ISO 9001: 2015 certification of all research activities of a university hospital center]

INTRODUCTION

In France, the number of hospitals involved in clinical research and committed to a quality approach is increasing. The objective of such approaches is to ensure the safety of patients involved in research projects by improving quality.

OBJECTIVE

The University Hospital of Amiens has chosen to certify all its clinical research activities in the same scope according to the ISO 9001: 2015 standard.

METHODS

Action planning has been established and a head of quality management has been appointed to oversee this process.

RESULTS

The activities in the five departments of our university hospital jointly certified in December 2019, are: activities related to internal and external sponsors, as well as methodology and monitoring of clinical research projects conducted in the Clinical Research and Innovation Department (CRID); help with clinical research investigations in the Clinical Research Center (CRC); management of the pathway of therapeutic units used in clinical research (excluding the manufacture of drugs) in the Clinical Trials Unit (CTU) of the Hospital Pharmacy; the conservation and provision of biological resources (tissues and fluids) for cancer research in the Tumor bank of Picardy; the collection, reception, preparation, quality control, conservation and provision of biological resources for research purposes. These activities fall within the framework of legal and regulatory activities and the provision of secure storage in the Biological Resources Center already ISO 9001 certified since 2004 and NF S96-900: 2011 certified since 2009.

CONCLUSIONS

The choice of a common quality approach has brought together more than 70 persons from 5 departments involved in clinical research projects within a single certificate with the aim of continuous improvement.

No Impact of Corticosteroid Use During the Acute Phase on Persistent Symptoms Post-COVID-19

Persistent COVID-19 symptoms may be related to residual inflammation, but no preventive treatment has been evaluated. This study aimed to analyze, in a prospective cohort, whether corticosteroid use in the acute phase of COVID-19 in hospitalized patients may reduce the risk of persistent COVID-19 symptoms. A total of 306 discharged patients, including 112 (36.6%) from the ICU, completed a structured face-to-face assessment 4 months after admission. Of these, 193 patients (63.1%) had at least one persistent symptom, mostly dyspnea (38.9%) and asthenia (37.6%). One-hundred and four patients have received corticosteroids. In multivariable adjusted regression analysis, corticosteroid use was not associated with the presence of at least one symptom (OR=1.00, 95% CI: 0.58–1.71, p=0.99) or with the number of persistent symptoms (p=0.74). Corticosteroid use remained ineffective when analyzing the ICU subpopulation separately. Our study suggests that corticosteroid use had no impact on persistent symptoms after COVID-19 in discharged patients.

Hospital-wide SARS-CoV-2 antibody screening of 4840 staff members in a University Medical Center in France: a cross-sectional study

OBJECTIVES

Healthcare workers are more likely to be infected by SARS-CoV-2. In order to assess the infectious risk associated with working in a hospital, we sought to estimate the proportion of healthcare professionals infected with SARS-CoV-2 by screening staff in a University Medical Center in France.

SETTING

A hospital-wide screening campaign (comprising a serological test and a questionnaire) ran from 18 May to 26 July 2020.

PRIMARY AND SECONDARY OUTCOME MEASURES

The seroprevalence rate was analysed in a multivariate analysis according to sociodemographic variables (age, sex and profession), exposure to SARS-CoV-2 and symptoms.

RESULTS

A total of 4840 professionals were included, corresponding to 74.5% of the centre's staff. The seroprevalence rate (95% CI) was 9.7% (7.0% to 12.4%). Contact with a confirmed case of COVID-19 was significantly associated with seropositivity (OR (95% CI: 1.43, (1.15 to 1.78)). The seroprevalence rate was significantly higher among nursing assistants (17.6%) than among other healthcare professionals. The following symptoms were predictive of COVID-19: anosmia (OR (95% CI): 1.55, (1.49 to 1.62)), ageusia (1.21, (1.16 to 1.27)), fever (1.15, (1.12 to 1.18)), myalgia (1.03, (1.01 to 1.06)) and headache (1.03, (1.01 to 1.04)).

Number of initial symptoms is more related to long COVID-19 than acute severity of infection: a prospective cohort of hospitalized patients

Objectives

Post–COVID-19 symptoms experienced by many survivors have a further devastating effect. This study aimed to analyze the risk factors associated with long COVID-19 in a prospective cohort of hospitalized patients including those requiring intensive care unit (ICU) transfer, taking into account objective measures of COVID-19 severity.

Methods

Hospitalized patients with confirmed COVID-19 were enrolled. A structured follow-up visit was performed 4 months after hospital admission. Multivariable adjusted regression models were used to analyse the association between parameters at the acute phase and persistent symptoms.

Results

A follow-up visit was performed in 316 patients including 115 (36.4%) discharged from the ICU. Mean age was 64.1 years, and 201 patients (58.3%) were men. Female sex (odds ratio [OR], 1.94; 95% confidence interval [CI], 1.17-3.22; P =.01), hypertension (OR, 2.01; 95% CI, 1.22-3.31; P <.01), and the number of initial symptoms (NIS) (OR, 1.35; 95% CI, 1.17-1.54; P <.001) were significantly associated with long COVID-19. Number of persistent symptoms was significantly associated with NIS (adjusted incidence rate ratio [aIRR], 1.16; 95% CI, 1.11-1.22; P <.001), female sex (aIRR, 1.56; 95% CI 1.29-1.87; P <.001), hypertension (aIRR, 1.23; 95% CI, 1.02-1.50; P =.03), and length of stay in hospital (aIRR, 1.01; 95% CI, 1.005-1.017; P <.001).

Conclusion

Our study suggested that female sex, hypertension, and NIS had a significant impact on persistent symptoms in hospitalized patients in contrast to severity of acute COVID-19 infection.

A highly virulent variant of HIV-1 circulating in the Netherlands

We discovered a highly virulent variant of subtype-B HIV-1 in the Netherlands. One hundred nine individuals with this variant had a 0.54 to 0.74 log₁₀ increase (i.e., a ~3.5-fold to 5.5-fold increase) in viral load compared with, and exhibited CD4 cell decline twice as fast as, 6604 individuals with other subtype-B strains. Without treatment, advanced HIV-CD4 cell counts below 350 cells per cubic millimeter, with long-term clinical consequences-is expected to be reached, on average, 9 months after diagnosis for individuals in their thirties with this variant. Age, sex, suspected mode of transmission, and place of birth for the aforementioned 109 individuals were typical for HIV-positive people in the Netherlands, which suggests that the increased virulence is attributable to the viral strain. Genetic sequence analysis suggests that this variant arose in the 1990s from de novo mutation, not recombination, with increased transmissibility and an unfamiliar molecular mechanism of virulence.

Mortality risk and antibiotic use for COVID-19 in hospitalized patients over 80

INTRODUCTION

Patients over 80 years of age are more prone to develop severe symptoms and die from COVID-19. Antibiotics were massively prescribed in the first days of the pandemic without evidence of super infection. Antibiotics may increase the risk of mortality in cases of viral pneumonia. With age and antibiotic use, the microbiota becomes altered and less protective effect against lethal viral pneumonia. Thus we assessed whether it is safe to prescribe antibiotics for COVID-19 pneumonia to patients over 80 years of age.

METHOD

We conducted a retrospective monocentric study in a 1240-bed university hospital. Our inclusion criteria were patients aged ≥ 80 years, hospitalized in a COVID-19 unit, with either a positive SARS-CoV-2 RT-PCR from a nasopharyngeal swab or a CT scan within 72 h after or prior to hospitalization in the unit suggestive of infection.

RESULTS

We included 101 patients who received antibiotics and 48 who did not. The demographics in the two groups were similar. Overall mortality was higher for the group that received antibiotics than for the other group (36.6% vs 14.6%,). According to univariate COX analysis, the risk of mortality was higher (HR = 1.98 [0.926; 4.23]) but non-significantly for the antibiotic group. In multivariate analysis, independent risk factors of mortality were an increased leukocyte count and decreased oxygen saturation (HR = 1.097 [1.022; 1.178] and HR = 0.927 [0.891; 0.964], respectively).

CONCLUSION

This study raises questions about the interest of antibiotic therapy, its efficacy, and its effect on COVID-19 and encourages further research.

Kinetics of SARS-CoV-2-Neutralising Antibodies of Residents of Long-Term Care Facilities

INTRODUCTION

Elderly residents of nursing homes (NHs) and long-term care units (LTCUs) have been shown to have a high risk of mortality and morbidity in cases of SARS-CoV-2 infection. The objective of this study was to examine the kinetics of neutralizing antibodies (NAbs) directed against the SARS-CoV-2 virus in residents of the NH and LTCU units of our University Hospital who were identified with positive serology after the first epidemic outbreak.

MATERIALS AND METHODS

The participants included were sampled every three months for qualitative serological testing, as well as quantitative testing by neutralization tests using retroviral particles containing the S glycoprotein of SARS-CoV-2. Vaccination using the Comirnaty (Pfizer BNT162b2) vaccine begun before the last serological follow-up.

RESULTS

The median NAb titer in June 2020 was 80 [40; 60] versus 40 [40; 160] three months later, showing a statistically significant decline (p < 0.007), but remained stable between the three- and six-month timepoints (p = 0.867). By nine months after vaccination, we observed a significant difference between vaccinated residents known to have positive serology before vaccination (SERO+, Vacc+) and those vaccinated without having previously shown COVID-19 seroconversion (SERO-, Vacc+), the latter group showing similar titers to the SERO+, Vacc- participants (p=0.166). The median antibody titer in SERO+, Vacc+ patients increased 15-fold following vaccination.

DISCUSSION

Humoral immunity against SARS-CoV-2 appears to be persistent in elderly institutionalized patients, with a good post-vaccination response by residents who had already shown seroconversion but a notably diminished response by those who were seronegative before vaccination. To evaluate immunity in its entirety and elaborate a sound vaccination strategy, the cellular immune response via T cells specific to SARS-CoV-2 merits analysis, as this response is susceptible to being affected by immunosenescence.

COVID-19 serology in nursing homes and long-term care facilities: prevalence of seroconversion in the Amiens-Picardie University Hospital

INTRODUCTION

Since December 2019, an emerging infectious viral disease triggered by SARS-CoV-2 has caused a global pandemic. Elderly people, being more fragile, are the most affected by the severity and lethality of this disease. The residential care facility for dependent elderly people (Ehpad) and the long-term care facilities at the Amiens University Hospital registered their first COVID-19 cases in February 2020, which lead to the opening of a dedicated COVID-19 unit and aspecific protocol for isolation.

METHODS

This descriptive study analysed the prevalence of COVID-19 seroconversion within the Ehpad and the long-term care facilities at the Amiens University Hospital. Both this screening test and the nasopharyngeal swab PCRs were used to assess the impact of the COVID-19 epidemic on the residents of the Ehpad and the long-term care facilities.

RESULTS

On 15 and 16 June 2020, the serological tests for COVID-19 were positive for 146 (66.1%) of the residents tested. The seroconversion rate was significantly different (p < 0.001) between the Ehpad (88.7%) and the long-term care facility (45.6%).

DISCUSSION

During the epidemic, there was no excess mortality index within the Ehpad and the long-term care facility services of the Amiens University Hospital. Among frail patients, the role of immunosenescence can be evoked to account for the absence of this inflammatory reaction. This study showed that isolating the infected patient in a dedicated unit significantly reduces the risk of seroconversion and contamination compared to isolating them within their own unit.

Which features of an outpatient treatment for COVID-19 would be most important for pandemic control? A modelling study

The global pandemic of coronavirus disease 2019 (COVID-19) has challenged healthcare systems worldwide. Lockdown, social distancing, and screening are thought to be the best means of stopping the virus from spreading and thus of preventing hospital capacity from being overloaded. However, it has also been suggested that effective outpatient treatment can control pandemics. We adapted a mathematical model of the beneficial effect of lockdown on viral transmission and used it to determine which characteristics of outpatient treatment would stop an epidemic. The data on confirmed cases, recovered cases, and deaths were collected from Santé Publique France. After defining components of the epidemic flow, we used a Morris global sensitivity analysis with a 10-level grid and 1000 trajectories to determine which of the treatment parameters had the largest effect. Treatment effectiveness was defined as a reduction in the patients' contagiousness. Early treatment initiation was associated with better disease control—as long as the treatment was highly effective. However, initiation of a treatment with a moderate effectiveness rate (5%) after the peak of the epidemic was still better than poor distancing (i.e. when compliance with social distancing rules was below 60%). Even though most of today's COVID-19 research is focused on inpatient treatment and vaccines, our results emphasize the potentially beneficial impact of even a moderately effective outpatient treatment on the current pandemic.

[Covid-19 serology in nursing home and long-term care: prevalence of seroconversion in the Amiens-Picardie University Hospital]

Since December 2019, an emerging infectious viral disease implicating a coronavirus SARS-CoV-2 has caused a global pandemic. Elderly people, being more fragile, are the most affected by the severity and lethality of this disease. The NH and LTCU of the Amiens University Hospital registered their first Covid-19 cases in February 2020, which lead to the opening of a Covid-19 dedicated unit and of specific protocol for confinement. This descriptive study was analyzing the prevalence of Covid-19 seroconversion within the NH and the LTCU of the Amiens University Hospital. Both this screening test and the nasopharyngeal swab PCRs were in order to assess the impact of the Covid-19 epidemic in NH and LTCU. On June 15th and 16th, the serological tests for Covid-19 were positive for 146 (66.1%) of the residents tested. The seroconversion rate was significantly different (p < 0.001) between the NH (88.7%) and the LTCU (45.6%). During the epidemic, there was no excess mortality index within the NH and LTCU services of the Amiens University Hospital. Among frail patients, the role of immunosenescence can be discussed to account for the absence of this inflammatory reaction. This study showed that isolating the infected patient in a dedicated unit significantly reduces the risk of seroconversion and contamination compared to isolating them within their own unit.

Comparison of nasopharyngeal and saliva swabs for the detection of RNA SARS-CoV-2 during mass screening (SALICOV study)

In the context of a second wave of SARS-CoV-2 transmission, the use of saliva sampling has become an issue of real importance. SARS-CoV-2 RNA screening was performed on nasopharyngeal and saliva swabs collected from 501 individuals from residential homes for the elderly. The saliva samples were collected at the same time as the nasopharyngeal samples. Nasopharyngeal samples yielded positive results for 26 individuals, only two of whom also tested positive with saliva swabs. In this context, saliva collected by swabbing the fluid is not an ideal sample.

The association between body mass index class and coronavirus disease 2019 outcomes

BACKGROUND/OBJECTIVES

A growing body of data suggests that obesity influences coronavirus disease 2019 (COVID-19). Our study's primary objective was to assess the association between body mass index (BMI) categories and critical forms of COVID-19.

SUBJECTS/METHODS

Data on consecutive adult patients hospitalized with laboratory-confirmed COVID-19 at Amiens University Hospital (Amiens, France) were extracted retrospectively. The association between BMI categories and the composite primary endpoint (admission to the intensive care unit or death) was probed in a logistic regression analysis.

RESULTS

In total, 433 patients were included, and BMI data were available for 329: 20 were underweight (6.1%), 95 have a normal weight (28.9%), 90 were overweight (27.4%), and 124 were obese (37.7%). The BMI category was associated with the primary endpoint in the fully adjusted model; the odds ratio (OR) [95% confidence interval (CI)] for overweight and obesity were respectively 1.58 [0.77-3.24] and 2.58 [1.28-5.31]. The ORs [95% CI] for ICU admission were similar for overweight (3.16 [1.29-8.06]) and obesity (3.05 [1.25-7.82]) in the fully adjusted model. The unadjusted ORs for death were similar in all BMI categories while obesity only was associated with higher risk after adjustment.

CONCLUSIONS

Our results suggest that overweight (and not only obesity) is associated with ICU admission, but overweight is not associated with death.

Anti-spike, Anti-nucleocapsid and Neutralizing Antibodies in SARS-CoV-2 Inpatients and Asymptomatic Individuals

A better understanding of the anti-SARS-CoV-2 immune response is necessary to finely evaluate commercial serological assays but also to predict protection against reinfection and to help the development of vaccines. For this reason, we monitored the anti-SARS-CoV-2 antibody response in infected patients. In order to assess the time of seroconversion, we used 151 samples from 30 COVID-19 inpatients and monitored the detection kinetics of anti-S1, anti-S2, anti-RBD and anti-N antibodies with in-house ELISAs. We observed that specific antibodies were detectable in all inpatients 2 weeks post-symptom onset and that the detection of the SARS-CoV-2 Nucleocapsid and RBD was more sensitive than the detection of the S1 or S2 subunits. Using retroviral particles pseudotyped with the spike of the SARS-CoV-2, we also monitored the presence of neutralizing antibodies in these samples as well as 25 samples from asymptomatic individuals that were shown SARS-CoV-2 seropositive using commercial serological tests. Neutralizing antibodies reached a plateau 2 weeks post-symptom onset and then declined in the majority of inpatients but they were undetectable in 56% of asymptomatic patients. Our results indicate that the SARS-CoV-2 does not induce a prolonged neutralizing antibody response. They also suggest that induction of neutralizing antibodies is not the only strategy to adopt for the development of a vaccine. Finally, they imply that anti-SARS-CoV-2 neutralizing antibodies should be titrated to optimize convalescent plasma therapy.

Abnormal laboratory findings and plasma concentration monitoring of lopinavir and ritonavir in COVID-19

It is not known whether the adverse events (AEs) associated with the administration of lopinavir and ritonavir (LPV/r) in the treatment of COVID-19 are concentration-dependent. In a retrospective study of 65 patients treated with LPV/r and therapeutic drug monitoring (TDM) for severe forms of COVID-19 (median age: 67; males: 41 [63.1%]), 33 (50.8%) displayed a grade ≥2 increase in plasma levels of hepatobiliary markers, lipase and/or triglycerides. A causal relationship between LPV/r and the AE was suspected in 9 of the 65 patients (13.8%). At 400 mg b.i.d., the plasma trough concentrations of LPV/r were high and showed marked interindividual variability (median [interquartile range]: 16,600 [11,430-20,842] ng/ml for lopinavir and 501 [247-891] ng/ml for ritonavir). The trough lopinavir concentration was negatively correlated with body mass index, while the trough ritonavir concentration was positively correlated with age and negatively correlated with prothrombin activity. However, the occurrence of abnormal laboratory values was not associated with higher trough plasma concentrations of LPV/r. Further studies will be needed to determine the value of TDM in LPV/r-treated patients with COVID-19.

The value of post-operative antibiotic therapy after laparoscopic appendectomy for complicated acute appendicitis: a prospective, randomized, double-blinded, placebo-controlled phase III study (ABAP study)

BACKGROUND

Approximately 30% of appendectomies are for complicated acute appendicitis (CAA). With laparoscopy, the main post-operative complication is deep abscesses (12% of cases of CAA, versus 4% for open surgery). A recent cohort study compared short and long courses of postoperative antibiotic therapy in patients with CAA. There was no significant intergroup difference in the post-operative complication rate (12% of organ/space surgical site infection (SSI)). Moreover, antibiotic therapy is increasingly less indicated for other situations (non-complicated appendicitis, post-operative course of cholecystitis, perianal abscess), calling into question whether post-operative antibiotic therapy is required after laparoscopic appendectomy for CAA.

METHODS/DESIGN

This study is a prospective, multicenter, parallel-group, randomized (1:1), double-blinded, placebo-controlled, phase III non-inferiority study with blind evaluation of the primary efficacy criterion. The primary objective is to evaluate the impact of the absence of post-operative antibiotic therapy on the organ/space surgical site infection (SSI) rate in patients presenting with CAA (other than in cases of generalized peritonitis). Patients in the experimental group will receive at least one dose of preoperative and perioperative antibiotic therapy (2 g ceftriaxone by intravenous injection every 24 h up to the operation) and metronidazole (500 mg by intravenous injection every 8 h up to the operation) and, in the post-operative period, a placebo for ceftriaxone (2 g/24 h in one intravenous injection) and a placebo for metronidazole (1500 mg/24 h in three intravenous injections, for 3 days). In the control group, patients will receive at least one dose of preoperative and perioperative antibiotic therapy (2 g ceftriaxone by intravenous injection every 24 h up to the operation) and metronidazole (500 mg by intravenous injection every 8 h up to the operation) and, in the post-operative period, antibiotic therapy (ceftriaxone 2 g/24 h and metronidazole 1500 mg/24 h for 3 days). In the event of allergy to ceftriaxone, it will be replaced by levofloxacin (500 mg/24 h in one intravenous injection, for 3 days). The expected organ space SSI rate is 12% in the population of patients with CAA operated on by laparoscopy. With a non-inferiority margin of 5%, a two-sided alpha risk of 5%, a beta risk of 20%, and a loss-to-follow-up rate of 10%, the calculated sample size is 1476 included patients, i.e., 738 per group. Due to three interim analyses at 10%, 25%, and 50% of the planned sample size, the total sample size increases to 1494 patients (747 per arm).

TRIAL REGISTRATION

Ethical authorization by the Comité de Protection des Personnes and the Agence Nationale de Sécurité du Médicament: ID-RCB 2017-00334-59. Registered on ClinicalTrials.gov (NCT03688295) on 28 September 2018.

Daptomycin versus Vancomycin as Post-Operative Empirical Antibiotic Treatment for Prosthetic Joint Infections: A Case-Control Study

Purpose: To compare safety and efficacy of Vancomycin (Van) versus Daptomycin (Dap) as post-operative empirical antibiotic treatment (PEAT) in patients with periprosthetic joint infections (PJIs).

Methods: Medical charts of patients treated empirically with Van or Dap in the post-operative period of total hip/knee prosthesis septic revision until the results of intra-operative culture were reviewed. Cefotaxime, cefepime or aztreonam were used in combination with Dap or Van.

Results: Twenty Dap patients were matched with 20 other Van patients according to the age and type of prosthesis. The ASA score and the distribution of the pathogens was similar in the two groups especially regarding the number of methicillin-resistant staphylococci. The mean duration of the PEAT was 6.07 ± 0.85 days. A total of 17 episodes of adverse events (AE) in 10 patients (25%) were recorded during the PEAT which led to discontinue the treatment in 5 patients, all of them treated with Van (P=0.02). At the end of a mean post-treatment follow-up of 618 +/- 219 days, 36 patients remained in remission of infection; 2 patients failed in each group.

Conclusions: Our observations suggest that PEAT with Van for septic revision of PJIs is associated with a higher discontinuation rate due to AE but with a similar outcome than it is with Dap.

[Ecology and fluoroquinolon resistance profiles in febrile urinary tract infections (FUTI) after prostate needle biopsy: A retrospective study in 466 biopsies]

OBJECTIVE

The biopsies of prostate are the reference examination to assert the diagnosis of prostate cancer. Even if the urinary infectious complications are rare thanks to the systematic oral antibiotic prophylaxis, they may still be serious. The SPILF (Society of Infectious Pathology and French language) published in 2014, an important increase of the resistances in fluoroquinolones for Escherichia coli (3 to 25%), whereas this is the most bacterium frequently found in the urinary infections (70-80%). The objectives of this study were to estimate the indicence of the febrile urinary tract infections after prostate needle biopsy and to define the ecology and the profile of E. coli's resistance.

METHODS

A total of 466 transrectal ultrasound-guided needle prostate biopsy were included in the study from 2012 to 2015. All the patients were taken care according to the recommendations of the AFU (Ouzzane et al., 2011). We estimated, for all the inclusive patients, if they had presented a clinic sign of urinary infection like fever or burning which suggestive of an urinary infection, and having a urines and blood culture, in the next 30 days the realization of the medical exam.

RESULTS

Among 466 realized biopsies, seven patients developed a febril urinary tract infection (1.5%) [prostatitis (n=6), orchitis (n=1)]. Five infections to E. coli were identified; two were resistant for fluoroquinolones (40%). No germ was able to be identified for two patients.

CONCLUSION

The infectious complications post-biopsy of prostate are rare (1.5%). E. coli is the germ most frequently identified with 40% of resistance with fluoroquinolones.

LEVEL OF EVIDENCE

4.

Factors associated with delayed screening of contacts of tuberculosis cases in the Somme, France

AIM

To analyze the factors associated with the time to initiating tuberculosis contact investigations in the Somme department, France.

METHODS

All reported tuberculosis cases and all their contacts screened between 2007 and 2011 were retrospectively included. Univariate and multivariate analyses were conducted to determine the factors associated with a "system delay"≤1 month and a "contact delay"≤0 days.

RESULTS

The mean time between the mandatory notification of a case of tuberculosis and the date set for the contact's screening (system delay) was 35.3 days and the average time between that date and when the contact was actually screened (contact delay) was 12.5 days. In multivariate analysis, a smear-positive sputum sample (OR: 3.68; 95% CI: 1.63-8.30) and a diagnosis at the university hospital (OR: 2.61; 95% CI: 1.14-5.96) were significantly associated with a system delay≤1 month. A smear-positive sputum sample (OR: 1.35; 95% CI: 1.08-1.69), male gender (OR: 1.21; 95% CI: 1.01-1.49), being born in a foreign country (OR: 1.31; 95% CI: 1.02-1.69), being a family member (OR: 1.37; 95% CI: 1.05-1.77), or being another type of close contact of the case (OR: 2.47; 95% CI: 1.81-3.36) were significantly associated with a contact delay≤0 days.

CONCLUSION

System and contact delays were longer than recommended, and the factors associated with the lengthening of these delays need to be taken into account.

Community-Acquired Infection With Healthcare-Associated Methicillin-Resistant Staphylococcus aureus: The Role of Home Nursing Care

Objective.

To better understand the role of indirect transmission in community-acquired infection with methicillin-resistant Staphylococcus aureus (MRSA).

Design.

Prospective case-control study.

Setting.

A French teaching hospital.

Patients.

A total of 198 case patients and 198 control patients with MRSA or methicillin-susceptible S. aureus infection diagnosed between April 2002 and July 2003.

Results.

Multivariate analysis showed a highly significant independent link between MRSA infection at admission and prior receipt of home nursing care (odds ratio [OR], 3.7; P<.001). Other independent risk factors were prior hospitalization (OR, 3.8; P<.001), transfer from another institution (OR, 2.3; P = .008), and age older than 65 years (OR, 1.6; P = .04). Prior home nursing care showed a frequency dose-response relationship. Eleven MRSA-infected patients had had home nursing procedures but no hospital stay in the previous 3 years. These patients' MRSA strains were related to the prevalent MRSA clone currently spreading in French hospitals.

Conclusion.

Home nursing care appears to be an independent risk factor for MRSA acquisition in the community. The reservoir probably consists of MRSA carriers discharged from the hospital. Community nurses seem to be a potential vector.

Morbimortality in adult patients with septic arthritis: a three-year hospital-based study

Background

The objective of this ambispective study was to determine outcomes and associated factors for adult patients with confirmed septic arthritis (SA).

Methods

All adult patients admitted to Amiens University Hospital between November 2010 and December 2013 with confirmed SA were included in the study. Patients with prosthetic joint infections were excluded. A statistical analysis was performed in order to identify risk factors associated with a poor outcome (including mortality directly attributable to SA).

Results

A total of 109 patients (mean ± SD age: 60.1 ± 20.1; 74 male/35 females) were diagnosed with SA during the study period. The most commonly involved sites were the small joints (n = 34, 31.2 %) and the knee (n = 25, 22.9 %). The most frequent concomitant conditions were cardiovascular disease (n = 45, 41.3 %) and rheumatic disease (n = 39, 35.8 %). One hundred patients (91.7 %) had a positive microbiological culture test, with Staphylococcus aureus as the most commonly detected pathogen (n = 59, 54.1 %). Mortality directly attributable to SA was relatively infrequent (n = 6, 5.6 %) and occurred soon after the onset of SA (median [range]: 24 days [1–42]). Major risk factors associated with death directly attributable to SA were older age (p = 0.023), high C-reactive protein levels (p = 0.002), diabetes mellitus (p = 0.028), rheumatoid arthritis and other inflammatory rheumatic diseases (p = 0.021), confusion on admission (p = 0.012), bacteraemia (p = 0.015), a low creatinine clearance rate (p = 0.009) and the presence of leg ulcers/eschars (p = 0.003). The median duration of follow-up (in patients who survived for more than 6 months) was 17 months [6–43]. The proportion of poor functional outcomes was high (31.8 %). Major risk factors associated with a poor functional outcome were older age (0.049), hip joint involvement (p = 0.003), the presence of leg ulcers/eschars (p = 0.012), longer time to presentation (0.034) and a low creatinine clearance rate (p = 0.013).

Conclusions

In a university hospital setting, SA is still associated with high morbidity and mortality rates.

X4 Tropic Virus Prediction Is Associated with a Nadir CD4 T-Cell Count below 100 Cells/mm

OBJECTIVE

The aim of this study was to evaluate tropism prediction performances of three algorithms [geno2pheno false-positive rate 10% (G2P10), position-specific scoring matrix (PSSM) and a combination of the 11/25 and net charge rules] and to investigate the viral and host factors potentially involved in the X4 or R5 prediction in human immunodeficiency virus-1 (HIV-1) patients.

METHODS

Viral tropism was determined in 179 HIV-1-infected patients eligible for CCR5 antagonist therapy. HIV-1 RNA or DNA was extracted and amplified for env gp120 sequencing. In parallel, demographic, viral, immunological and clinical determinants were analyzed.

RESULTS

According to the G2P10 algorithm, 48 patients harbored X4 or X4R5 virus. The tropism prediction was concordant for 87.7 and 88.2% of samples when comparing G2P10 with PSSM or with a combination of the 11/25 and net charge rules, respectively. X4 prediction was significantly associated with more than 35 amino acids in the V3 domain (p < 0.0001) and loss of an N-linked glycosylation site (p < 0.0001). Of the factors studied, only the nadir CD4 T-cell count was significantly associated with X4 tropism (p = 0.01).

CONCLUSION

We determined that the X4 virus detection is closely linked to the nadir CD4 T-cell count below 100 cells/mm(3) that must be taken into account when considering a CCR5 antagonist therapy switch.

Adult patients hospitalized for measles in France, in the 21st century

BACKGROUND

An epidemic of measles broke out in France in 2008. We designed a retrospective study focusing on adults hospitalized for measles in 2010/2011.

METHODS

A case was any patient aged more than 15 years, hospitalized (September 2010 to September 2011) with a typical rash or a biological diagnosis. Data was collected with standardized questionnaires in participating hospitals.

RESULTS

Four hundred and sixty cases were reported: sex-ratio (M/F) = 0.93, median age 26 years (σ = 8.8). Twenty-nine cases were severe (6.5%), 27 of which hospitalized in an ICU. Three hundred and twelve (68%) cases had elevated serum transaminases (EST), 155 (34%) cases had pneumonia, 34 (7%) cases had elevated serum creatinine (ESC), four (0.9%) cases had elevated serum amylase and lipase (ESAL), and three (0.7%) cases had neurological symptoms. One hundred and four (23%) patients presented simultaneously with EST and pneumonia. One patient presenting with severe pneumonia died (0.2%). One hundred and ten (24%) patients received antibiotics during a median seven days.

CONCLUSION

Measles can present as various syndromes in adults and be responsible for a high burden during outbreaks. The immediate outcome is favorable in most patients. Long-term outcome needs further investigations to identify possible late complications.

Prevention of healthcare-associated infections in general practice: current practice and drivers for change in a French study

PURPOSE

The fight against Healthcare-associated infections is a public health priority and a major challenge for the safety and quality of care. The objective was to assess hygiene in general practitioners' (GPs') office and identify barriers to and drivers for better practice.

MATERIALS AND METHODS

We performed a cross-sectional study in which a questionnaire was sent to a randomly selected, representative sample of 800 GPs. We used a self-administered questionnaire. The first part assessed current practice and the second part focused on barriers and motivating factors for better practice. We performed a descriptive statistical analysis of the responses to closed questions and a qualitative analysis of the responses to open-ended questions.

RESULTS

Only a third of the GPs were aware of the current guidelines. Disposable equipment was used by 31% of the GPs. For the remainder, only 38% complied with the recommended procedures for sterilisation or disinfection. Seventy-two percent of the GPs washed their hands between consultations in the office. A significant minority of physicians disregarded the guidelines by never wearing gloves to perform sutures (11%), treat wounds (10%), fit intrauterine devices (18%) or perform injections (18%). The main barriers to good practice were the high cost of modifications and lack of time/space. Two third of the GPs did not intend to change their practices. The drivers for change were pressure from patients (4.8 on a scale of 1 to 7), inspection by the health authorities (4.8) and the fear of legal action (4.4).

CONCLUSIONS

Our results show that there are significant differences between current practice and laid-down professional guidelines. Policies for improvement of hygiene must take into account barriers and motivating factors.

Assessing urine human papillomavirus polymerase chain reaction testing as a tool for screening anal HPV infection in HIV-positive MSM

Multiple types of human papillomavirus (HPV) are responsible for most cervical cancers but also cause anal cancers-especially in HIV-positive patients. Furthermore, men who have sex with men (MSM) are twice as likely to develop anal cancers as non-MSM. A simple screening test for HPV infection would be useful in these patients. The aim of our study was to evaluate the detection of HPV by real-time polymerase chain reaction (PCR) in urine as a marker of anal infection in MSM. The study included 52 HIV-positive MSM treated at Amiens University Hospital (Amiens, France). After obtaining informed consent, we performed an anal swab and gathered 10 mL of first-void urine. Samples were extracted and amplified in a real-time PCR. Genotypes were determined with a PapilloCheck(®) system (Greiner Bio-One, Frickenhausen, Germany). The anal test was the gold standard for calculating the characteristics of the urine test. The sensitivity of the urine test for diagnosing anal HPV infection was 15%, the specificity was 66%, the positive predictive value was 87.5%, and negative predictive value was 4.5%. The prevalence of anal HPV infection in the study population was 94%. Genotype 42 was the most common. The anal HPV viral load was significantly lower in men in a stable relationship than in single men. However, there was no statistically significant relationship between anal viral load and anal intraepithelial lesions. We conclude that urine-based HPV is a poor predictor of anal HPV infection in HIV-positive MSM.

Neisseria meningitidis serogroup B meningitis relapse after five days of cefotaxime treatment: what went wrong?

The authors describe a case of relapse of Neisseria meningitidis serogroup B meningitis in a 21-y-old male, 48 h after a 5-day treatment with cefotaxime 215 mg/kg per day. Brain magnetic resonance imaging (MRI) excluded the hypothesis of cerebral abscess or central venous septic thrombosis, and transthoracic echocardiography excluded bacterial endocarditis. Complement, properdin, and protein electrophoresis were normal. The plausible explanations for this relapse and the implications for other similar cases are discussed.

High rate of early virological failure with the once-daily tenofovir/lamivudine/nevirapine combination in naive HIV-1-infected patients

BACKGROUND

The combination of one non-nucleoside reverse transcriptase inhibitor (NNRTI) with two nucleoside reverse transcriptase inhibitors is a validated first-line antiretroviral (ARV) therapy. The once-daily combination of lamivudine, tenofovirDF and nevirapine has not been evaluated in a clinical trial.

METHODS

Randomized, open-label, multicentre, non-inferiority trial comparing lamivudine, tenofovirDF and nevirapine once daily (Group 2) with zidovudine/lamivudine and nevirapine twice daily (Group 1), in naive HIV-1-infected patients with a CD4 count <350/mm(3). We planned to enroll 250 patients.

RESULTS

As of May 2006, 71 patients had been enrolled (35 in Group 1 and 36 in Group 2) and an unplanned interim analysis was done. The groups were comparable at baseline: median CD4 count was 195 and 191/mm(3) and median plasma viral load was 4.9 log(10) and 5.01 log(10), respectively, in Groups 1 and 2. Eight early non-responses (22.2%) were observed, all in Group 2, while two later viral rebounds occurred. Resistance genotypes for the nine Group 2 failing patients showed the mutations M184V/I (n = 3), K65R (n = 6), one or more NNRTI resistance mutations in all cases. At baseline, the nine Group 2 patients who failed had higher median plasma viral load (5.4 log(10)) and lower median CD4 count (110/mm(3)) than the other Group 2 patients (4.7 log(10), P = 0.002 and 223/mm(3), P = 0.004). Nevirapine trough concentrations were not different between the two groups, nor between patients with full viral suppression or those who failed in Group 2. Due to slow recruitment, and those results, the steering committee decided to stop the trial at 12 months.

CONCLUSIONS

In ARV-naive HIV-1-infected patients, the once-daily lamivudine, tenofovirDF and nevirapine regimen resulted in a high rate of early virological failures. The reasons for the failures remain unclear.

Non-tuberculous mycobacteria pulmonary infection: Management and follow-up of 31 infected patients

BACKGROUND

The global number of non-tuberculous mycobacteria (NTM) pulmonary infections is increasing. Treatment decisions and management are difficult and the prognosis of these infections has been rarely evaluated.

METHODS

The aim of this study was to evaluate management and prognosis of patients with NTM pulmonary infection in a French teaching hospital. In this study, we evaluated management of patients satisfying the ATS (American Thoracic Society) criteria for NTM pulmonary infection in Amiens hospital from 1992 to 2002 and retrospectively compared this management to ATS guidelines. Short-term and long-term survival was also described.

RESULTS

Thirty-one patients satisfying the ATS criteria for NTM pulmonary infection were included: 15 patients were infected with Mycobacterium xenopi, nine with Mycobacterium avium intracellulare, four with Mycobacterium kansasii and three patients were infected with rapidly growing mycobacteria. Twenty-seven patients had past or concomitant diseases responsible for local or systemic immunosuppression. Eleven patients were not treated. In the 20 treated patients, 13 different antibiotic combinations were used, often comprising three or more drugs. The median survival was 15 months. Twenty-one patients (67%) died before 5 years of follow-up. Thirty per cent of deaths were attributed to NTM pulmonary infection. Adjusting treatment to the results of susceptibility tests or ATS guidelines was not associated with any significant difference in survival.

CONCLUSION

As the high mortality rate may be related to concomitant diseases, management of NTM pulmonary infection also depends on comorbidities, and should be defined according to the severity of underlying diseases.

Overlap syndrome of primary biliary cirrhosis and autoimmune hepatitis: a retrospective study of 115 cases of autoimmune liver disease

OBJECTIVE

The aim of this retrospective study was to compare clinical, biological, and histological features and treatment response in 115 patients with overlap syndrome (OS), autoimmune hepatitis (AIH) or primary biliary cirrhosis (PBC).

METHODS

Consecutive patients with AIH, PBC or OS followed between 1984 and 2005 in five different centers were included. All data were re-evaluated using current diagnostic criteria of each disease.

RESULTS

Fifteen patients had OS (13 females), 48 AIH (40 females) and 52 PBC (49 females). Patients with OS were significantly younger than patients with PBC (median age: 44 vs 59 years). Jaundice (20%) and pruritus (20%) were the main initial symptoms in OS. Patients with OS had serum transaminase and gammaglobulin levels significantly higher than patients with PBC; serum alkaline phosphatase, gamma-glutamyl-transpeptidase and IgM levels were significantly higher in OS than in patients with AIH. Histological analysis showed moderate or severe piecemeal necrosis in 86% and destructive cholangitis in 93% in OS group. Among 11 patients with OS treated with ursodeoxycholic acid (UDCA) or immunosuppressors alone, only 6 had a complete biochemical response. In contrast, all patients with OS receiving combined therapy, as first or second line, responded, 5 patients to the combination corticosteroids-azathioprine-UDCA and 2 to the combination cyclosporine-UDCA.

CONCLUSION

OS is not rare and accounts for 13.9% of patients with autoimmune liver disease in our series. Combination of immunosuppressors and UDCA appears the most efficient treatment in these patients.

[Bilharziasis caused by Schistosoma mansoni in a traveler returning from Guinea: failure of serodiagnostic testing]

The purpose of this report is to describe a case of febrile hypereosinophilic syndrome in a traveler three weeks after returning from a sightseeing trip to Guinea. Laboratory testing demonstrated an inflammatory response syndrome and hepatic cytolysis. Parasite serology led to suspicion of toxocariasis that was treated using albendazole. Follow-up tests at two months showed the presence of Schistosoma mansoni eggs in stools despite negative standard serodiagnostic testing (hemagglutination). Secondarily Western blot testing of serum samples at one, two and 14 months after returning from Guinea continued to show only protein bands specific to toxocariasis with no bands specific to bilhariziasis. These findings provide further evidence of the limitations of serological testing for detection of bilharziasis in travelers and the difficulty of diagnosis. Guinea is a high-risk tourist destination. Intestinal and urinary bilharziasis are endemic over three-fourths of country. Travelers planning even short stays in areas where bilharziasis is endemic should be advised on preventive measures.

Incidence of and risk factors for severe liver toxicity in HIV-infected patients on anti-tuberculosis treatment

OBJECTIVE

To assess the incidence and risk factors for severe liver toxicity in human immunodeficiency virus (HIV) infected patients on anti-tuberculosis treatment and the impact of patients' characteristics and concomitant medications instituted during the first week of antituberculosis treatment.

METHODS

HIV-infected patients referred to six French hospitals between 1 January 1992 and 31 December 2004, with confirmed or 'presumptive' tuberculosis (TB). Liver toxicity was studied during the first 2 months of TB treatment.

RESULTS

During the 12 years of the study period, 144 patients were enrolled. Severe liver toxicity developed in 15 (10.7%). The median time to development of liver toxicity was 14 days. In the univariate analysis, high baseline bilirubin levels (P = 0.004), CD4 cell counts between 50 and 100 cells/mm3 (P = 0.022) and the use of fluconazole (P = 0.0005) were associated with liver toxicity. In the multivariate analysis, independent risk factors were abnormal baseline alanine aminotransferase (ALT) (P = 0.028) and bilirubin levels (P = 0.033) and the use of fluconazole (P = 0.008).

CONCLUSION

Severe liver toxicity is frequent, and occurs early in the course of anti-tuberculosis treatment. ALT and bilirubin levels should be closely monitored during the first month of treatment, especially in patients with high baseline ALT or bilirubin levels. We suggest caution when prescribing fluconazole and anti-tuberculosis drugs concomitantly, although this needs to be confirmed and further investigated.

Consideration of age at admission for selective screening to identify methicillin-resistant Staphylococcus aureus carriers to control dissemination in a medical ward

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) has become an increasingly important pathogen responsible for hospital-acquired infections. Our study was to evaluate the efficiency of our selective screening program for methicillin-resistant Staphylococcus aureus (MRSA) carriers at admission to nonintensive care units.

METHODS

During 6 months, all patients were screened at admission to an internal medicine ward, at which time they were classified as patients at risk of carriage (PRC) and those with no known risk factor. The amplitude of cross transmission was estimated using various indicators during this universal screening period and during the same calendar period of the preceding year (selective screening).

RESULTS

The prevalence of MRSA carriage at admission was 5.5%. Among the 22 carriers identified, only 10 were PRC. Age >80 years was significantly associated with MRSA carriage upon admission (OR, 3.5; P < .01). All estimation indicators of MRSA dissemination amplitude were significantly lower during universal screening (relative risks varied from 2.79 to 26.4 according to indicators), demonstrating the need to broaden our criteria defining PRC.

CONCLUSION

Adding patients >80 years of age to our PRC definition would increase screening sensitivity (15 carriers identified for 128 patients sampled) and would enable early implementation of barrier precautions for the additional carriers identified.

Community-acquired bacteraemic pneumococcal pneumonia in adults: effect of diminished penicillin susceptibility on clinical outcome

Pneumococcal pneumonia remains a common disease with a high mortality rate. Between 1995 and 2000, we prospectively analyzed 95 consecutive adult cases of community-acquired bacteraemic pneumococcal pneumonia treated in a single centre. The incidence of pneumococcal resistance to penicillin increased from 19 to 50% during the study period. Multivariate analysis showed that only age and recent hospitalization were independently associated with fatal outcome. The proportion of penicillin-resistant strains was slightly but not significantly higher among patients who died before the fourth hospital day than among those who died later. Patients who died before D4 were more likely to have a recent history of hospitalization, cancer and/or chemotherapy. It thus appears that infection by a resistant pneumococcal strain is not in itself a gravity factor in this setting, but that their acquisition is associated with pejorative clinical features.

The usefulness of 99mTc sulfur colloid bone marrow scintigraphy combined with 111In leucocyte scintigraphy in prosthetic joint infection

AIM

To assess the extent to which bone marrow scintigraphy (BMS) makes the interpretation of leucocyte scintigraphy (LS) easier and improves its diagnostic value.

METHODS

Seventy-three 111In LSs, 99mTc hydroxymethylene diphosphonate bone scintigraphies (BSs) and 99mTc sulfur colloid BMSs were performed in 60 patients with suspected infection related to a hip prosthesis or knee prosthesis, either in situ (+group, n = 43) or after removal for septic loosening (-group, n = 30). Bacteriological samples were obtained from all patients. LS was interpreted together with BS (LS-BS) or with BMS (LS-BMS) by three independent readers.

RESULTS

The concordance among readers, estimated by the kappa test, was average with LS-BS (kappa/kappam coefficients = 0.58, 0.58 and 0.46, respectively, for the three pairs of readers) and excellent with LS-BMS (kappa/kappam coefficients = 1.00 for the three pairs of readers). With LS-BS, 64/219 interpretations were equivocal whereas only one was equivocal with LS-BMS. Sensitivity, specificity and accuracy of LS-BMS were, respectively, 80%, 94% and 91% in the +group, and 33%, 100% and 93% in the -group.

CONCLUSION

We conclude that (1) the interpretation of the results for LS-BMS is very easy, in contrast to LS-BS; (2) the diagnostic value of LS-BMS for detecting infected joint prostheses is good; and (3) additional data are needed to assess the accuracy of LS-BMS when the prosthesis has been removed.

Increased prevalence of hypothyroidism among human immunodeficiency virus-infected patients: a need for screening

The aim of this cross-sectional multicenter study was to determine the prevalence of and risk factors for hypothyroidism in human immunodeficiency virus (HIV)-infected patients. Free T4, free T3, and thyroid-stimulating hormone levels were determined. Data on age, sex, weight variation, smoking status, duration of HIV infection, Centers for Disease Control and Prevention disease stage, CD4 cell count, HIV RNA load, lipodystrophy, HIV-hepatitis C virus coinfection, and antiretroviral treatment (type of drugs and total cumulative dose) were collected. The prevalence study included 350 HIV-infected patients. Sixteen percent of patients had hypothyroidism: 2.6% had overt hypothyroidism, 6.6% had subclinical hypothyroidism, and 6.8% had a low free T4 level. The prevalence of subclinical hypothyroidism was higher among HIV-infected men than among HIV-infected women. A case-control study was conducted that compared hypothyroid (n=56) and euthyroid (n=287) patients. In the multivariate analysis, receipt of stavudine and low CD4 cell count were associated with hypothyroidism. Therefore, screening may be indicated for patients, especially men, who have received stavudine or have decreased CD4 cell counts.

Multilocus Genotyping of Pneumocystis jirovecii in Patients Developing Diverse Forms of Parasitism: Implication for a Wide Human Reservoir for the Fungus

Pneumocystis jirovecii ITS and DHPS genotypes were identified in 3 patient groups developing diverse forms of P. jirovecii infections: 13 patients with Pneumocystis pneumonia, 8 patients merely colonized by the fungus, and 19 immunocompetent infants with bronchiolitis developing mild P. jirovecii infection. Common P. jirovecii genotypes were found in the 3 patient groups, suggesting that common sources of P. jirovecii were involved in the fungus acquisition, and that transmission cycles of P. jirovecii infections in these patient groups are not independent. Parasitized patients, whatever the form of parasitism they present, may be part of a common reservoir for P. jirovecii.

Pneumocystis jiroveci internal transcribed spacer types in patients colonized by the fungus and in patients with pneumocystosis from the same French geographic region

Pneumocystis jiroveci (human-derived Pneumocystis) infections can display a broad spectrum of clinical presentations, of which pulmonary colonization with the fungus may represent an important part, occurring frequently in patients with various underlying diseases and presenting alternative diagnoses of acute pneumocystosis (Pneumocystis carinii pneumonia [PCP]). There are few data concerning the P. jiroveci genotypes involved in pulmonary colonization, whereas several genotypes responsible for PCP in immunocompromised patients have been described. In this study, P. jiroveci genotypes have retrospectively been investigated and compared in 6 colonized patients and in 11 patients with PCP who were in the same hospital. Seventeen archival bronchoalveolar lavage samples were genotyped at internal-transcribed spacer 1 (ITS1) and ITS2 of the nuclear rRNA operon. Fourteen different genotypes were identified, of which 1 was found only in colonized patients, 10 were found only in patients with PCP, and 3 were found in both patient populations. Mixed infections were diagnosed in 2 of the 6 colonized patients and in 6 of the 11 patients with PCP. The results show that similar genotypes can be responsible for PCP as well as pulmonary colonization. There is a high diversity of genotypes in colonized patients and in patients with PCP. Mixed infections may occur in these two patient populations. These shared features of P. jiroveci ITS genotypes in colonized patients and patients with PCP suggest that human populations infected by P. jiroveci, whatever the clinical manifestation, may play a role as a common reservoir for the fungus.

[Evaluation of the efficacy of a multiresistant bacteria control programme in a teaching hospital, studying the evolution of methicillin-resistant Staphylococcus aureus incidence]

Methicillin-resistant Staphylococcus aureus (MRSA) constitute the most important multiresistant bacteria (MRB) recovered in French hospitals. Our objective was to measure these MRSA diffusion in our hospital to evaluate the MRB control programme which had been implemented in the beginning of 1999. This study was conducted in a teaching hospital containing 1800 beds, from February 1999 to January 2001. All MRSA isolated in clinical samples were included. Duplicates (same bacteria in the same patient) were excluded. The detection of methicillin-resistance was performed at 30 degrees C, by disk diffusion method. Incidence densities were determined with their 95% confidence interval (CI 95%). Their evolution by four-month period was evaluated with the chi-square test for trend. During the two-year period, 866 MRSA were isolated. The global incidence was 0,88 per 1000 patient-days (PD) (IC 95% = left open bracket 0,83-0,93 right open bracket ). For cases acquired in our hospital the incidence was 0,66 per 1000 PD, whereas it was 0,26 per 1000 PD for imported cases. Concerning the evolution of incidences, no significant trend was observed for global incidence. The incidence of acquired MRSA decreased during the first year, but increased thereafter. The incidence of imported MRSA increased with a significant trend (p < 10(-5)). The number of these imported MRSA isolated in our hospital was twice fold higher in 2000. This study emphasizes an important actual problem : the increase of patient colonization pressure at the time of admission in hospitals. This increase, which can be due in part to a community transmission, is responsible for a reduction of the efficacy of MRSA control programmes.

Iliac muscle abcess and staphylococcal metastatic infection in a diabetic patient

We report the case of a 44-year-old obese diabetic woman admitted for fever. Blood cultures grew Staphylococcus Aureus and antibiotherapy was started. Iliac abscess was diagnosed and surgical drainage done. Clinical evolution was marked by metastatic dissemination: sacroiliac osteolysis, right shoulder osteoarthritis, spondylitis of the third lumbar vertebra and pulmonary localizations. This case-report shows diagnosis and treatment difficulties of an iliac muscle abscess with metastatic localization in a diabetic patient.

Antimicrobial use prior to the acquisition of multiresistant bacteria

We assessed whether patients who acquired methicillin-resistant Staphylococcus aureus (MRSA) had less exposure to antimicrobial agents than did those who acquired Enterobacteriaceae that produced extended-spectrum beta-lactamase (ESbetaL). In a 6-month, prospective study, ESbetaL carriers had received antimicrobial therapy more often than had MRSA carriers. Amoxicillin-clavulanic acid, fluoroquinolones, and third-generation cephalosporins, especially ceftazidime, had been prescribed more often for ESbetaL carriers than for MRSA carriers.

[Atypical cutaneous leishmaniasis]

French Guyana is an endemic area for American cutaneous leishmaniasis. At the start, the initial red lesion may be mistaken for a whitlow. Twenty percent of developed forms exhibit a sporotrichosis pattern. The notion of travel to an endemic area is very important for diagnosis. We report the case of a young man from French Guyana presenting with a cutaneous lesion of the finger. After numerous surgical treatments for a "whitlow", the final diagnosis of leishmaniasis was difficult because of local-complications and cutaneous rearrangement. Erroneous initial orientation in a unit unaware of tropical diseases can forestall appropriate care of the patients. Epidemiological, clinical and therapeutic data on American tegument leishmaniasis are discussed.

Determinants of transfusion-associated bacterial contamination: results of the French BACTHEM Case-Control Study

BACKGROUND

Transfusion-associated bacterial contamination (TABC), probably the most frequent transfusion-transmitted infection, may induce serious adverse events. Systematic information and documentation on determinants are lacking.

STUDY DESIGN AND METHODS

The BACTHEM Study is a French matched case-control study assessing TABC determinants. Included were cases of TABC reported in France in a 2-year period, as determined from uniform definitions. Information on recipient-, blood component-, and donor-related potential determinants was collected on site. ORs were estimated by conditional logistic regression.

RESULTS

Of the 158 cases of suspected TABC reported, 41 that involved transfusion with 25 RBCs and 16 platelet concentrates were included. Gram-negative rods accounted for nearly half of the bacteria species involved and for all six deaths. In comparison with the risk of TABC for patients receiving RBCs for anemia, the risk was higher for patients receiving RBCs for pancytopenia (OR, 7.3; 95% CI, 1.3-41.0) and for those receiving platelets for thrombocytopenia (OR, 5.3; 95% CI, 1.2-24.1). Other potential determinants were platelet transfusion for pancytopenia (OR, 4.5; 95% CI, 0.5-40.0), immunosuppressive treatment (OR, 2.8; 95% CI, 0.7-10.6), shelf-life of more than 1 day for platelets or 8 days for RBCs (OR, 2.6; 95% CI, 0.7-9.6), and more than 20 previous donations by donors (OR, 1.9; 95% CI, 0.7-5.3).

CONCLUSION

This first comparative study revealed TABC determinants that suggest approaches for prevention.

[A prospective study on erysipelas and infectious cellulitis: how are they dealt within hospital?]

771 cases of erysipelas and 52 cases of infectious cellulitis were collected over 3 months in a prospective study carried out in French hospitals. The mean age was 62.7 +/- 19.3 years for the erysipelas patients and 69.7 +/- 16 years for the cellulitis patients. Sex-ratios were respectively 0.92 and 2.7. The infection was mainly localized in the lower limbs in both categories (90.9 p. 100 and 71 p. 100); the upper limbs and the face were more often involved in cellulitis than in erysipelas (13 p. 100 versus 5.2 p. 100 and 10 p. 100 versus 2.5 p. 100). Penicillin G was the initial antimicrobial treatment in 45 p. 100 of the erysipelas cases, whereas amoxicillin-clavulanic acid was used in 32.7 p. 100 of the cellulitis cases. Other antibiotics used were pristinamycin, antistaphylococcal penicillin, and amoxicillin. Combinations of antibiotics were used to treat 50 p. 100 of the cellulitis cases but only 11 p. 100 of the erysipelas cases. Anticoagulants were used in 67.4 p. 100 of the erysipelas cases and in 59.7 p. 100 of the cellulitis cases. Surgery was performed in 52 p. 100 of the cellulitis cases, and hyperbaric oxygen in 4.2 p. 100. The outcome was quite different for the 2 diseases: cure rate without complications reached 86.6 p. 100 for erysipelas, and only 48.1 p. 100 for cellulitis; death rates reached respectively 0.77 p. 100 and 5.7 p. 100, median length of hospitalization 8 days and 21 days, and median length of antibiotic treatment 15 days and 21 days.