Campylobacter coli enteritis associated with Campylobacter fetus bacteremia, spondylodiscitis, and late CIED-related endocarditis, a case report

Campylobacter sp. is widely considered a leading causative agent of bacterial food-borne gastrointestinal illness. Discitis and endocarditis caused by Campylobacter spp. are extremely rare. We describe the case of a 94-year-old man who was admitted for recent lumbar pain, diarrhea, and fever. C. fetus and C. coli were identified by MALDI-TOF from blood and stool samples respectively. MRI of the spine showed L5-S1 discitis. Patient was treated with 6 weeks of amoxicillin with clinical and microbiological response until cardiac implantable electronic device (CIED) related endocarditis occurred four weeks after the end of the antibiotic treatment. He was treated with another 6 weeks amoxicillin regimen, with a favorable outcome after a 6-month follow-up. Enteric infection with Campylobacter spp. in a debilitated patient should raise the possibility of a co-infection with another more invasive species such as C. fetus, leading to systemic invasion. In case of Campylobacter fetus bacteremia, a search for endocarditis and spondylodiscitis is recommended even in the absence of specific clinical signs.

Sarilumab in adults hospitalised with moderate-to-severe COVID-19 pneumonia (CORIMUNO-SARI-1): An open-label randomised controlled trial

Background

Patients with COVID-19 pneumonia can have increased inflammation and elevated cytokines, including interleukin (IL)-6, which might be deleterious. Thus, sarilumab, a high-affinity anti-IL-6 receptor antibody, might improve the outcome of patients with moderate-to-severe COVID-19 pneumonia.

Methods

We did a multicentric, open-label, Bayesian randomised, adaptive, phase 2/3 clinical trial, nested within the CORIMUNO-19 cohort, to test a superiority hypothesis. Patients 18 years or older hospitalised with COVID-19 in six French centres, requiring at least 3L/min of oxygen but without ventilation assistance and a WHO Clinical Progression Scale [CPS] score of 5 were enrolled. Patients were randomly assigned (1:1) via a web-based system, according to a randomisation list stratified on centre and with blocks randomly selected among 2 and 4, to receive usual care plus 400 mg of sarilumab intravenously on day 1 and on day 3 if clinically indicated (sarilumab group) or usual care alone (usual care group). Primary outcomes were the proportion of patients with WHO-CPS scores greater than 5 on the 10-point scale on day 4 and survival without invasive or non-invasive ventilation at day 14. This completed trial is closed to new participants and is registered with ClinicalTrials.gov, NCT04324073.

Findings

165 patients were recruited from March 27 to April 6, 2020, and 148 patients were randomised (68 patients to the sarilumab group and 80 to the usual care group) and followed up for 90 days. Median age was 61·7 years [IQR 53·0–71·1] in the sarilumab group and 62·8 years [56·0–71·7] in the usual care group. In the sarilumab group 49 (72%) of 68 were men and in the usual care group 59 (78%) of 76 were men. Four patients in the usual care group withdrew consent and were not analysed. 18 (26%) of 68 patients in the sarilumab group had a WHO-CPS score greater than 5 at day 4 versus 20 (26%) of 76 in the usual care group (median posterior absolute risk difference 0·2%; 90% credible interval [CrI] −11·7 to 12·2), with a posterior probability of absolute risk difference greater than 0 of 48·9%. At day 14, 25 (37%) patients in the sarilumab and 26 (34%) patients in the usual care group needed ventilation or died, (median posterior hazard ratio [HR] 1·10; 90% CrI 0·69–1·74) with a posterior probability HR greater than 1 of 37·4%. Serious adverse events occurred in 27 (40%) patients in the sarilumab group and 28 (37%) patients in the usual care group (p=0·73).

Interpretation

Sarilumab treatment did not improve early outcomes in patients with moderate-to-severe COVID-19 pneumonia. Further studies are warranted to evaluate the effect of sarilumab on long-term survival.

Funding

Assistance publique—Hôpitaux de Paris

Germs of thrones - spontaneous decolonization of Carbapenem-Resistant Enterobacteriaceae (CRE) and Vancomycin-Resistant Enterococci (VRE) in Western Europe: is this myth or reality?

Background

In France, Carbapenem-Resistant Enterobacteriaceae (CRE) and Vancomycin-Resistant Enterococci (VRE) are considered as Extensively Drug-Resistant (XDR) bacteria. Their management requires reinforcement of hospital’s hygiene policies, and currently there is few consistent data concerning the spontaneous decolonization in XDR colonized patients. Our aim is to study the natural history of decolonization of XDR carriers over time in a hospital setting in a low prevalence country.

Material and methods

Retrospective multicenter study over 2 years (2015–2016) in 2 different tertiary care hospital sites and units having an agreement for permanent cohorting of such XDR carriers. We gathered the type of microorganisms, risk factors for colonization and rectal swabs from patient’s follow-up. We also evaluated patient care considering isolation precautions.

Results

We included 125 patients, aged 63+/−19y, including 72.8% of CRE (n = 91), 24.8% of VRE (n = 31) and 2.4% (n = 3) co-colonized with CRE and VRE. CRE were mainly E. coli (n = 54), K. pneumoniae (n = 51) and E. cloacae (n = 6). Mechanisms of resistance were mainly OXA-48 (n = 69), NDM-1 (n = 11), OXA-232 (n = 8) and KPC (n = 3).

Prior antibiotic therapy was reported in 38.4% (n = 48) of cases. Conversely, 17.6% (n = 22) received antibiotics during follow-up.

Spontaneous decolonization occurred within the first 30 days in 16.4% (n = 19/116) of cases and up to 48.2% after day-90 with a median follow-up of 96 days (0–974).

We estimated that XDR carriage was associated with a larger care burden in 13.6% (n = 17) of cases, especially due to a prolongation of hospitalization of 32.5 days (15–300).

Conclusions

Our study shows that spontaneous decolonization is increasing over time (up to 48.2%). We can regret that only few patients underwent screening after 1 year, emphasizing the need for more monitoring and prospective studies.

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

BACKGROUND

Carbapenem-resistant Enterobacteriaceae (CRE) and vancomycin-resistant enterococci (VRE) carriage are increasing worldwide. Faecal microbiota transplantation (FMT) appears to be an attractive option for decolonization. This study aimed to evaluate CRE vs VRE clearance by FMT among carriers.

METHODS

A multi-centre trial was undertaken on patients with CRE or VRE digestive tract colonization who received FMT between January 2015 and April 2017. Adult patients with CRE or VRE colonization, confirmed by three consecutive rectal swabs at weekly intervals, including one in the week prior to FMT, were included in the study. Patients with immunosuppression or concomitant antibiotic prescription at the time of FMT were excluded. Successful decolonization was determined by at least two consecutive negative rectal swabs [polymerase chain reaction (PCR) and culture] on Days 7, 14, 21 and 28, and monthly for three months following FMT.

RESULTS

Seventeen patients were included, with a median age of 73 years [interquartile range (IQR) 64.3-79.0]. Median duration of carriage of CRE or VRE before FMT was 62.5 days (IQR 57.0-77.5). One week after FMT, three of eight patients were free of CRE colonization and three of nine patients were free of VRE colonization. After three months, four of eight patients were free of CRE colonization and seven of eight patients were free of VRE colonization. Qualitative PCR results were concordant with culture. Six patients received antibiotics during follow-up, three in each group. No adverse events were reported.

CONCLUSION

CRE and VRE clearance rates were not significantly different in this study, possibly due to the small sample size, but a trend was observed. These data should be confirmed by larger cohorts and randomized trials.

Impact of Fecal Microbiota Transplantation on Digestive Tract Colonization due to Carbapenem-resistant Enterobacteriacae and Vancomycin-resistant Enterococci

Background

Fecal Microbiota Transplantation (FMT) has proved to be an efficient therapy for recurrent C. difficile infection. Its indication is currently discussed for the decolonization of Multidrug-resistant organisms (MDRO) on the basis of mice experiments. Two recent publications suggest that it could be an efficient strategy for patients colonized with digestive MDRO colonization but few data are available for Carbapenem-Resistant Enterobacteria (CRE) and Vancomycin-Resistant Enterococcus (VRE) colonization.

Methods

We performed a FMT among patients colonized by CRE or VRE documented by at least 3 nonconsecutive positive swabs (including one in the week prior to the FMT).

Procedure: 2 days prior to the FMT, patients received a proton pump inhibitor and a naso-duodenal tube was inserted to perform a bowel lavage with X-prep. FMT was performed with frozen feces from 4 donors previously screened for potential diseases using 5 syringes of 50 cc of feces diluted with saline. Patients were discharged after 24h and benefited of outpatient control swabs (PCR + culture) on day 7, 14, 21, 28 and each month during 3 months in order to assess the decolonization. The study is registered at ClinicalTrials.gov (NCT03029078).

Results

Seventeen individuals were included. Mean age was 69 ± 12.7 (SD) years.

Eight patients were positive for CRE (KPC, OXA48 or NDM-1) and 9 for VRE.

All suffered from severe underlying condition (hemodialysis, dementia, cirrhosis) or chronic wounds. Median functional autonomy scale was evaluated using the French Iso-Resources Groups (GIR)=4/6 IQR[3–6] supporting they were dependent persons.

At 1-month follow-up, 3/8 patients were free from CRE and 5/9 from VRE. At 3-month follow-up, 3/8 patients were still free from CRE whereas 7/8 were free from VRE, considering one death from cirrhosis.

Moreover, one of them received antibiotics during a week for a hospital-acquired infection a long time after FMT. No adverse events were reported.

Conclusion

FMT seems to be an attractive option to eradicate colonization of MDRO, especially for VRE. Limited data are available in the literature to determine response factors. Meanwhile its efficacy is moderate; it provides an alternative solution to quarantine for fragile and frequently hospitalized patients. More data and a controlled trial are required.

Disclosures

All authors: No reported disclosures.

Is faecal microbiota transplantation an option to eradicate highly drug-resistant enteric bacteria carriage?

Carbapenem-resistant Enterobacteriaceae (CRE) or vancomycin-resistant enterococci (VRE) carriage present a major public health challenge. Decolonization strategies are lacking. We aimed to evaluate the impact of faecal microbiota transplantation (FMT) on a cohort of patients with digestive tract colonization by CRE or VRE. Eight patients were included: six carrying CRE and two colonized by VRE. One month after FMT, two patients were free from CRE carriage, and another patient was free from VRE after three months. In our experience, this strategy is safe.

[Endobronchial ultrasonography (EBUS) for the internist]

Endobronchial ultrasonography (EBUS) is a recent mini-invasive technique allowing transbronchial needle aspiration (TBNA) of mediastinal lymph nodes as well as peribronchial lesions. EBUS was initially developed for lung cancer mediastinal staging. Over the years, indications for EBUS have been progressively extended to the scope of inflammatory disorders, mediastinal lymphomas, and infectious diseases. Particularly in immunosuppressed patients, including HIV-infected patients, EBUS allows the diagnosis of several diseases that involve the mediastinum, avoiding invasive surgical explorations such as mediastinoscopy or thoracoscopy. This review aims at discussing the technical aspects, and specifies indications, results, and limits of EBUS for the internist.

Cytokines in HIV-associated cardiomyopathy

Among the multiple cardiac manifestations occurring in HIV-infected patients, cardiomyopathy is one of the most challenging. Its incidence has only slightly decreased since the introduction of highly active antiretroviral therapy (HAART). Also, its pathogenesis remains relatively unclear. Although several studies demonstrated the presence of HIV genome in the heart of patients, more recent developments found that viral infection plays an indirect role only, as well as they recognized the contribution of proinflammatory cytokines in the progression of the disease. Experimental studies on animals and cultured myocytes have established the signalling pathway triggered by proinflammatory cytokines in heart failure and cardiomyopathy. Tumor necrosis factor-alpha (TNF-alpha), interleukin-1 (IL-1) and IL-6 promote expression of inducible nitric oxide synthase (iNOS) in cardiomyocytes through activation of p38 mitogen-activated protein kinase (p38 MAPK) and nuclear factor kappaB (NFkappaB). TNF-alpha and high concentrations of NO also induce cardiomyocyte apoptosis by TNF type 1 receptor activation. This biological framework, which is also involved in progression of cardiomyopathy in humans, is more pronounced in HIV-infected patients, in whom proinflammatory cytokines TNF-alpha, IL-1 and IL-6 are increased, resulting in an enhanced expression of cardiac iNOS, especially in patients with a low CD4 T cell count. This may account for the worse outcome of heart failure in HIV-infected patients. However, there are only few data today to support future therapeutic implications of cytokines antagonism in treatment of HIV-infected patients with cardiomyopathy. Whether modulation of TNF production or selective inhibition of p38 MAPK pathway could be useful approaches remains uncertain.

Impact of Insertions in the HIV-1 P6 Ptapp Region on the Virological Response to Amprenavir

We evaluated the impact of genetic changes within p6Gag gene on the virological response (VR, mean decrease in plasma viral load at week 12) to unboosted amprenavir (APV). Gag-protease fragments, including gag p2, p7, p1, p6 regions and whole protease (PR) were sequenced from baseline plasma specimens of 84 highly pre-treated but APV-naive patients included in the NARVAL (ANRS 088) trial. The correlation between baseline p6Gag polymorphism, PR mutations, baseline characteristics and VR to APV was analysed in univariate analysis. Insertions (P459Ins) within p6 protein, leading to partial or complete duplication of the PTAPP motif, were significantly associated with a decreased VR (P459Ins versus wild-type; –0.3 ±0.8 vs –1.1 ±1.2 log copies/ml, P=0.007) and were more frequent when the V82A/F/T/S PR mutation was present ( P=0.020). In multivariate analysis, after adjustment on the predictive factors of the VR in the NARVAL trial and on the PR mutations linked with response, there was a strong trend to an association ( P=0.058) between the presence of P459Ins and an altered VR. In conclusion, these results suggest that insertions in the p6 region of HIV-1 gag gene may affect the VR, in highly pre-treated patients receiving an unboosted APV-containing regimen.

Coronary artery disease in HIV infected patients

OBJECTIVE

To assess the incidence, clinical features, treatment, and follow-up of coronary events in HIV-infected patients over a period of 5 years.

PATIENTS AND PARTICIPANTS

A cohort of 840 patients.

MEASUREMENTS AND RESULTS

A coronary event occurred in 17 patients (5.9/1000 persons-years). Sixteen of them were exposed to highly active antiretroviral therapy (HAART). Patients with coronary events differed in age (48.3 vs. 43 years), CD4 T-cell count (284 vs. 486/mm(3)), total cholesterol (6.2 vs. 5.3 mmol/l), HDL cholesterol (0.72 vs. 1.16 mmol/l), and LDL cholesterol (4.95 vs. 3.391.61 mmol/l). No difference was observed regarding duration of HAART, weight, glucose level, or smoking status between the two groups. Acute coronary syndrome was the first manifestation in 14 patients. Coronary angiography showed 2.56 stenosis per patient, with a single vessel involvement in one-half. Percutaneous angioplasty was performed in all cases, with stenting in 11. After a mean follow-up of 36 months, 14 patients remain alive. Restenosis ( n=4) occurred in 3 patients (PTCA 3; stenting 4). All 14 patients are free of heart failure symptoms. Their mean left ventricular ejection fraction is 61%.

CONCLUSIONS

A higher coronary-event rate is observed among HIV-infected patients, associated with drug-induced metabolic disturbances and a high prevalence of tobacco smoking. However, treatment and prognosis of acute myocardial infarction has no specificity.

Brief report: carotid intima-media thickness in heavily pretreated HIV-infected patients

The authors used ultrasonography to measure carotid artery intima-media thickness (IMT) in 36 HIV-infected patients taking highly active antiretroviral therapy (cases) and in two control groups without (control group 1) or with (control group 2) blood lipid and glucose disturbances similar to those of the patients. Case IMT values were 8% higher than control group 1 IMT values (p <.05) but not different from control group 2 IMT values. Positive independent associations of IMT with the total-to-HDL cholesterol ratio and waist circumference existed for cases (p <.05) but not for controls. Case IMT did not correlate with parameters of HIV infection and antiretroviral treatment. This case-control study suggests that lipid disturbances, mainly hypoHDLemia, may be involved in the early atherosclerotic process in HIV-infected patients.

Coronary heart disease in HIV-infected patients in the highly active antiretroviral treatment era

OBJECTIVES

To assess the incidence and the clinical features of coronary heart disease in HIV-infected patients. To assess atherosclerosis risk factors in this population.

METHODS

A review of our experience consisting of 16 patients with acute myocardial infarction (AMI) was the basis of our retrospective analysis of two cohorts in France. Incidence was compared with the national database on the incidence of AMI in the general population.

RESULTS

Incidence appears to be between 5 and 5.5 per 1000 person-years among HIV-infected patients. This accounts for at least a threefold increase in incidence (1.52 per 1000 person-years reported in the Monica database registry in France). Age of onset of AMI in HIV-infected patients (younger than 50 years in most cases) is a point of major concern and is an indirect way to confirm the increased incidence. AMI was typically of sudden onset without prior history of angina pectoris. Treatment and prognosis of AMI in this population has no specificity. Patients with coronary heart disease present several risk factors such as tobacco smoking, hypertension, diabetes mellitus and low high-density lipoprotein level. The links between AMI and protease inhibitor exposure is still a matter of debate, and longer duration of follow-up is needed in order to reach any conclusion.

CONCLUSIONS

Coronary heart disease is of a higher than expected incidence in HIV-infected patients. The limitation of risk factors (mainly tobacco smoking) is a new challenge. An adaptation of the Framingham score is necessary to state the individual risk. Prospective, controlled studies are necessary to assess new strategies such as the role of statins and switching therapeutic regimens.

[Acute coronary syndromes in patients treated with HIV protease inhibitors]

INTRODUCTION

Cardiovascular complications occurring in patients infected by the human immunodeficient virus (HIV) have considerably changed since the appearance, in April 1996, of highly active antiretroviral tri-therapy (HAART), associating reverse transcriptase and protease HIV-1 inhibitors. The spectacular efficacy of anti-proteases has led to the almost complete disappearance of these opportunistic complications. However, in May 1998, acute coronary accidents were reported in the literature, thus questioning the possible responsibility of antiprotease treatment in the occurrence of accelerated atheroma.

METHOD

We report a series of 8 seropositive patients in whom an acute coronary event had occurred between February 1997 and February 1999.

RESULTS

The patients were young and all exhibited cardiovascular risk factors (smoking, dyslipidemia) and were treated with HIV-1 protease inhibitors. Six patients presented myocardial infarction, one patient unstable angina and one patient effort angina.

COMMENTS

A rise in triglycerides was observed principally on ingestion of ritonavir and a rise in cholesterol and LDL-cholesterol with all the antiprotease agents. Glucose intolerance was observed with indinavir. The occurrence of acute coronary events appeared to be related to antiprotease treatment (at the origin of metabolic disorders, endothelial dysfunction...), although it was impossible to say whether the antiprotease agents were responsible for the early atheroma or whether they simply contributed to the event. The coronary lesions were characterized by their number (single artery) and their topography (proximal or median). Nelfinavir may carry less cardiovascular risks than the other antiproteases. Mean term prognosis was relatively good, after therapeutic adjustment (change in antiprotease, strategic measures against cardiovascular risk factors, introduction of anti-anginal treatment...).

CONCLUSION

Larger and longer studies would help to specify the role of antiproteases in the occurrence of early coronary events. Rigorous monitoring (lipid and glucose measurements, tests to search for myocardial infarction,..) together with the development of new antiretroviral molecules would reduce the number of coronary events in this type of patient.

[Cardiac side effects of anti-HIV agents]

Both nature and prognosis of cardiac complications occurring in patients infected by the Human Immunodeficiency Virus-1 (HIV-1) have changed considerably since the introduction of highly acive and anti-retroviral triple therapy ("HART"). Opportunist cardiac infections have thus been displaced and side effects of drugs now occupy the primary aetiological role. Torsades de pointe may be exceptionally triggered by anti-infectious agents such as pentacarinat or trimethoprime-sulfamethoxazole, as are those induced by the association of ketoconazole and terfenadine or cisapride, the dangers of which are well known and the prevention more effective, especially with the association with HIV antiproteases which inhibit the cytochrome P450. The diagnosis of iatrogenic myocardial dysfunction is more difficult, except when it occurs acutely as with phosphonoformate (Foscarnet), or interleukine-2. Progressive cardiomyopathy caused by -interferon and dideoxynucleosides (zidovudine, didanosine and zalcitabine), reversible on withdrawal of the drug responsible in half the cases, should be distinguished from those due to the HIV itself (therapeutic relay) or to another associated cause (alcohol, coronary artery disease). The coronary complications of diseases treated by antiproteases usually occur in smokers whose cholesterol and triglyceride levels are rapidly increased with HAART. In a series of 9 patients (amongst 700 treated with the antiproteases), after the acute phase of myocardial infarction during which the interventional approach is often preferred, the medium-term prognosis is relatively good, on condition that the patients correct the hyperlipidaemia and give up smoking.