Risk factors and prognostic significance of infection of totally implantable vascular access port in solid tumor patients: A prospective cohort study

OBJECTIVES

Totally implantable venous access ports (TIVAP) are devices mainly used to deliver antineoplastic chemotherapies, of which the insertion may be complicated by TIVAP-related infection (TIVAP-RI). This study aims to provide data on the risk factors for TIVAP-RI and its influence on patient prognosis.

PATIENTS AND METHODS

Prospective observational study including adult patients with solid tumors, in whom a TIVAP was inserted to deliver antineoplastic chemotherapy between January 2018 and October 2019. Factors associated with TIVAP-RI and one-year mortality were determined using multiple logistic regressions.

RESULTS

More than a thousand (1014) patients were included, among whom 48 (4.7%) presented with TIVAP-RI. Gram-positive cocci and Gram-negative bacilli represented 51% and 41% of the pathogens isolated, respectively. Young age (odds ratio [OR] 0.67; 95% Confidence Interval [0.53-0.83] per 10-year increase), WHO performance status ≥ 1 (OR 3.24 [1.52-7.79]), chemotherapy administration in the month before TIVAP placement (OR 2.26 [1.17-4.26]), and radiation therapy of the homolateral chest wall (OR 3.28 [1.51-6.67]) were independently associated with TIVAP-RI occurrence. During the year following TIVAP insertion, 287 (28%) patients died. TIVAP-RI was not associated with one-year mortality (OR 1.56 [0.75-3.19]).

CONCLUSION

TIVAP insertion in adult patients with solid tumors is associated with a low infection rate, which did not influence one-year mortality. In addition to young age and impaired health status, TIVAP insertion in the month following initiation of the antineoplastic chemotherapy and TIVAP insertion in an irradiated area are two newly reported preventable TIVAP-RI risk factors.

Why are people still dying of drug-susceptible TB in Paris in the 21st century?

BACKGROUND: Although the burden of TB is lower in France than in low-income countries, patients continue to die from TB in Paris. Our goal was to describe TB-related deaths and to identify associated risk factors.METHODS: We conducted a retrospective cohort study in two hospitals in Paris between 2013 and 2018. All patients with drug-susceptible TB were included and followed until end of treatment. The primary outcome was death. We performed univariate and multivariate analysis using Cox proportional hazard model.RESULTS: Of the 523 patients included, 362 were men (median age 37 years), of whom 24 patients died (4.5%). The final survival model concluded that age (HR 1.1 for each additional year), not living in one´s own accommodation (HR 5.9), being born in France (HR 8.0), being alcoholic (HR 4.2), having a history of cancer (HR 7.1) or meningeal or miliary TB (HR 8.2) were associated with a higher risk of death.CONCLUSION: The rate of TB-associated death is unacceptably high for a curable disease. To note, patients born in France were much more at risk of death than immigrants. We believe raising awareness among healthcare professionals is a potentially easy and efficient lever for improving care.

A case of tuberculosis and black-grain eumycetoma co-infection in a non-endemic country: clinical presentation and therapeutic management

We report a case of black-grain eumycetoma co-localized with Mycobacterium tuberculosis infection, presenting as a painless leg abscess and associated with vertebral tuberculosis. The rare association of these two pathogens raises several challenges regarding foreseeable drug interactions, side effects, the most appropriate management, and the potential link between these two diseases.

Pyogenic lung abscess in an infectious disease unit: a 20-year retrospective study

Background:

Pyogenic lung abscesses are rare and poorly described infections. This study aimed to describe their prognostic factors.

Methods:

We retrospectively included all patients hospitalized between 1 January 1998 and 1 June 2018, with an International Classification of Diseases, version 10 (IDC-10) diagnosis of pyogenic lung abscess, from the Diamm based medical records (Micro6, Nancy, France). Parasitic, fungal, or mycobacterial lung abscesses were excluded.

Results:

A total of 64 patients were included. Abscesses were associated with immunosuppression in 28 patients, including HIV infection and immunosuppressive therapy for eight and 12 patients, respectively. Bacterial identification was obtained for 36 patients. Nine patients (14%) developed lung abscesses after hematogenous dissemination. They differed from bronchogenic abscesses by their younger age (p = 0.03), the absence of smoking or emphysema (p = 0.05), Staphylococcus aureus (p = 0.001) or Streptococcus spp. (p = 0.05) isolation, and the smaller size of their abscess (p = 0.02). Overall, evolution was marked by radiological sequelae (46.9%), relapse (12.5%), and death (4.8%). Radiological sequelae occurred more frequently during the course of bronchogenic abscesses (p = 0.02), particularly when they spontaneously discharged (p = 0.04). Relapses were more frequent in patients with emphysema (p = 0.04) and when Haemophilus influenzae was isolated (p = 0.04). In multivariate analysis, poor outcomes, including death, sequelae, and relapse occurred more frequently in patients who had bronchogenic abscess (p = 0.02), and in those who received antibiotics during less than 6 weeks (p = 0.05).

Conclusion:

A duration of antibiotic treatment of less than 6 weeks and bronchogenic presentation were globally associated with poor outcome of pyogenic lung abscesses. These data should be considered when proposing guidelines for the care of pyogenic lung abscesses.

The reviews of this paper are available via the supplemental material section.

Daily multidisciplinary COVID-19 meeting: Experiences from a French university hospital

Objectives

In March 2020, the World Health Organization declared the coronavirus disease 2019 (COVID-19) a pandemic. In absence of official recommendations, implementing daily multidisciplinary team (MDT) COVID-19 meetings was urgently needed. Our aim was to describe our initial institutional standard operating procedures for implementing these meetings, and their impact on daily practice.

Methods

All consecutive patients who were hospitalized in our institution due to COVID 19, from March 31 to April 15, 2020, were included. Criteria to be presented at MDT meetings were defined as a proven COVID-19 by PCR or strongly suspected on CT scan, requiring hospitalization and treatment not included in the standard of care. Three investigators identified the patients who met the predefined criteria and compared the treatment and outcomes of patients with predefined criteria that were presented during MDT meeting with those not presented during MDT meeting. COVID-19 MDT meeting implementation and adhesion were also assessed by a hospital medical staff survey.

Results

In all, 318 patients with confirmed or suspected COVID-19 were examined in our hospital. Of these, 230 (87%) were hospitalized in a COVID-19 unit, 91 (40%) of whom met predefined MDT meeting criteria. Fifty (55%) patients were presented at a MDT meeting versus 41 (45%) were not. Complementary exploration and inclusion in the CorImmuno cohort were higher in MDT meeting group (respectively 35 vs. 15%, P = 0.03 and 80 versus 49%, P = 0.0007). Prescription of hydrocortisone hemisuccinate was higher in group of patients not presented during MDT meeting (24 vs. 51%, P = 0.007). Almost half of the patients fulfilling the inclusion criteria were not presented at MDT meeting, which can be partly explained by technical software issues.

Conclusions

Multidisciplinary COVID-19 meetings helped implementing a single standard of care, avoided using treatments that were untested or currently being tested, and facilitated the inclusion of patients in prospective cohorts and therapeutic trials.

Derivation and Validation of a Predictive Score for Disease Worsening in Patients with COVID-19

The prospective observational cohort study COMPASS-COVID-19 aimed to develop a risk assessment model for early identification of hospitalized COVID-19 patients at risk for worsening disease. Patients with confirmed COVID-19 ( n  = 430) hospitalized between March 18 and April 21, 2020 were divided in derivation ( n  = 310) and validation ( n  = 120) cohorts. Two groups became evident: (1) good prognosis group (G-group) with patients hospitalized at the conventional COVID-19 ward and (2) Worsening disease group (W-group) with patients admitted to the intensive care unit (ICU) from the emergency departments. The study end point was disease worsening (acute respiratory failure, shock, myocardial dysfunction, bacterial or viral coinfections, and acute kidney injury) requiring ICU admission. All patients were routinely evaluated for full blood count, prothrombin time, fibrinogen, D-dimers, antithrombin (AT), and protein C activity. Data from the first hospitalization day at the conventional ward or the ICU were analyzed. Cardiovascular risk factors and comorbidities were routinely registered. Obesity, hypertension, diabetes and male gender, increased fibrinogen and D-dimers, thrombocytopenia, AT deficiency, lymphopenia, and an International Society on Thrombosis and Haemostasis (ISTH) score for compensated disseminated intravascular coagulation score (cDIC-ISTH) ≥ 5 were significant risk factors for worsening disease. The COMPASS-COVID-19 score was derived from multivariate analyses and includes obesity, gender, hemoglobin, lymphocyte, and the cDIC-ISTH score (including platelet count, prothrombin time, D-dimers, AT, and protein C levels). The score has a very good discriminating capacity to stratify patients at high and low risk for worsening disease, with an area under the receiver operating characteristic curve value of 0.77, a sensitivity of 81%, and a specificity of 60%. Application of the COMPASS-COVID-19 score at the validation cohort showed 96% sensitivity. The COMPASS-COVID-19 score is an accurate clinical decision-making tool for an easy identification of COVID-19 patients being at high risk for disease worsening.

[Term Prelabor Rupture of Membranes: CNGOF Guidelines for Clinical Practice - Short Text]

OBJECTIVE

To determine the management of patients with term prelabor rupture of membranes.

METHODS

Synthesis of the literature from the PubMed and Cochrane databases and the recommendations of French and foreign societies and colleges.

RESULTS

Term prelabor rupture of membranes is considered a physiological process up to 12hours of rupture (Professional consensus). In case of expectant management and with a low rate of antibiotic prophylaxis, home care compared to hospitalization could be associated with an increase in neonatal infections (LE3), especially in case of group B streptococcus colonization (LE3). Home care is therefore not recommended (Grade C). In the absence of spontaneous labor within 12hours of rupture, antibiotic prophylaxis could reduce the risk of maternal intrauterine infection but not of neonatal infection (LE3). Its use after 12hours of rupture in term prelabor rupture of the membranes is therefore recommended (Grade C). When antibiotic prophylaxis is indicated, intravenous beta-lactams are recommended (Grade C). Induction of labor with oxytocin (LE1), prostaglandin E2 (LE1) or misoprostol (LE1), is associated with shorter rupture of membranes to delivery intervals when compared to expectant management. Compared with expectant management, immediate induction of labor is not associated with lower rates of neonatal infection (LE1), even among women with a positive streptococcus B vaginal swab (LE2). Thus, expectant management can be offered without increasing the risk of neonatal infection (Grade B). Induction of labor is not associated with an increase or decrease in the cesarean delivery rate (LE2), whatever parity (LE2) or Bishop score at admission (LE3). Induction can thus be proposed without increasing the risk of cesarean delivery (Grade B). No induction method (oxytocin, dinoprostone, misoprostol or Foley® catheter) has demonstrated superiority over another, whether to reduce rate of intrauterine or neonatal infection, rate of cesarean delivery or to shorten rupture of membranes to delivery intervals regardless of Bishop's score and parity.

CONCLUSION

Term prelabor rupture of membranes is a frequent event. A 12-hour delay without onset of spontaneous labor was chosen to differentiate a physiological condition from a potentially unsafe situation justifying an antibiotic prophylaxis. Expectant management or induction of labor can both be proposed, even in case of positive screening for streptococcus B, depending on the patient's wishes and maternity units' organization (Professional consensus).

[Malaria among immigrants, experience of a Parisian hospital (2006-2010)]

In recent days immigrants represent the main risk group for imported malaria in northern countries. Most of them are migrants returning to their country of origin to visit friends and relatives (VFR). We retrospectively examined the main clinical, biological, and therapeutic data of all malaria cases in immigrants from 2006 to 2010 in Tenon hospital, Paris. The hospital is situated in a Paris district with an important African community. During the study period 239 imported malaria cases were observed in adults of which 199 were immigrants, 186 VFR, and 13 recently arrived. Most cases were from sub-Saharan Africa and Comoro islands. Chimioprophylaxis was not taken in 81.2% of VFR. It was inadequate in 43.7% and not taken correctly in 84.4%. Plasmodium falciparum was the most frequent species identified: 190/199 (95.5%). Severe P. falciparum malaria was observed in 25 cases (13.2%); two of them were recently arrived. One patient, African VFR, died. In this series two high-risk groups were represented: HIV-infected patients and pregnant women. Six of the HIV patients had severe malaria and all pregnant women had anemia. Our results are similar to those observed recently in other European countries. Mean age of VFR is increasing and the risk for severe P. falciparum malaria became identical to the one observed in non-immune travelers. Protection measures remain still insufficient in this population of travelers.

Outbreak of CTX-M-15-producing Klebsiella pneumoniae in the intensive care unit of a French hospital

The CTX-M-15 extended spectrum beta-lactamase (ESBL)-producing Klebsiella pneumoniae isolates were identified in 36 patients hospitalized from December 2006 to September 2007 in the medical intensive care unit (ICU) of the Bicêtre hospital, South Paris, France. The incidence of colonization and/or infection was 4.8%. Eighty-nine percent of the ESBL-producing K. pneumoniae isolates were acquired in the ICU, and only 8.3% of the patients were infected. Pulsed field gel electrophoresis (PFGE) analysis of the isolates showed that 32 isolates were clonally related and contained a 160-kb plasmid carrying the bla(CTX-M-15), bla(OXA-1), bla(TEM-1), and aac6'-Ib-cr genes. CTX-M-15-producing Escherichia coli isolates collected in the ward during the same period of time contained distinct plasmids and were not clonally related. This study highlights the possible occurrence of outbreaks due to CTX-M-producing K. pneumoniae within hospital settings, whereas CTX-Ms are mostly reported in E. coli in community-acquired infections.

[Acute pancreatitis induced by major hypertriglyceridemia during pregnancy. A case report]

A parturient in the 37th week of gestation is referred to the obstetrical emergency ward for an acute abdominal pain with vomiting and fever. Few hours after her admission, a caesarean section is performed for acute fetal distress. It gave birth to a 3940 g healthy newborn. An abundant and milky peritoneal fluid is noted during the C-section related to a major hypertriglyceridemia (84,47 g/L) which induced an acute pancreatitis explaining the early symptoms. The patient is then hospitalized in surgical reanimation: heparin and a low fat diet led to a quick decrease of triglyceridemia and the healing of the acute pancreatitis. We review the most recent literature about acute pancreatitis during pregnancy, especially induced by hypertriglyceridemia, and the different management option: heparin, parenteral nutrition or plasmapheresis.

Risk factors for Staphylococcus aureus infection in liver transplant recipients

Staphylococcus aureus is the leading cause of bacterial infection in liver transplant recipients. Preoperative nasal carriage of methicillin-resistant S. aureus (MRSA) is associated with a high risk of infection. We conducted a retrospective cohort study in order to identify independent risk factors for early-onset S. aureus infection after liver transplantation. Patients were screened preoperatively for methicillin-susceptible S. aureus (MSSA) and MRSA nasal carriage. Risk factor analysis was performed by univariate analysis followed by stepwise logistic regression. Of the 323 patients included, 63 (19.5%) patients developed S. aureus infection (36 MRSA, 27 MSSA) within 1 month of surgery. Variables significantly associated with infection in the univariate analysis were MRSA and MSSA nasal carriage, alcoholic cirrhosis, absence of hepatocellular carcinoma, decreased prothrombin ratio, and presence of ascites. In the multivariate analysis, MRSA carriage (odds ratio [OR]: 20.9, P < 0.0001), MSSA carriage (OR: 3.4, P = 0.0004), alcoholic cirrhosis (OR: 2.4, P = 0.01) and decreased prothrombin ratio (OR: 1.2, P = 0.01) were independent predictors of infection. Molecular typing showed that the infecting isolate was identical to the isolate from the nose in most patients. In conclusion, preoperative nasal carriage of MRSA and MSSA is an independent risk factor for S. aureus infection in liver transplant recipients. The infection is most often of endogenous origin. Alcoholic cirrhosis and the severity of liver failure are also associated with a high risk of infection.

[Antenatal metastatic neuroblastoma: prognostic criteria. A case report]

Neuroblastoma, the most common malignant tumor in the neonatal period is metastatic in 25 to 50% of cases. While the prognosis of antenatal neuroblastoma is often considered as favorable, included in the most common metastatic stage (Stage IV S), it can lead to fetal or neonatal death. We report a case of a fetus with a stage IV neuroblastoma who died in utero. The most important prognostic factor is tumor stage, making sonographic detection of metastasis essential. Nevertheless, accurate staging remains difficult by sonography. When metastatic neuroblastoma is suspected, sonographic survey has to be reinforced, and if serious criteria such as massive hepatomegaly, placentomegally or hydrops appear, delivery must be considered.

[Markers of infection and inflammation in the amniotic fluid: therapeutic contribution of amniocentesis]

A part of preterm labor with intact membranes seems to be related to amniotic infection or local inflammatory process. In these cases, amniotic fluid is collected by amniocentesis for bacteriological studies: amniotic cultures are positive in 10% and polymerase chain reaction (PCR) in 40-50%. Interleukin 6 (IL6) concentrations are elevated in cases with amniotic infection and in some cases with negative cultures. IL6 amniotic concentrations are predictive of premature delivery and neonatal morbidity. Matrix metalloproteinases (MMP) are endogenous enzymes implicated in membrane weakening. Amniotic concentrations of these enzymes seem to be predictive of premature delivery and neonatal prognosis. Furthermore, at the time of genetic amniocentesis, IL6 and MMP concentrations are markers for preterm delivery. In the second half of gestation, amniocentesis is a safe procedure complicated in less than 1% of cases, although specific evaluation in cases of premature labor is missing. Nevertheless, as long as there is no evidence of any benefit in this procedure, there is no indication for amniocentesis in premature labor with intact membranes in general practice.

[Intravenous beta-2-adrenergic agonists for tocolytic therapy in pre-eclampsia: two cases of acute pulmonary edema]

Two cases of pulmonary oedema during beta 2-adrenergic agonist therapy in pre-eclampsia pregnant patients are reported. In our first case, the pulmonary oedema was exceptionally severe, because the patient (twins at 26 SA) had to be intubated and ventilated, but the caesarean section was performed only 6 weeks later. These two clinical observations underline the fact that B2 adrenergic agonist are not indicated for the treatment of preeclampsy. Furthermore they suggest that such patients should be rapidly admitted to intensive care units.

Patent ductus arteriosus and cystic periventricular leucomalacia in preterm infants

AIM

To test the association between early disturbances in hemodynamics induced by left-to-right shunting through the duct and cystic periventricular leucomalacia.

PATIENTS

Forty-six preterm infants (27-32 wk) admitted to the neonatal intensive care unit with risk criteria.

METHODS

Patent ductus arteriosus was evaluated on days 1 and 4, and was significant (sPDA) in cases of absent or reversed end diastolic flow in the subductal aorta. Resistance index was measured in the anterior cerebral artery and in the subductal aorta.

MAIN OUTCOME

Diagnosis of cystic periventricular leucomalacia between day 10 and day 50.

RESULTS

The 12 infants who developed cystic periventricular leucomalacia were compared with those who did not. On day 1, sPDA was more frequent (64% vs 26%; p = 0.03) in the cystic periventricular leucomalacia group, left ventricular output was higher (median = 341 vs 279 ml kg-1.min-1; p = 0.005), and rescue surfactant was more frequently used (83% vs 47%; p = 0.03). This latter association was confirmed by multivariate analysis. Resistance index in the anterior cerebral artery was increased in cases of significant patent ductus arteriosus (p < 0.01) and was correlated with resistance index in the subductal aorta.

CONCLUSION

On day 1 in this selected population, sPDA has an effect on blood flow velocity waveform in cerebral arteries and is associated with an increase in the emergence of cystic periventricular leucomalacia. This association could be casual rather than causal.

[Management of premature rupture of the membranes at term: how long to delay? Results of a prospective multicentric study in 713 cases]

OBJECTIVE

The aim of our study was to define he best delay for management of spontaneous rupture of the membranes at term.

MATERIALS AND METHODS

We conducted a prospective multicentric study in western France defining 3 groups of expectancy (6, 12 and 24 hours) to assess obstetrical, neonatal and maternal outcomes.

RESULTS

We included 713 patients. There was no significant difference in neonatal and maternal morbidity between the 3 groups. The rate of cesarean section was statistically higher in the 6-hour group (12%). There was no statistical difference between 12 and 24 hours but the rate was lower in the 12-hour group (5.5 versus 7.9%).

CONCLUSION

Based on our findings and a review of the literature, we have decided that in cased of premature rupture of the membranes at term, a 12 hour delay is best. At most two prostaglandin maturations can be performed in unfavorable cervixes.

[Percutaneous umbilical blood sampling in pregnant women with thrombocytopenia. Apropos of 35 cases]

OBJECTIVE

To determine the interest of percutaneous umbilical blood sampling in maternal thrombocytopenia.

PATIENTS AND METHOD

We performed a retrospective study of 36 percutaneous umbilical samples in pregnant women with thrombocytopenia. We included patients with a platelet count less than 100,000/mm(3) or a previous diagnosis of idiopathic thrombocytopenic purpura. Patients were divided into two groups. Group A consisted of women whose thrombocytopenia was caused by idiopathic thrombocytopenic purpura. The other patients were included in the group B. Percutaneous umbilical blood samples were performed by direct ultrasound guidance under sterile conditions, after 37 weeks gestation. Cesarean section was indicated if the fetal platelet count was < or =50 000/mm(3), in other cases obstetric indications were followed.

RESULTS

Percutaneous umbilical blood samples were performed at a mean age of 38.5 gestational weeks. Fetal blood sampling was successful in 34 of the 36 cases. There was no fetal complication. In group A, two fetuses had low cord-blood platelet counts (20,000 and 98,000 per cubic millimeter). There was no fetal thrombopenia in group B. Three cesarean sections were performed, in one case because of severe fetal thrombocytopenia and in 2 cases because of an unsuccessful percutaneous umbilical blood sampling (in both, neonatal platelet count was normal). There was no significant complication in infants. There was a significant correlation between fetal and neonatal platelet count.

CONCLUSION

There is no maternal predictive factor for fetal thrombocytopenia. Percutaneous umbilical blood sampling is feasible and has a good diagnostic value. The overall risk of fetal loss is low. But there is no indication of percutaneous umbilical blood sampling in the management of thrombocytopenia in pregnancy because severity of thrombopenia is not directly related to the severity of maternal disease and there are no series large enough to assess the association between delivery method and intracranial hemorrhage in thrombocytopenic infants born of mothers with idiopathic thrombocytopenic purpura. More subjectively than on scientific arguments a percutaneous umbilical blood sampling could be performed for patients with idiopathic thrombocytopenia purpura and a past history of neonatal intracranial hemorrhage. A cesarean section could be done if the platelet count is less than 100 000/mm(3), no intracranial hemorrhage has been described above this level.