Factors of loss to follow-up during tuberculosis treatment in a low-incidence region

OBJECTIVE

The proportion of successfully treated tuberculosis (TB) patients remains below the WHO target in France, because of a high proportion of loss to follow-up. We aimed to identify factors associated with loss to follow-up in northern France, a low-incidence area.

METHODS

Between 1997 and 2017, all consecutive patients diagnosed with TB at the Tourcoing Hospital, except those infected with multidrug-resistant or extensively drug-resistant strains, were included in a retrospective cohort study. A logistic regression analysis was performed to determine factors associated with loss to follow-up.

RESULTS

One hundred and ninety patients were included. Previous TB treatment was reported in 32 patients (17%), extrapulmonary TB in 107 (56%), and HIV infection in 44 (23%). The proportion of loss to follow-up was 15%. In multivariate analysis, the risk of loss to follow-up decreased in case of first TB treatment (OR 0.36; 95% CI: 0.14-0.92, P=0.03) and increased in non-HIV-infected patients (OR 7.67; 95% CI: 1.00-59.0, p=0.05). Support for compliance was more frequent in HIV-infected patients (23% vs. 7%, p=0.005).

CONCLUSION

The proportion of loss to follow-up was high. HIV infection was associated with a lower risk of loss to follow-up, likely to be due to more frequent support for compliance.

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.

Suppressive antibiotic therapy with oral tetracyclines for prosthetic joint infections: a retrospective study of 78 patients

PURPOSE

This study aimed at describing the use of oral cyclines (i.e., doxycycline and minocycline) as suppressive antibiotic therapy (SAT) in patients with periprosthetic joint infections (PJIs).

METHODS

Medical charts of all patients with surgical revisions for PJIs who were given cycline-based SAT because of a high failure of various origins were reviewed. Data regarding tolerability and effectiveness of cycline-based SAT were analysed.

RESULTS

Seventy-eight patients of mean age 64 ± 17 years received cycline-base SAT in the period from January 2006 to January 2014. PJIs involved the knee in 37 patients (47%), the hip in 35 (45%), the elbow in 4 (5%), and the shoulder in 2 (3%) and were qualified as early in 31 patients (39.7%). Staphylococcus spp. were the most common pathogens accounting for 72.1% of the total number of bacterial strains identified. All included patients had surgery which consisted in debridement and implant retention in 59 of them (75.6%). Doxycycline and minocycline were prescribed as SAT in 72 (92%) and 6 (8%) patients, respectively. Adverse events were reported in 14 patients (18%), leading to SAT discontinuation in 6 of them (8%). After a mean follow-up of 1020 ± 597 days, a total of 22 (28.2%) patients had failed including 3 cases (3.8%) with documented acquisition of tetracycline resistance in initial pathogen(s).

CONCLUSIONS

Our results suggest that oral cyclines used as SAT in patients treated for PJI have an acceptable tolerability and effectiveness and appear to be a reasonable option in this setting.

Suppressive antibiotic therapy with oral doxycycline for Staphylococcus aureus prosthetic joint infection: a retrospective study of 39 patients

The aim of this study was to describe the use of oral doxycycline as suppressive antibiotic therapy (SAT) in patients with Staphylococcus aureus periprosthetic (hip or knee) joint infections. The medical charts of all patients with surgical revisions for S. aureus hip or knee prosthetic joint infections (PJIs) who were given doxycycline-based SAT because of a high risk of failure of various origins were reviewed. Data regarding tolerability and effectiveness of doxycycline-based SAT were analysed. A total of 39 patients (mean age 66.1 ± 16.3 years) received doxycycline-base SAT in the period from January 2006 to January 2014. PJIs involved the hip in 23 patients (59.0%) and the knee in 16 (41.0%), and were qualified as early in 15 patients (38.5%). Methicillin-resistant S. aureus (MRSA) accounted for 22% of the total number of bacterial strains identified. All patients included in the study had surgery, which consisted of debridement and implant retention in 32 (82.1%). Adverse events likely attributable to SAT were reported in six patients (15.4%), leading to discontinuation of SAT in three (7.7%). A total of 29 patients (74.4%) remained event-free and 10 (25.6%) failed, including 8 (20.5%) relapses and 2 (5.1%) superinfections. Overall, 8 of the 10 failure cases were related to a doxycycline-susceptible pathogen. These results suggest that oral doxycycline used as SAT in patients treated for S. aureus hip or knee PJIs has an acceptable tolerability and effectiveness and appears to be a reasonable option in this setting.

Outcome of patients with streptococcal prosthetic joint infections with special reference to rifampicin combinations

BACKGROUND

Outcome of patients with streptococcal prosthetic joint infections (PJIs) is not well known.

METHODS

We performed a retrospective multicenter cohort study that involved patients with total hip/knee prosthetic joint (THP/TKP) infections due to Streptococcus spp. from 2001 through 2009.

RESULTS

Ninety-five streptococcal PJI episodes (50 THP and 45 TKP) in 87 patients of mean age 69.1 ± 13.7 years met the inclusion criteria. In all, 55 out of 95 cases (57.9 %) were treated with debridement and retention of the infected implants with antibiotic therapy (DAIR). Rifampicin-combinations, including with levofloxacin, were used in 52 (54.7 %) and 28 (29.5 %) cases, respectively. After a mean follow-up period of 895 days (IQR: 395-1649), the remission rate was 70.5 % (67/95). Patients with PJIs due to S. agalactiae failed in the same proportion as in the other patients (10/37 (27.1 %) versus 19/58 (32.7 %); p = .55). In the univariate analysis, antibiotic monotherapy, DAIR, antibiotic treatments other than rifampicin-combinations, and TKP were all associated with a worse outcome. The only independent variable significantly associated with the patients' outcomes was the location of the prosthesis (i.e., hip versus knee) (OR = 0.19; 95 % CI 0.04-0.93; p value 0.04).

CONCLUSIONS

The prognosis of streptococcal PJIs may not be as good as previously reported, especially for patients with an infected total knee arthroplasty. Rifampicin combinations, especially with levofloxacin, appear to be suitable antibiotic regimens for these patients.

Management and control of a carbapenem-resistant Acinetobacter baumannii outbreak in an intensive care unit

OBJECTIVE

We had for aim to describe the identification and management of a 14-clonal carbapenem-resistant Acinetobacter baumannii (CRAB) outbreak, following admission of a known CRAB-infected patient in an ICU.

METHODS

We reviewed the carriers' files and outbreak management procedures.

RESULTS

The index patient was admitted with strict isolation precautions. The outbreak started 2 months after his discharge. It persisted despite reinforcement of strict isolation precautions, staff and patient cohorting, and extensive environmental decontamination including 2 rounds of routine terminal cleaning and disinfection or 1 round of cleaning and disinfection followed by hydrogen peroxide treatment. A second epidemic peak, after 4 weeks without any case, led to another wide environmental sampling and decontamination rounds. The source of the CRAB outbreak was suspected to be the blood pressure cuffs Velcro. Switching to cuffs submersible in a disinfectant stopped the outbreak.

CONCLUSIONS

CRAB outbreaks are difficult to manage and sources of persistent colonization can be unexpected.