Suppressive antibiotic therapy for infectious endocarditis

OBJECTIVES

Suppressive antibiotic therapy (SAT) is a long-term antibiotic strategy at times applied when an indicated surgical management of infective endocarditis (IE) is not possible. Our aim was to describe the characteristics and outcomes of patients having received SAT for IE.

METHODS

We conducted a retrospective, observational study at Strasbourg University Hospital, France between January 2020 and May 2023. We reviewed all medical files taken into consideration at weekly meetings of the local Multidisciplinary Endocarditis Team (MET) during the study period. We included patients having received SAT following the MET evaluation. The primary endpoint was all-cause mortality at most recent follow-up. Secondary endpoints included all-cause mortality at 3 and 6 months, infection relapse, and tolerance issues attributed to SAT.

RESULTS

The MET considered 251 patients during the study time, among whom 22 (9 %) had received SAT. Mean age was 77.2 ± 12.3 years. Patients were highly comorbid with a mean Charlson index score of 6.6 ± 2.5. Main indication for SAT was surgery indicated but not performed or an infected device not removed (20/22). Fourteen patients had prosthetic valve IE, including 9 TAVIs. Six patients had IE affecting cardiac implantable electronic devices. Staphylococcus aureus and enterococci were the main bacteria involved (6/22 each). Median follow-up time was 249 days (IQR 95-457 days). Mortality at most recent follow-up was 23 % (5/22). Three patients (14 %) presented tolerance issues attributed to SAT, and two patients suffered late infectious relapse.

CONCLUSION

Mortality at most recent follow-up was low and tolerance issues were rare for patients under SAT, which might be a palliative approach to consider when optimal surgery or device removal is not possible.

Incidence and Time-to-Onset of Carbapenemase-Producing Enterobacterales (CPE) Infections in CPE Carriers: a Retrospective Cohort Study

This study aimed to assess the proportion of carbapenemase-producing Enterobacterales (CPE) infections among all infectious episodes in CPE carriers, compare the time-to-onset of CPE infections with that of other infections, assess the mortality of patients with CPE infections, and identify risk factors for CPE infections in CPE carriers. A retrospective cohort study was performed over a 10-year period in our University Hospital, and 274 CPE carriers were identified. All infectious episodes within the first 6 months following the diagnosis of CPE rectal carriage were considered. Risk factor analysis for CPE infections in CPE carriers was performed by univariate and multivariate analyses. This study revealed an incidence of 24.1% (66/274) of CPE infection within 6 months of CPE carriage diagnosis. The 28-day all-cause mortality due to CPE infections was 25.7%. CPE infections represented 52.6% (70/133) of all infectious episodes in CPE carriers in the first 6 months following CPE carriage detection, and these significantly occurred earlier than non-CPE infections, with a median time of 15 versus 51 days, respectively (P < 0.01). Based on the multivariate analysis, prior neurological disease was the only risk factor associated with CPE infections in CPE carriers. CPE infections have an early onset, accounting for a large proportion of infections in CPE carriers, and are associated with high mortality. IMPORTANCE Carbapenemase-producing Enterobacterales (CPE) infections are emerging infections and may represent a therapeutic challenge, while effective antibiotic therapy is likely to be delayed. We aimed to assess the proportion of CPE infections in CPE carriers and to identify risk factors of CPE infections among this population that could guide empirical antibiotic therapy. We showed that CPE infections are frequent in CPE carriers, have an early onset after CPE carriage diagnosis, and represent a significant proportion of all infectious episodes in CPE carriers. No significant risk factors for CPE infections could be identified. Overall, this study suggests that empirical antibiotic treatment covering CPE might be initiated in CPE carriers at least in the first month after its diagnosis and in severe infections due to the high frequency and early occurrence of CPE infections in these patients.

Coordination régionale et suivi prospectif du traitement prophylactique et curatif de 301 patients traités par anticorps monoclonaux anti-SARS-CoV-2

Introduction

La pandémie a particulièrement mis en danger nos patients immunodéprimés et questionne notre place dans l’organisation de l’administration des anticorps monoclonaux à titre préventif et curatif. L’objectif de l’étude a été d’évaluer l’activité d’une cellule régionale mise en place pour évaluer l’indication, organiser le traitement prophylactique ou curatif par anticorps monoclonaux ou par antiviraux, quelle que soit la pathologie chronique des patients concernés.

Matériels et méthodes

La cellule « anticorps monoclonaux et traitements du COVID », composée d’un médecin coordonnateur, de médecins retraités, et d’une secrétaire médicale, a été mise en place début janvier 2022 grâce à un financement par l’ARS. Tous les médecins ont été informés par l’ARS et les URPS, des critères d’éligibilité aux anticorps monoclonaux et du rôle de la cellule dans l’évaluation de l’indication, l’aide apportée pour la demande d’accès précoce et la logistique (injections en hospitalisation de jour ou en hospitalisation à domicile (HAD)). Les structures d’HAD ont été spécifiquement formées aux formalités de prescription, à l’administration et au suivi de ces patients. Les patients ayant reçu un traitement prophylactique ont été recontactés par la cellule la semaine suivant l’injection, 3 mois et 6 mois suivant l’injection. Des questionnaires ont été adressés aux médecins généralistes pour évaluer leur perception concernant les anticorps monoclonaux et les antiviraux.

Résultats

Au total, 216 patients (dont 121 patients ayant des facteurs de risque cardiovasculaire) ont reçu un traitement prophylactique par anticorps monoclonaux (Evusheld), pour les indications suivantes : 110 patients transplantés d’organe, 95 patients traités par anti-CD20, 2 patients traités par chimiothérapie, 8 patients ayant d’autres facteurs d’immunodépression et 1 contre-indication au vaccin. Les sollicitations de la cellule dans cette indication émanaient quasi exclusivement de médecins spécialistes. Avec un suivi médian de 6 mois, aucun événement indésirable (EI) grave, y compris cardiovasculaire, n’est survenu. Des EI non graves ont été observés chez 50 patients (23 %). Trente patients (14 %) ont été infectés par le SARS-CoV-2, dont 2 ont été traités par anticorps monoclonaux à titre curatif et 2 par Paxlovid. Aucun patient n’a été hospitalisé pour COVID, aucun n’a développé de COVID sévère. Sur les 214 patients recontactés pour une ré-administration d’anticorps à visée prophylactique, 12 (5 %) l’ont refusée. Au total, 85 patients ont été traités par anticorps monoclonaux à visée curative dont 3 par Ronapreve, 68 par Xevudy, 14 par Evusheld, dont 53 (62,3 %) en HAD et 30 patients ont été traités par Paxlovid. Les sollicitations de la cellule dans cette indication émanaient le plus souvent de médecins généralistes. Aucun effet indésirable grave n’a été observé.

Conclusion

La coordination régionale pour l’aide au traitement par anticorps monoclonaux et antiviraux est utile pour faciliter la prescription de ces traitements. Le suivi prospectif confirme leur tolérance très satisfaisante. Cette coordination a également permis d’évaluer les difficultés rencontrées par les médecins généralistes, en partie liées au caractère innovant, aux difficultés logistiques ou aux contraintes administratives de ces traitements.

Factors associated with treatment failure after advice from infectious disease specialists

OBJECTIVE

Risk factors associated with treatment failure after the infectious disease specialist's (IDS) advice remain unknown. We aimed to identify these risk factors.

METHODS

We included patients hospitalized in our tertiary care center who consulted an infectious disease specialist between January 2013 and April 2015. Treatment failure was defined by a composite criterion: signs of sepsis beyond Day 3, ICU admission, or death. Treatment success was defined by the patient's sustained clinical improvement.

RESULTS

A total of 240 IDS recommendations were made. Diagnosis was changed for 64 patients (26.7%) and 50 patients experienced treatment failure after the IDS advice. In multivariate analysis, compliance with the IDS advice was associated with a higher rate of success (OR=0.09, 95%CI [0.01-0.67]). Variables associated with treatment failure in the multivariate analysis were Charlson comorbidity score at admission (OR=1.24, 95%CI [1.03-1.50]), a history of infection or colonization with multidrug-resistant bacteria (OR=8.27, 95%CI [1.37-49.80]), and deterioration of the patient's status three days after the IDS advice (OR=12.50, 95%CI [3.16-49.46]).

CONCLUSION

Reassessing IDS recommendations could be interesting for specific patients to further adapt and improve them.

[Neurosyphilis: A retrospective study of 13 cases at Strasbourg University Hospital]

OBJECTIVE

After a decade of constant decline, the number of syphilis cases has been steadily increasing since the 2000s, particularly in HIV infected patients. Neurosyphilis is a rare manifestation of this sexually transmitted disease for which we performed a retrospective study and analyzed clinical manifestations.

PATIENTS AND METHODS

We reviewed retrospectively all the neurosyphilis cases admitted to Strasbourg University Hospital between 2004 and 2014. We included and analyzed 13 patients admitted during this period who met the diagnostic criteria for neurosyphilis.

RESULTS

Nine of 13 patients had isolated visual manifestations; three (23.1%) experienced posterior uveitis, two (15.4%), panuveitis, and 4 (30.8%) had papillitis. Out of five patients (38.5%) who were HIV positive, three (60%) had a CD4 cell count above 400/mm³ at the time of diagnosis of neurosyphilis. All patients received parenteral penicillin G or cephalosporin, and 5/13 (38.5%) received systemic corticotherapy.

CONCLUSION

Ophthalmologists appear as key players in the identification, management and follow-up of neurosyphilis, since ocular findings are key diagnostic features in these patients.

VISLISI trial, a prospective clinical study allowing identification of a new metalloprotease and putative virulence factor from Staphylococcus lugdunensis

OBJECTIVE

Staphylococcus lugdunensis is a coagulase-negative staphylococcus that displays an unusually high virulence rate close to that of Staphylococcus aureus. It also shares phenotypic properties with S. aureus and several studies found putative virulence factors. The objective of the study was to describe the clinical manifestations of S. lugdunensis infections and investigate putative virulence factors.

METHOD

We conducted a prospective study from November 2013 to March 2016 at the University Hospital of Strasbourg. Putative virulence factors were investigated by clumping factor detection, screening for proteolytic activity, and sequence analysis using tandem nano-liquid chromatography-mass spectrometry.

RESULTS

In total, 347 positive samples for S. lugdunensis were collected, of which 129 (37.2%) were from confirmed cases of S. lugdunensis infection. Eighty-one of these 129 patients were included in the study. Bone and prosthetic joints (PJI) were the most frequent sites of infection (n=28; 34.6%) followed by skin and soft tissues (n=23; 28.4%). We identified and purified a novel protease secreted by 50 samples (61.7%), most frequently associated with samples from deep infections and PJI (pr 0.97 and pr 0.91, respectively). Protease peptide sequencing by nano-liquid chromatography-mass spectrometry revealed a novel protease bearing 62.42% identity with ShpI, a metalloprotease secreted by Staphylococcus hyicus.

CONCLUSION

This study confirms the pathogenicity of S. lugdunensis, particularly in bone and PJI. We also identified a novel metalloprotease called lugdulysin that may contribute to virulence.

Feedback on difficulties raised by the interpretation of serological tests for the diagnosis of Lyme disease

OBJECTIVES

We had for objectives: i) to evaluate the accuracy of serologic testing for Lyme borreliosis performed in a private medical laboratory (PML); ii) to evaluate the impact of these tests on the practices of infectious diseases specialists (IDS).

PATIENTS AND METHOD

This study was performed in two steps: i) retrospective study of patients followed in a university hospital infectious diseases outpatient clinic for suspected Lyme borreliosis, tested (ELISA and Western blot) by both the PML and the National Reference Center (NRC); ii) national survey on IDS practices concerning patients consulting for suspected Lyme borreliosis.

RESULTS

Between July 2008 and July 2011, 128 patients consulting for suspected Lyme borreliosis were tested by both laboratories. Serological tests came back positive in 91% of cases from the PML versus 8% of cases from the NRC. Lyme borreliosis was the IDS's final diagnosis for 3.6% of patients. The survey on practices revealed that: i) the modal duration of consultation for suspected Lyme borreliosis was 30-60 minutes; ii) for 33% of patients, serologic test results performed at the PML were the only reason to suspect Lyme borreliosis; iii) 60% of patients had no indication for antibiotics.

CONCLUSION

The serological test performed in the PML were positive most of the time, but were not confirmed by tests performed at the NRC. This discrepancy lead to multiple and prolonged consultations in infectious diseases clinics, and discordance in the indications for antibiotics.

[Epidemiology of the resistance of Mycobacterium tuberculosis to antituberculosis drugs at the main hospital in Dakar, Senegal. A 4-year retrospective study (2000-2003)]

A retrospective study was carried out from January 2000 to December 2003 to assess the resistance of Mycobacterium tuberculosis to antituberculosis drugs and the impact of this on the treatment result. Two hundred and two patients' files were studied (average age: 36 years; sex-ratio: 1.7). Pulmonary localisation (85.7%) or extrapulmonary localisation (14.3%). HIV status is negative (71.3%), positive (10.8%) or unknown (17.9%). The overall recovery rate is 60.7% (61.4% in HIV-; 46.1% in HIV+), the rate of treatment failure is 2.7% (1.1% in HIV-; 15.4% in HIV+), the death rate due to tuberculosis is 6.3% (2.3% in HIV-; 23.1% in HIV+), and the rate of patients who disappeared from the system is 30.3% (35.2% in HIV-; 14.2% in HIV+). Hepatotoxicity that occurred during treatment is observed in 14.3% of cases (recovery: 56.2%; failure: 6.2%; lost from the system: 18.8%). Eighty-four percent of patients never received antituberculosis treatment (group A) versus 15.8% of patients who had already received one or more antituberculosis drugs (group B). The rates of resistance to isoniazid are 6.4% (A) and 12.5% (B), to rifampicin 1.7% (A) and 12.5% (B), to ethambutol 0.5% (A) and 0% (B), to streptomycin 24.1% (A) and 46.8% (B). The percentage of multiresistant strains is 1% in patients not treated previously and 11% in those who had already received antituberculosis treatment. When the patients are carriers of a strain that is responsive to the treatment administered, the recovery rate is 64.2% versus 46.7% in patients whose strain is resistant to at least one of the treatments administered.

[Shoulder pain revealing tuberculosis of the humerus]

Tuberculous spondylitis is the most common form of musculoskeletal tuberculosis. However, extraspinal manifestations have been described with tuberculosis of the wrist, femur, foot or shoulder, as in the patient presented. Because of an often-indolent clinical presentation, the diagnosis is delayed and antituberculous treatment is not able to prevent serious bone destruction.

Risk factors for death among tuberculosis cases: analysis of European surveillance data

The proportion of tuberculosis (TB) patients in the European Union (EU) who die remains high (8% overall). The aim of the present study was to quantify the risk of dying associated with demographic and clinical factors. Case-based data on 39,566 TB patients notified by 15 EU countries during 2002-2004 were analysed using logistic regression. It was observed that advancing age and resistance to isoniazid and rifampicin were the strongest determinants of death, while male sex, European origin, pulmonary site of disease and previous anti-TB treatment were weaker predictors. Risk varied between reporting countries, presumably reflecting differences in patient profiles, reporting practices and programme effectiveness. In conclusion, earlier suspicion, diagnosis and treatment may reduce deaths, particularly among the elderly. Special attention is needed to avert the development and transmission of multidrug-resistant tuberculosis.

[Poster presentations]

Posters have become an essential tool for dissemination of study findings at medical meetings. By presenting a quick snapshot, posters can be an effective means of communicating the main findings of the research quickly and of stimulating rewarding exchanges with the people in attendance. Success depends on catching and holding the attention of passing attendees long enough to establish contact and share knowledge and experience. The purpose of this article is to provide a few guidelines and techniques for preparing and presenting effective and clear research posters at scientific meetings.

[Empiric antituberculous therapy in patients with unexplained exsudative pleural effusion. Is it valid in Senegal?]

AIM

Pleural biopsy and adenosine deaminase activity are not available at our center and the treatment begins without substantiation diagnosis in patients with tuberculous pleural effusion (PE).

METHODS

In order to evaluate the validity of an empiric antituberculous therapy in exsudative PE with high prevalence of lymphocytes, we conducted a retrospective study during 1 year. Patient was enrolled if no signs of tuberculous infection, pneumonia or cancer were present.

RESULTS

During 1 year, 38 patients were enrolled (23 males, mean age=36 years). PE was major (> 2/3 of the lung) in 14 cases, moderate (between 1/3 and 2/3) In 18 cases and minor (<1/3) in 6 cases. Tuberculous contagion was observed in 10 patients. Tuberculinic test was positive in all patients (12-24 mm). Clinical and radiological cure was obtained in 37 cases, except 1 patient who died from acute heart failure. No recurrence of PE was observed after 1 year follow-up.

CONCLUSION

In our endemic areas, empiric antituberculous treatment seems to be an effective strategy in patients with exsudative PE.

[Invasive Streptococcus agalactiae infections in non-pregnant adults]

OBJECTIVES

Streptococcus agalactiae (Group B streptococcus) is a major cause of invasive diseases in non-pregnant adults, particularly in the elderly and those with underlying conditions. We describe these conditions and clinical characteristics of patients followed in our teaching hospital.

METHODS

We retrospectively reviewed clinical records of 64 patients with S. agalactiae-related invasive infection, hospitalized between January 1997 and January 2006.

RESULTS

The mean age of patients was 59 (+/-17 years). The H:F sex ratio was 1.06. At least one underlying condition was found in 90.6%. Diabetes mellitus (43.7%), peripheral vascular disease (34.4%), myocardial ischemia (20.3%) and malignant neoplasms (20.3%) were among the most frequent conditions. The mean index of comorbidity (Charlson) was 2.5 (+/-2). Common clinical manifestations included infection of the urinary tract (32.8%), skin and soft-tissue (25%), and osteoarthritis (21.9%). Bacteremia occurred in 31.2% with no identified source in 2 patients. During the first month, 2 cases of endocarditis, 1 case of meningitis, and 4 deaths occurred.

CONCLUSION

We confirm the importance of underlying diseases in the emergence of S. agalactiae infections.

[Using PubMed subject headings to enhance reference searches]

The PubMed search engine is an essential tool to stay abreast of the latest medical literature on specific topics. While the basic search techniques are common knowledge, the ability to use medical subject headings properly is an essential in obtaining valuable references. The purpose of this article is to explain what medical subject headings are and how they can be used to improve the results of reference searches in PubMed.

Implication du traitement adjuvant par dexaméthasone dans la survenue d'une artérite septique cérébrale au cours d'une méningite à Streptococcus pneumoniae

Few adverse effects have been reported with adjunctive dexamethasone treatment in pneumococcal meningitis. Nevertheless, we report a case of cerebral vasculitis. A 49-year-old man was admitted for fever and altered mental status. Lumbar puncture revealed a high inflammatory response and Streptococcus pneumoniae was identified by culture. Antibacterial therapy and adjunctive dexamethasone treatment were initiated as recommended. The immediate outcome was favorable but due to the onset of focal cerebral abnormalities, a CT scan was performed on the ninth day showing cerebral vasculitis. The patient died on the thirteenth day despite antibacterial therapy and resuscitation. In our case, a secondary neurological worsening appeared when adjunctive dexamethasone treatment was stopped suggesting a rebound effect. Observation of similar cases may lead to modifying adjunctive dexamethasone treatment protocol in bacterial meningitis.

[An unusual mediastinal opacity]

A 36-year old immunocompetent male from Senegal with an uneventful history was admitted for exploration of a bullous collection in the posterior mediastinum. Multifocal tuberculosis was diagnosed. Computed tomography-guided drainage removed 600 cc of caseum. The diagnosis as rupture of intrathoracic Pott's abscess complicated by a probably esophageal fistula. The clinical course was rapidly favorable with later development of mediastinal fibrosis. This uncommon case illustrates the contribution of interventional radiology recently developed in the Principal Hospital in Dakar, Senegal.

[Clinical and laboratory features of typhoid fever in Senegal. A 70-case study]

Clinical and laboratory features, complications and treatment were retrospectively studied in 70 patients with bacteriologically documented typhoid fever, treated between January 1995 and June 2002 at Principal Hospital in Dakar, Senegal. Data analysis was done on a global basis as well as comparatively between the 37 children (under 15 years) and 33 adults. Mean age was 16.7 years (range, 1 to 52). The sex ratio was 1.4. Clinical manifestations included fever (97%), headache (50%), vomiting (71%), abdominal pain (54%), diarrhoea (49%), nnd splenomegaly (10%) without statistically significant difference between children and adults. Lyinphopenia was found in 51% of patients and anaemia in 78%. Coexisting illnesses Included malaria in 25.5% (mainly children) and hepatitis (transminases > 10N) in 24%. Complications included cholecystitis in 3 patients, gastrointestinal haemorrhage in 2, peritonitis in one, endocnrditis in one and osteomyelitis in one. Only one patient (HIV-positive) died. The incidence of antibiotic resistance was low, i.e., ainoxicilline: 2%, nalidixic acid: 1% and cotrimoxazole: 8.2%. No multidrug resistance was observed. This study shows that typhoid fever remains a major health problem in Dakar with slow resolution and potential complications. Amoxicililne and chloramphenicol can still be used for first-line treatment of typhoid fever. Little difference was found between children and adults.

[Exercise-induced dyspnea and hilar enlargement]

We report the case of a 46-year-old man with an uneventful history who was hospitalized for suspected pulmonary embolism. The chest x-ray did not reveal any parenchymatous anomaly but disclosed pseudo-tumoral enlargement of the pulmonary arteries. There was no right ventricular overload at cardiac echography and the pulmonary arterial pressure was normal. Helicoidal angioscan demonstrated aneurismal dilatation of the both pulmonary arteries, complicated by a thrombus on the right. Outcome was favorable with anticoagulation. After ruling out acquired aneurysm, the diagnosis retained was idiopathic aneurysm of the pulmonary arteries.

[Coagulation disorders and arterial thromboembolic events in non-small-cell lung cancer. A case report]

Certain coagulation disorders can occur in patients with cancer and thromboembolic complications are frequent. We report the case of a 53-Year-old patient with metastatic adenocarcinoma of the lung treated with chemotherapy who presented several cerebral arterial thromboembolic events leading to death a few weeks after the initial diagnosis of cancer. This case illustrates the important role of certain satellite disorders related to coagulation activation: non-bacterial thrombotic endocarditis, disseminated intravascular coagulation, anti-phospholipid antibody syndrome. The role of anticancer chemotherapy as a favoring factor for thromboembolic events is also emphasized in patients with non-small-cell lung cancer.

Gastric mucosal pH and blood flow during weaning from mechanical ventilation in patients with chronic obstructive pulmonary disease

To determine if gastric intramucosal pH changes during weaning from mechanical ventilation are related to gastric mucosal blood flow modifications, we studied 16 ventilator-supported patients with chronic obstructive pulmonary disease (COPD) who tolerated a 2-h trial of spontaneous breathing with pressure support ventilation and were successfully extubated and 11 patients with COPD who failed such a trial. Gastric mucosal perfusion was assessed using gastric intramucosal pH (pH(i)) by tonometry and laser-Doppler flowmetry. During the weaning attempt, the failure weaning group developed a rapid, shallow breathing pattern with acute respiratory acidosis. The pH(i) was lower and gastric intramucosal PCO(2) (PCO(2)im) was higher in the failure weaning group than in the successful weaning group (p < 0.05). No change in gastric intramucosal-arterial PCO(2) difference was observed and a linear correlation was found between arterial PCO(2) and PCO(2)im (r(2) = 0.70; p < 0.001). Cardiac index increased in the failure group (p < 0.05) and remained stable in the success group whereas gastric mucosal blood flow decreased in the failure group (H(120) (min): -22 +/- 11% from baseline; p < 0.05) and increased in the success group (H(120) (min): 85 +/- 27% from baseline; p < 0.05). We conclude that gastric intramucosal pH changes during a 2-h weaning trial are mainly due to arterial PCO(2) variations. Nevertheless, gastric mucosal blood flow changes do occur and differ according to the weaning success or failure.