One-stage revision for infected shoulder arthroplasty: prospective, observational study of 37 patients

Background

Periprosthetic joint infection is a severe complication of joint replacement surgery. Thus two-stage exchange remains the gold standard, one-stage exchange is now widely recommended. We hypothesized that, for patients with chronic periprosthetic shoulder infection (PSI), treatment with a one-stage exchange would be an effective approach to eradicate infection, relieve pain, and restore function to the involved shoulder.

Materials and methods

This monocenter cohort study in a Bone and Joint Infection Referral Center (11/2003-05/2020) included all patients with confirmed PSI treated by one-stage revision. Data were extracted from the prospective database, including demographics, infection characteristics, and functional evaluations (range of motion and Constant Score at admission and last follow-up). The primary outcome was the 2-year reinfection-free rate.

Results

We included 37 patients. The refection-free rate was 5%. The most commonly isolated pathogen was Cutibacterium acnes (68%), isolated alone (15 patients, 41%) or as polymicrobial infections (10 patients, 27%). The Constant Score increased significantly from 24 to 53 (P = .001). Range of motion (forward elevation, abduction) was also significantly improved after surgery. Mean active forward elevation increased significantly by 45° from 60° to 105° postoperatively (P < .001), mean abduction increased by 42° from 55° to 97° (P < .001).

Discussion

Results from our prospective cohort-extracted series suggest that one-stage revision is a reliable treatment with a low infection recurrence rate. Improved functional outcomes can be achieved with one-stage exchange. Our patients' overall functional results were similar to those previously reported for one-stage revision and better than those reported after two-stage exchange. Patients with multiple previous surgeries seem to have worse functional outcomes than the subgroup without surgery before the index arthroplasty.

Conclusions

Our results and literature search findings suggest that one-stage revisions effectively eradicate PSIs, with good functional outcomes.

Antimicrobial for 7 or 14 Days for Febrile Urinary Tract Infection in Men: A Multicenter Noninferiority Double-Blind, Placebo-Controlled, Randomized Clinical Trial

BACKGROUND

The optimal duration of antimicrobial therapy for urinary tract infections (UTIs) in men remains controversial.

METHODS

To compare 7 days to 14 days of total antibiotic treatment for febrile UTIs in men, this multicenter randomized, double-blind. placebo-controlled noninferiority trial enrolled 282 men from 27 centers in France. Men were eligible if they had a febrile UTI and urine culture showing a single uropathogen. Participants were treated with ofloxacin or a third-generation cephalosporin at day 1, then randomized at day 3-4 to either continue ofloxacin for 14 days total treatment, or for 7 days followed by placebo until day 14. The primary endpoint was treatment success, defined as a negative urine culture and the absence of fever and of subsequent antibiotic treatment between the end of treatment and 6 weeks after day 1. Secondary endpoints included recurrent UTI within weeks 6 and 12 after day 1, rectal carriage of antimicrobial-resistant Enterobacterales, and drug-related events.

RESULTS

Two hundred forty participants were randomly assigned to receive antibiotic therapy for 7 days (115 participants) or 14 days (125 participants). In the intention-to-treat analysis, treatment success occurred in 64 participants (55.7%) in the 7-day group and in 97 participants (77.6%) in the 14-day group (risk difference, -21.9 [95% confidence interval, -33.3 to -10.1]), demonstrating inferiority. Adverse events during antibiotic therapy were reported in 4 participants in the 7-day arm and 7 in the 14-day arm. Rectal carriage of resistant Enterobacterales did not differ between both groups.

CONCLUSIONS

A treatment with ofloxacin for 7 days was inferior to 14 days for febrile UTI in men and should therefore not be recommended.

CLINICAL TRIALS REGISTRATION

NCT02424461; Eudra-CT: 2013-001647-32.

[Management of bone and joint infections: update]

This article highlights four recent updates in infectious disease in the management of bone and joint infections (BJI). During the first six weeks of treatment of a BJI, with or without orthopedic implant, oral antimicrobial therapy is as effective as intravenous therapy. For periprosthetic joint infections, a randomized control study failed to demonstrate non-inferiority of 6 versus 12 weeks of antibiotic therapy. In diabetic foot osteomyelitis, a 3-week course of antibiotics appears to be non-inferior to a 6-week course. Phage therapy seems promising in adjunctive therapy of complex BJI.

SPILF update on bacterial arthritis in adults and children

In 2020 the French Society of Rhumatology (SFR) published an update of the 1990 recommendations for management of bacterial arthritis in adults. While we (French ID Society, SPILF) totally endorse this update, we wished to provide further information about specific antibiotic treatments. The present update focuses on antibiotics with good distribution in bone and joint. It is important to monitor their dosage, which should be maximized according to PK/PD parameters. Dosages proposed in this update are high, with the optimized mode of administration for intravenous betalactams (continuous or intermittent infusion). We give tools for the best dosage adaptation to conditions such as obesity or renal insufficiency. In case of enterobacter infection, with an antibiogram result "susceptible for high dosage", we recommend the requesting of specialized advice from an ID physician. More often than not, it is possible to prescribe antibiotics via the oral route as soon as blood cultures are sterile and clinical have symptoms shown improvement. Duration of antibiotic treatment is 6 weeks for Staphylococcus aureus, and 4 weeks for the other bacteria (except for Neisseria: 7 days).

Cutibacterium acnes Prosthetic Joint Infections: Is Rifampicin-Combination Therapy Beneficial?

No consensus has been reached on the optimal antibiotic regimen to treat Cutibacterium acnes PJIs (Ca-PJIs). In vitro studies showed excellent rifampicin efficacy against biofilm-associated C. acnes infections, but clinical studies did not confirm the superiority of rifampicin-combined therapy over monotherapy. This prospective cohort study was undertaken to analyze the outcomes of 70 patients who underwent exchange arthroplasty for chronic monomicrobial Ca-PJI and were treated with rifampicin or without between 2004 and 2019. The 37 patients treated from January 2004 to August 2014 were prescribed rifampicin-combination therapy and the 33 treated from September 2014 to December 2019 received monotherapy without rifampicin. The primary endpoint was the 2-year Kaplan-Meier-estimated reinfection-free probability, including relapses and new-pathogen PJIs. The 2-year reinfection-free rate was high and not different for patients who had received rifampicin or not (89.2% vs. 93.8%, respectively; p = 0.524). None of the patients relapsed and six developed new-pathogen PJIs. Our results do not support a benefit of rifampicin-combination therapy for patients who underwent exchange arthroplasty for chronic Ca-PJIs.

Pseudomonas aeruginosa prosthetic joint-infection outcomes: Prospective, observational study on 43 patients

Objectives

Analysis the outcomes of Pseudomonas aeruginosa prosthetic joint infection (PJI), and of their clinical and microbiological characteristics, surgical strategies and antibiotic treatments.

Methods

Monocenter cohort study in a Bone-and-Joint-Infection Referral Center (08/2004 to 10/2018) including all consecutive P. aeruginosa PJIs. Data were extracted from the prospective database, including the following events: relapses, new PJIs, related deaths.

Results

Median [IQR]: among the 43 patients included (28 females; 72 [63-80] years old; 27 hip, 15 knee, and 1 shoulder PJIs), 29 (67%) had underlying comorbidities, 12 (28%) had previously been treated for another PJI and 9 (21%) had undergone previous surgeries for their P. aeruginosa PJI. Eleven (26%) PJIs were polymicrobial, 16 (37%) strains were wild type, 8 (19%) ciprofloxacin-resistant. PJIs were classified as late chronic (n = 33), early postoperative (n = 9) or acute hematogenous infection (n = 1). Forty patients underwent surgery: 27 one-stage and 5 two-stage exchanges, 3 debridement and implant retention, and 5 other surgical strategies. Antibiotic treatments were: 29 received 41 [37-43] days of combination therapy (IV anti-pseudomonal β-lactam and 3-5 days of amikacin, then β-lactam and oral ciprofloxacin), followed by oral ciprofloxacin for a total of 12 weeks; 10 received only IV antibiotics for 83 [77-86] days, including 37 [32-46] days of combination therapy; 49 days of ceftazidime alone for 1. During follow-up lasting 33 [24-64.5] months, 2 relapses, 3 new PJIs, and 2 related deaths occurred. Thirty-three (82%) patients and 93% of those managed with one-stage exchange experienced no event.

Conclusion

Outcomes of our cohort's P. aeruginosa PJIs-predominantly monomicrobial, chronic, ciprofloxacin-susceptible, treated with one-stage exchange and prolonged IV antibiotics-were 82% favorable.

Streptococcal and Staphylococcus aureus prosthetic joint infections: are they really different?

Background

Staphylococci and streptococci are the most frequent pathogens isolated from prosthetic joint infections (PJIs). The aim of this study was to analyze the outcome of streptococcal and methicillin-susceptible Staphylococcus aureus (MSSA) PJIs.

Methods

All monomicrobial streptococcal and MSSA PJIs managed in a French Referral Center (2010–2017) were sampled from the prospective PJIs cohort study. The primary outcome of interest was the cumulative reinfection-free survival at a 2-year follow-up.

Results

Two hundred and nine patients with 91 streptococcal and 132 staphylococcal infections were analyzed. Patients with streptococcal PJI were older, and infection was more frequently hematogenous. Reinfection-free survival rates at 2-years after all treatment strategies were higher for patients with streptococcal PJI (91% vs 81%; P = .012), but differed according to the strategy. After exchange arthroplasty, no outcome differences were observed (89% vs 93%; P = .878); after debridement, antibiotics and implant retention (DAIR), the reinfection-free survival rate was higher for patients with streptococcal PJI (87% vs 60%; P = .062). For patients managed with prolonged suppressive antibiotic therapy (SAT) alone, those with streptococcal PJIs had a 100% infection-free survival (100% vs 31%; P < .0001).

Conclusions

Reinfection-free survival after DAIR and SAT was better for patients with streptococcal than those with MSSA PJIs. No difference was observed after prosthesis exchange.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07532-x.

Successive new-pathogen prosthetic joint reinfections: Observational cohort study on 61 patients

OBJECTIVES

s (PJI) treatment failure may be due to relapsing infection (same microorganism) or new-pathogen reinfection (npPJI). The aim was to describe npPJI epidemiological, clinical and microbiological characteristics, their treatments and outcomes, and identify their risk factors.

METHODS

This observational, single-center, cohort study was conducted in a French Referral Center for Bone-and-Joint Infections between September 2004 and December 2015. Patients treated for at least two successive hip or knee PJIs in the same joint with a different pathogen were identified in the prospective database. We compared each patient's first PJI and subsequent npPJI(s) to analyze the type and microbiological characteristics of npPJIs. To search for npPJI risk factors, we compared those cases to a random selection of 122 "unique-episode" PJIs treated during the study period.

RESULTS

Among 990 PJIs, 79 (8%) npPJIs occurring in 61 patients were included. New-pathogen prosthetic joint infections (npPJIs) s developed more frequently in knee (14%) than hip prostheses (5%). Median interval from the first PJI to the npPJI was 26 months. New-pathogen prosthetic joint infections (npPJIs) s more frequently spread hematogenously (60% vs 33%) and were predominantly caused by Staphylococcus (36%) or Streptococcus (33%) species. Multivariate analysis identified two risk factors: chronic dermatitis (odds ratio: 6.23; P<0.05) and cardiovascular diseases (odds ratio: 2.71; P<0.01). A curative strategy was applied to 70%: DAIR (29%), one-stage (28%), two-stage exchange arthroplasty (7%) or other strategies (7%). The others received prolonged suppressive antibiotic therapy (29%).

CONCLUSIONS

New-pathogen prosthetic joint infections (npPJIs) s are complex infections requiring management by multidisciplinary teams that should be adapted to each clinical situation.

No evidence of tocilizumab treatment efficacy for severe to critical SARS-CoV2 infected patients: Results from a retrospective controlled multicenter study

To assess tocilizumab (TCZ) efficacy associated to standard of care (SOC) compared to SOC alone in severe coronavirus associated disease 2019 (COVID-19) patients. In a matched case-control study from 3 French Hospital COVID-19 Departments, 27 patients with severe COVID-19 treated with TCZ and SOC were matched for baseline epidemiological and clinical features and compared to 27 severe COVID-19 patients treated with SOC alone. Baseline characteristics of the study population were comparable between groups. Eleven patients (20%) died. TCZ was not associated with clinical improvement as compared to SOC regarding oxygen-free status (44% vs 63%) and death (18.5% vs 22%), despite a higher decrease of the C-reactive protein at Day 7 (10.7 vs 52 mg/L; P < 10-3). Compared to the 43 patients alive at the end-of follow-up, patients who died were older (78 vs 64 years; P < 10-3), with 82% of them older than 72 years vs only 23% of live patients (P < 10-3). Age (OR = 1.15; 95%CI = 1.04-1.3; P = .008) and age over 72 years (OR) = 14.85; 95%CI = 2.7-80; P = .002) were independently associated with mortality. TCZ in addition to SOC for severe COVID-19 patients did not reduce mortality, subsequent need for invasive mechanical ventilation nor did it shorten the time of oxygen support, despite better control of the inflammatory response. More powerful and randomized controlled trials are warranted to determine if TCZ is effective in the management of COVID-19.

One-Stage Exchange Arthroplasty for Fistulizing Periprosthetic Joint Infection of the Hip: An Effective Strategy

Background: Prosthetic hip infection (PHI) is a disastrous scenario after an arthroplasty. International guidelines contraindicate one-stage exchange arthroplasty for fistulizing chronic prosthetic hip infection (FCPHI), nevertheless few surgical teams, mostly from Europe, support one stage procedure for this indication.

Questions/Purposes: Analysis of infection recurrence and implant failure of a series of FCPHIs treated with one stage arthroplasty.

Patients and Methods: Sixty-six FCPHIs treated with one-stage exchange arthroplasty were prospectively followed up at least 2 years. Clinical, radiological and bacteriological signs suggestive of reinfection were sought, as well as implant failures and PHI related deaths.

Results: Thirty-four females and thirty-two males with median age of 69.5 years [61–77] and BMI of 26 kg/m² [22-31] were included. Fistulae were productive in 50 patients (76%). Staphylococcus was responsible for 45% of PHI and 21% were polymicrobial. Twenty-nine patients (44%) received preoperative antibiotic therapy. After a median 60-month follow-up [35–82], 3 patients (4.5%) presented reinfection (two new infections, one relapse) and 3 patients experienced implant failure (1 femoral fracture, 1 stem breakage, 1 recurrent dislocation). One death was related to PHI. After a minimum of 2 years, the infection control rate was of 95.3% (±0.02).

Conclusion: One-stage exchange arthroplasty for FCPHIs showed a good infection control rate similar to that of non-fistulizing PHI. Systematic preoperative microbiological documentation with joint aspiration and, in some specific cases, the use of preoperative antibiotic therapy are among the optimizations accounting for the success of the one-stage arthroplasty. In light of these results, and those of other studies, international recommendations could evolve.

Level of Evidence: Descriptive therapeutic prospective cohort study. Level of evidence: IV.

Cryptococcal arthritis in an immunocompetent migrant

Cryptococcosis is a rare infection in immunocompetent patients. While the lungs and the central nervous system are most often involved, skeletal cryptococcosis is uncommon.

We report a case of isolated osteoarthritis of the ankle due to Cryptococcus neoformans in a 24-year-old immunocompetent patient, who underwent surgical and medical treatment with total recovery at 6 months.

Minocycline Combined with Vancomycin for the Treatment of Methicillin-Resistant Coagulase-Negative Staphylococcal Prosthetic Joint Infection Managed with Exchange Arthroplasty

Introduction: Treatment of methicillin-resistant (MR) staphylococcal prosthetic joint infections (PJIs) remains a matter of discussion, with vancomycin-rifampin combination therapy being the preferred treatment for DAIR and one-stage exchange arthroplasty strategies. This study analyzes the outcomes of patients with chronic methicillin-resistant coagulase-negative staphylococcal PJIs treated with vancomycin-minocycline combination therapy.

Methods: This prospective, single center cohort study included all chronic MR coagulase-negative staphylococcal PJIs (01/2004-12/2014) treated with exchange arthroplasty and at least 4 weeks of minocycline-vancomycin. The following endpoints were considered: reinfection including relapse (same microorganism) and a new infection (different microorganism) and PJI-related deaths. Their outcomes were compared with PJIs treated with rifampin-vancomycin during the same period.

Results: Thirty-four patients (median age, 69 years) with 22 hip and 12 knee arthroplasty infections were included. Sixteen (47%) had previously been managed in another center. Median vancomycin MIC of strains was 3 mg/L. Nineteen underwent one-stage, 15 two-stage exchange arthroplasty. After a median [IQR] follow-up of 43 [26-68] months, 2 patients relapsed and 6 developed a new PJI. Compared to 36 rifampin-vancomycin treated PJIs, relapse- or reinfection-free survival rates didn't differ, but more new infections developed in the minocycline group (6 vs 3; P 0.3).

Conclusions: Minocycline-vancomycin combination therapy for chronic MR coagulase-negative staphylococcal PJIs seems to be an interesting therapeutic alternative.

Gardnerella vaginalis, from the Vaginal Microbiota to Prosthetic Joint Infection

We describe two cases of chronic Gardnerella vaginalis prosthetic hip infections, in an immunocompetent postmenopausal woman and a young immunocompromised woman. G. vaginalis was also isolated from the genital tract, suggesting hematogenous spread of the bacterium. Outcomes were favorable after one-stage exchange arthroplasty and prolonged antibiotic therapy.

Haematogenous prosthetic knee infections: Prospective cohort study of 58 patients

BACKGROUND

Prosthetic joint infection (PJI) is a rare (incidence, 0.15% to 0.9%) but serious complication of knee arthroplasty. Haematogenous PJI of the knee (KhPJI) which accounts for 10% of cases, has been less studied than PJI due to other mechanisms. The primary objective of this study in patients with KhPJI of the knee was to determine the 2-year infection eradication failure rate after either exchange arthroplasty or arthrotomy/synovectomy/irrigation (ASI), combined with prolonged peri-operative antibiotic therapy, at a referral centre for complex osteo-articular infections.

HYPOTHESIS

ASI within 2 weeks after symptom onset and one-stage exchange arthroplasty produce similar 2-year success rates in patients with KhPJI of the knee.

MATERIAL AND METHODS

A prospective observational cohort study was performed in patients managed for PJI of the knee between 2003 and 2015. The primary outcome measure was the occurrence of a septic event or of KhPJI -related death during a minimum follow-up of 2 years.

RESULTS

Of 265 patients with PJI after total knee arthroplasty, 58 (22.1%) had KhPJI with onset more than 3 months after the last arthroplasty procedure and were included in the study. Among them, one-third had immune deficiencies. The most common causative organisms were streptococci (n=25, 43%) and Staphylococcusaureus (n=20, 34%). The primary focus of infection was identified in only 64% of patients and was most often cutaneous (n=19, 33%) or dental (n=11, 19%). A septic event or KhPJI-related death occurred in 5/34 (15%) patients after one-stage exchange arthroplasty and 6/19 (32%) patients after ASI within 15 days after symptom onset (p=0.03). Patient characteristics, type of prosthesis, and causative organism were not significantly associated with failure to eradicate the infection.

CONCLUSION

ASI carried a high failure rate despite being performed within 15 days after symptom onset. One-stage exchange arthroplasty seems to be the best surgical option, particularly as the exact time of symptom onset may be difficult to determine. Identifying and eradicating the primary focus of infection is crucial.

LEVEL OF EVIDENCE

II, low-powered prospective cohort study.

Curative treatment of prosthetic joint infection in patients younger than 80 vs. 80 or older

OBJECTIVE

Prosthetic joint infection (PJI) is a serious complication of joint replacement surgery. The major pharmacological and surgical treatments required by PJI increase the risk of peri-operative complications in elderly patients. The increase in life expectancy combined with procedural advances make these treatments possible even in the oldest patients. Here, our objective was to compare the characteristics and outcomes of curative PJI treatment in patients < 80 years vs. ≥ 80 years.

METHODS

A prospective single-center design was used to compare the characteristics and outcomes of curative treatment for hip or knee PJI in patients < 80 years and ≥ 80 years admitted in 2004-2014.

RESULTS

Of 765 patients admitted for PJI, 590 were < 80 years and 124 were ≥ 80 years. Medical history and comorbidities were similar in the two groups. The older group had a significantly higher proportion of patients with American Society of Anesthesiologists Scores ≥ 3 and with streptococcal infection (20% vs. 13%, P < 0.05). After complete surgical excision and prolonged antibiotic therapy, the only event whose frequency differed significantly between the two groups was PJI-related death, which was more common in the older patients (6.5% vs. 0.8%, P < 0.05). The 2-year survival rate after one-stage exchange arthroplasty was > 90% in the  ≥80 year group.

CONCLUSION

Patients aged 80 years or older are eligible for the same curative pharmacological and surgical PJI treatments used in their younger counterparts. Before surgery, the risk/benefit ratio of the major surgical procedure required to treat PJI must be assessed on a case-by-case basis.

Totally Implantable Venous-Access Device Infection Causing Hematogenous Prosthetic Joint Infection: A Retrospective Case Series

Introduction: Prosthetic joint infections (PJIs) can be acquired hematogenously from a distant site or device. Notably, 30%-40% of patients with PJIs have Staphylococcus aureus bacteremia. No case reports or series of PJIs acquired from totally implantable venous-access device (TIVAD) infection or colonization have been published. This study was undertaken to describe epidemiological, clinical, microbiological and radiological characteristics of such PJIs, their treatments and outcomes. Methods: This retrospective study included all patients, identified in a prospective French Bone-and-Joint Infections Referral Center cohort treated between 2004 and 2017, with PJI secondary to TIVAD infection, with the same microbiologically documented microorganism isolated from both. Results: We describe six consecutive hematogenous PJIs (4 women, 2 men; median age: 66.5 years) acquired from TIVAD primary infections. The main infection risk factors were malignancy (n=5) and prior septic arthritis (n=2). Four participants' TIVADs were implanted for chemotherapy, preceding the prosthesis for one patient. The median TIVAD-implantation-to-symptom-onset interval was 12 months. Microorganisms were Staphylococcus epidermidis (n=4), Staphylococcus capitis (n=1) and Staphylococcus aureus (n=1). All TIVADs were removed. Five participants received curative treatment, with a median of 12 weeks of antibiotics. After median follow-up of 42 months, none have relapsed. Conclusions: When PJI occurs in a patient with a TIVAD, the latter must be tested as a potential source of the prosthesis infection. Conversely, PJIs must sought in all patients with bacteremia.

A Case Of Recurrent Helicobacter cinaedi Prosthetic Joint Infection In An HIV-Infected Man

We describe the case of an HIV-infected man who developed twice a Helicobacter cinaedi prosthetic joint infection. In our knowledge, it is the first case to date. Furthermore, it illustrates the fact that this bacterium is difficult to isolate and that recurrences can occur even after apparently successful treatment.

Analysis of postoperative and hematogenous prosthetic joint-infection microbiological patterns in a large cohort

OBJECTIVES

This study was undertaken to analyze prosthetic joint infection (PJI)-causing microorganisms and compare their distribution patterns according to PJI classification.

METHODS

Cohort study from a single referral center for bone-and-joint infections from January 2004 to December 2015.

RESULTS

Nine hundred and twenty-six patients, who developed 997 PJIs, involving the hip (62%), knee (35%) and/or shoulder (1%), were included. PJIs were classified as early postoperative (19%), late chronic (30%), hematogenous (35%) and undetermined (16%). Pathogens most frequently isolated from early-postoperative PJIs were staphylococci (57%), with 25% each Staphylococcus aureus or Staphylococcus epidermidis; 21% were polymicrobial and 10% Gram-negative rods. For late-chronic PJIs, the most frequent microbes were staphylococci (61%), predominantly S. epidermidis (35%); anaerobic bacteria were isolated from 15%; 11% were polymicrobial. Hematogenous PJIs were 99% monomicrobial. Although S. aureus was the most frequently isolated species (28%), streptococci were isolated slightly more often than staphylococci (39% vs. 36%). Among streptococci, group B streptococci were the most frequent (15%). The portal of entry was identified for 52% of hematogenous PJIs: 15% cutaneous, 11% dental, 9% gastrointestinal, 6% urinary, and 11% miscellaneous.

CONCLUSION

Although a wide variety of microorganisms was isolated from PJIs, specific microbiological patterns were observed according to infection classification.

Musculoskeletal manifestations of Fabry disease: A retrospective study

OBJECTIVES

Fabry disease is a rare X-linked metabolic disorder characterized by a deficiency in the enzyme alpha-galactosidase A. Both males and females can be affected. The main presenting symptom is pain in the extremities, whereas at a more advanced stage, the manifestations include hypertrophic cardiomyopathy, cardiac dysrhythmia, proteinuria, chronic kidney dysfunction, stroke, and hearing loss. When not diagnosed and treated, Fabry disease causes early death. No studies specifically designed to describe the musculoskeletal manifestations of Fabry disease are available.

METHODS

We conducted a single-center retrospective study of patients receiving follow-up at a Fabry disease referral center. We described the musculoskeletal manifestations and analyzed the differential diagnoses.

RESULTS

Our study included 40 patients belonging to 20 families, including 25 females with a mean age of 44.2 years (range, 20-76 years) and 15 males with a mean age of 40.1 years (range, 16-61 years). Mean age at the diagnosis of Fabry disease was 37.2 years (range, 7-71 years) in the females and 26.9 years (range, 9-51 years) in the males. Specific enzyme replacement therapy was given to 10 (40%) females and 12 (80%) males. Musculoskeletal manifestations were as follows: past or present pain in the extremities (13 females and 10 males), combined in some patients with vasomotor disorders in the extremities and telangiectasia; exercise intolerance (12 females and 12 males); osteoporotic fractures (2 brothers aged 45 and 44 years, respectively); osteoporosis (3 females, aged 57, 63, and 75 years, respectively), which contributed to death in the oldest patient; osteopenia (2 females aged 38 and 47 years, respectively; and 1 male aged 43 years); Charcot foot and lymphedema with serious infectious complications (4 males older than 40 years), with avascular osteonecrosis of the lower limbs in 2 cases; toe amputations (3 cases); bilateral lower-limb amputation (1 case); abnormally slender lower limbs (5 females and 8 males); acute gout (3 males with severe chronic kidney failure); and carpal tunnel syndrome (1 female and 1 male, both younger than 40 years). Mistaken diagnoses that were made at an early stage, contributing to delay the identification of Fabry disease, included rheumatic fever (2 females and 2 males), growing pains (2 males), pain with paralysis (1 female), chilblains of the lower limbs (1 female), and erythermalgia (1 female). In adulthood, the following mistaken diagnoses were made: Sjögren's syndrome and/or sicca syndrome (6 females), systemic sclerosis (1 male), dysautonomia (1 female), and familial Mediterranean fever (1 female).

CONCLUSION

The diagnosis of Fabry disease is usually delayed, due to confusion with more common disorders. Musculoskeletal manifestations may constitute the presenting symptoms. Past or present pain in the extremities is typical. Osteoporosis may develop early and become severe. Together with the family history, the presence of musculoskeletal manifestations can lead to the correct diagnosis by prompting alpha-galactosidase assays in males and genetic testing in females. Fabry disease is often responsible for musculoskeletal manifestations, of which the most common are pain in the extremities and osteoporosis. These manifestations can be inaugural and lead to diagnostic wanderings. They require specific treatment strategies.

High Rate of Multidrug-Resistant Gram-Negative Bacilli Carriage and Infection in Hospitalized Returning Travelers: A Cross-Sectional Cohort Study

BACKGROUND

Carriage of and infection with multidrug-resistant Gram-negative bacilli (MDR-GNB) are a potential cause of concern in travelers with no history of hospitalization abroad.

METHODS

All consecutive returning travelers hospitalized in our department between February 2012 and January 2013 were prospectively screened for MDR-GNB gastrointestinal tract carriage or infection. We compared the prevalence of MDR-GNB in travelers to a non-travelers nonexposed group. Then among the travelers, MDR-GNB carriers were compared to noncarriers to determine risk factors of acquisition of MDR-GNB.

RESULTS

Overall, 359 patients (191 travelers, 168 non-travelers) were included, and 25 (6.4%), including 23 travelers, harbored MDR-GNB. Five travelers had an MDR-GNB infection while 18 were asymptomatic enteric carriers. MDR-GNB carriage or infection was significantly more frequent in travelers (11.0% vs 1.2% for non-travelers, odds ratio (OR) = 11.3, p < 0.001) and in patients born outside France (OR = 1.67; p = 0.03). Among travelers, in multivariate analysis, factors independently associated with MDR-GNB carriage or infection were traveling to Asia (OR = 3.1; p = 0.01) and visiting friends and relatives (VFR) or migrants (OR=3.6; p = 0.01).

CONCLUSIONS

The 10-fold higher prevalence rate of MDR-GNB in travelers raises the issues of systematic screening of all travelers, and of the choice of first line antibiotic therapy when treating urinary tract infections in travelers, especially those VFR, migrants, and those returning from Asia.

Rifampicin mono-resistant tuberculosis in France: a 2005-2010 retrospective cohort analysis

BACKGROUND

Rifampicin resistance is a risk factor for poor outcome in tuberculosis. Therefore, we sought to describe the characteristics and management of Rifampicin monoresistant (RMR) tuberculosis (TB) in France.

METHODS

We conducted a retrospective cohort analysis in 2012 on RMR TB patients diagnosed in France between 2005 and 2010 by using a national laboratory network. A standardized questionnaire was used to collect basic demographic data, region of birth, history of TB, HIV-coinfection, alcohol use, and antituberculosis treatment. Outcome was assessed after at least 18 months of follow-up.

RESULTS

A total of 39 patients with RMR TB were reported (0.12% of all TB cases). Overall, 19 (49%) had a previous history of treatment, 9 (23%) were HIV-coinfected, and 24 (62%) were smear-positive. Patient with secondary RMR were more likely to have alcohol abuse (P = 0.04) and HIV-coinfection (p = 0.04). Treatment outcome could be assessed for 30 patients, the nine others being dead or lost to follow-up. A total of 20 (67%) of the 30 assessed were cured, 3 (10%) died, 3 (10%) relapsed, and 4 (13%) were lost to follow up. Four (13%) received less than 6 months of treatment, 3 did not have any modification of the standardized regimen, 13 (43%) received fluoroquinolones, 4 (13%) aminoglycosides, and 8 (26%) a combination of both.

CONCLUSIONS

RMR TB is a rare disease in France, and its management was heterogeneous. The lack of treatment standardization may be a consequence of low expertise and may lead to the unsatisfactory low success rate.

Methicillin resistance is not a predictor of severity in community-acquired Staphylococcus aureus necrotizing pneumonia--results of a prospective observational study

Staphylococcal necrotizing pneumonia (NP) is a severe disease associated with Panton-Valentine leucocidin (PVL). NP was initially described for methicillin-susceptible Staphylococcus aureus (MSSA) infection, but cases associated with methicillin-resistant S. aureus (MRSA) infection have increased concomitantly with the incidence of community-acquired MRSA worldwide. The role of methicillin resistance in the severity of NP remains controversial. The characteristics and outcomes of 133 patients with PVL-positive S. aureus community-acquired pneumonia (CAP) were compared according to methicillin resistance. Data from patients hospitalized for PVL-positive S. aureus CAP in France from 1986 to 2010 were reported to the National Reference Centre for Staphylococci and were included in the study. The primary end point was mortality. Multivariate logistic modelling and the Cox regression were used for subsequent analyses. We analysed 29 cases of PVL-MRSA and 104 cases of PVL-MSSA pneumonia. Airway haemorrhages were more frequently associated with PVL-MSSA pneumonia. However, no differences in the initial severity or the management were found between these two types of pneumonia. The rate of lethality was 39% regardless of methicillin resistance. By Cox regression analysis, methicillin resistance was not found to be a significant independent predictor of mortality at 7 or 30 days (p 0.65 and p 0.71, respectively). Our study demonstrates that methicillin resistance is not associated with the severity of staphylococcal necrotizing pneumonia.

Performance of Quantiferon(®) for the diagnosis TB

OBJECTIVES

The aim of the study was to evaluate the performance of Quantiferon Gold-In-Tube(®) (QFN) for the diagnosis of tuberculosis (TB) during hospitalization in an infectious diseases department.

PATIENTS AND METHODS

QFN was performed in 245 patients recently hospitalized for suspected TB. Subsets of patients underwent tuberculin skin tests (TST), and microbiological cultures were performed.

RESULT

TB was diagnosed in 57 (23%) patients: pulmonary in 23 (40%), extrapulmonary in 16 (28%), and disseminated in 18 (32%). Seventeen (30%) of these TB patients were immunocompromised, including 12 with HIV infection. The sensitivity of QFN was 74%, its specificity 56%, its positive predictive value 43% and negative predictive value (NPV) 92%. The sensitivity was similar in pulmonary and extrapulmonary TB but lower in disseminated TB, although not significantly so. The sensitivity was also lower (P=0.04) in immunocompromised patients. The specificity was lower in migrants than in native French patients (P=0.01), and lower in patients with a history of TB than in those without (P<0.001). Finally, combining culture with QFN significantly increased the sensitivity (P=0.008), and produced a higher NPV, as for the combination with TST, but not significantly different than with QFN alone.

CONCLUSION

The performance of QFN was weak in this context, especially in subgroups at high risk for latent TB. However, combined negative results of QFN or TST and culture could be useful to rule out active TB.

Factors associated with delayed tuberculosis diagnosis in China

BACKGROUND

Delays in the diagnosis of tuberculosis reflect a lack of access to care, and contribute to ongoing tuberculosis transmission in the community. The objective of this study was to evaluate the delay in tuberculosis testing and the associated risk factors in Shanghai, Shandong and Sichuan provinces in China.

METHODS

A prospective cohort study of 765 culture-positive pulmonary tuberculosis patients registered between December 2006 and December 2008. The delay between the onset of symptoms and tuberculosis diagnosis testing and patient information were recorded in a questionnaire and analysed.

RESULTS

The median delay was 36 days and was significantly shorter in patients from Shanghai compared with other places (30 vs. 42 days, P < 0.001). Multivariate analysis revealed that cough in Shanghai patients, lowest income level, being married and presenting expectoration in Shandong and Sichuan patients, were associated with a delay in the diagnosis testing of tuberculosis of >30 days. The only factor associated with a delay of >90 days was, in Shandong and Sichuan provinces only, female gender. The presence of other pulmonary symptoms like haemoptysis and loss of weight, fever and chills could shorten these delays.

CONCLUSION

Efforts to shorten delays in the diagnosis of tuberculosis must target vulnerable populations. The non-specific symptom of cough is a risk factor associated with longer delays. Training for healthcare workers in areas with a high incidence of tuberculosis, where a delayed diagnosis in coughers may enhance tuberculosis transmission in the community, is of paramount importance.

[Antibiotherapy of infectious endocarditis]

Antibiotherapy is the pillar of the infectious endocarditis treatment. Bactericidal drugs must be used and their choice has to be adapted to bacterial sensitivity. The duration of treatment, traditionaly lengthy, especially in prosthetic valve endocarditis, depends on bacteria and has been shortened in some guidelines because of the combination of aminoglycoside.

[Measles in adults: an emerging disease not sparing medical staff]

BACKGROUND

A large outbreak of measles is taking place in Europe and is related to a low vaccination coverage. Measles is observed in adults.

METHODS

We retrospectively studied all the consecutive cases of measles seen in adults between the 1/1/2007 and the 30/4/2009 in four Parisian hospitals.

RESULTS

Twenty-one patients were included. Six patients (29%) were health care workers (HCW) including five (83%) who were vaccinated. Twenty (95%) patients were hospitalized. All patients presented with febrile exanthema, cough and rhinitis in association with hepatic involvement in 71%. Neither death nor sequelae were reported.

CONCLUSION

Measles may occur in HCW, most of them being insufficiently covered by the vaccination. Therefore, since 2010, one injection of measles vaccine is now recommended in France, for HCW without history of measles or vaccination with two doses. Furthermore, adequate respiratory precautions should be taken when seeing patients with febrile exanthema and cough.

Molecular study of microsporidiosis due to Enterocytozoon bieneusi and Encephalitozoon intestinalis among human immunodeficiency virus-infected patients from two geographical areas: Niamey, Niger, and Hanoi, Vietnam

Microsporidiosis cases due to Enterocytozoon bieneusi and Encephalitozoon intestinalis are emerging opportunistic infections associated with a wide range of clinical syndromes in humans. The aim of this study was to specify microsporidial epidemiology in two different geographical areas. From November 2004 to August 2005, 228 and 42 stool samples were collected in Niamey, Niger, and Hanoi, Vietnam, respectively. Screening for microsporidia was performed using UV-light microscopy. Detection was confirmed by molecular biology using two methods specific for E. bieneusi and E. intestinalis. All samples positive for E. bieneusi were subjected to genotyping. In this study, we found high prevalences of microsporidiosis among human immunodeficiency virus-infected patients, 10.5% and 9.5%, respectively, in Niamey and Hanoi. These levels of prevalence are similar to those recorded in European countries before highly active antiretroviral therapy was introduced. In the samples positive for E. bieneusi, we found seven distinct genotypes, including two genotypes not previously described. The E. bieneusi genotype distributions in the two geographical areas suggest different routes of infection transmission, person-to-person in Niger and zoonotic in Vietnam.