Intra-abdominal abscesses: Microbiological epidemiology and empirical antibiotherapy.

PURPOSE: Data on the microbiological epidemiology of Intra-Abdominal Abscesses (IAAs) are very scarce. We aimed to study the microbiological epidemiology of these infections in order to optimize empirical antibiotic therapy. PATIENTS AND METHODS: Between January 2015 and December 2020, we retrospectively analyzed all IAAs files in our hospital. Clinical and microbiological data such as antibiotic susceptibilities were collected. RESULTS: We studied 243 IAA cases. All in all, 139 (57.2%) IAAs were healthcare-associated and 201 (82.7%) were drained. The highest risk situations for IAAs were appendicitis (n = 69) and diverticulitis (n = 37). Out of the 163 microbiologically documented infections, 136 (81.9%) were polymicrobial. Enterobacterales (n = 192, 36.1%), Enterococcus sp. (n = 84, 17.6%) and anaerobes (n = 66, 16.1%) were the most frequently identified bacteria. Gram-negative bacteria were susceptible to amoxicillin-acid clavulanic, piperacillin-tazobactam, cefotaxime, meropenem in 55.2%, 84.9%, 77.6% and 99.5% of cases, respectively. Concerning Gram-positive bacteria, the susceptibility rate was 81.8% for amoxicillin-clavulanic acid, piperacillin-tazobactam and meropenem, and decreased to 63.4% for cefotaxime. CONCLUSION: This study highlights the polymicrobial profile of IAAs and their low susceptibility to amoxicillin and clavulanic acid. The piperacillin-tazobactam association remained the most appropriate empirical antibiotic therapy.

Tuberculosis treatment outcomes among precarious patients in France.

OBJECTIVES: Patients lost to follow-up and treatment failure in tuberculosis disease (TB) are major public health issues. In the absence of appropriate treatment, approximately 70 % of smear-positive patients will die within 10 years of disease progression. This study, conducted in the French region with the highest incidence, aimed to assess tuberculosis treatment outcomes and its determinants. PATIENTS AND METHODS: A prospective, multicenter cohort study (CO1TB) of adults and children treated for TB was conducted in four hospitals in the North of Paris. Treatment outcome at 1 year and associated socioeconomic and clinical factors were studied by multivariate logistic regression. RESULTS: Among 145 TB cases included from May 2018 to January 2020, patients were mainly born abroad and most lived in difficult socioeconomic conditions. During treatment, 25/145 (17 %) patients experienced adverse effects, which were not significantly associated with discontinuation of treatment (p = 0.99). At 1 year, 114 (78 %) had completed treatments, 26 (19 %) were lost to follow-up, three (2.1 %) were still being treated and two (1.4 %) had died. In the multivariate analysis, a history of TB was significantly associated with unfavorable treatment outcome (aOR = 5.3, 95 %CI (1.5;18.6) and a trend towards significance (p < 0.2) was observed among patients aged under 24 years (aOR = 2.9, 95 %-CI 0.95;8.5). CONCLUSION: In this precarious population, socioeconomic conditions were not found to be associated with unfavorable treatment outcome, whereas history of tuberculosis and young age played a role. Increased monitoring is thus required for these patients.

A Randomized Placebo-Controlled Efficacy Study of a Prime Boost Therapeutic Vaccination Strategy in HIV-1-Infected Individuals: VRI02 ANRS 149 LIGHT Phase II Trial.

In this placebo-controlled phase II randomized clinical trial, 103 human immunodeficiency virus type 1 (HIV-1)-infected patients under cART (combined antiretroviral treatment) were randomized 2:1 to receive either 3 doses of DNA GTU-MultiHIV B (coding for Rev, Nef, Tat, Gag, and gp160) at week 0 (W0), W4, and W12, followed by 2 doses of LIPO-5 vaccine containing long peptides from Gag, Pol, and Nef at W20 and W24, or placebo. Analytical treatment interruption (ATI) was performed between W36 to W48. At W28, vaccinees experienced an increase in functional CD4+ T-cell responses (P < 0.001 for each cytokine compared to W0) measured, predominantly against Gag and Pol/Env, and an increase in HIV-specific CD8+ T cells producing interleukin 2 (IL-2) and tumor necrosis factor alpha (TNF-α) (P = 0.001 and 0.013, respectively), predominantly against Pol/Env and Nef. However, analysis of T-cell subsets by mass cytometry in a subpopulation showed an increase in the W28/W0 ratio for memory CD8+ T cells coexpressing exhaustion and senescence markers such as PD-1/TIGIT (P = 0.004) and CD27/CD57 (P = 0.044) in vaccinees compared to the placebo group. During ATI, all patients experienced viral rebound, with the maximum observed HIV RNA level at W42 (median, 4.63 log10 copies [cp]/ml; interquartile range [IQR], 4.00 to 5.09), without any difference between arms. No patient resumed cART for CD4 cell count drop. Globally, the vaccine strategy was safe. However, a secondary HIV transmission during ATI was observed. These data show that the prime-boost combination of DNA and LIPO-5 vaccines elicited broad and polyfunctional T cells. The contrast between the quality of immune responses and the lack of potent viral control underscores the need for combined immunomodulatory strategies. (This study has been registered at ClinicalTrials.gov under registration no. NCT01492985.)IMPORTANCE In this placebo-controlled phase II randomized clinical trial, we evaluated the safety and immunogenicity of a therapeutic prime-boost vaccine strategy using a recombinant DNA vaccine (GTU-MultiHIV B clade) followed by a boost vaccination with a lipopeptide vaccine (HIV-LIPO-5) in HIV-infected patients on combined antiretroviral therapy. We show here that this prime-boost strategy is well tolerated, consistently with previous studies in HIV-1-infected individuals and healthy volunteers who received each vaccine component individually. Compared to the placebo group, vaccinees elicited strong and polyfunctional HIV-specific CD4+ and CD8+ T-cell responses. However, these immune responses presented some qualitative defects and were not able to control viremia following antiretroviral treatment interruption, as no difference in HIV viral rebound was observed in the vaccine and placebo groups. Several lessons were learned from these results, pointing out the urgent need to combine vaccine strategies with other immune-based interventions.

Pulmonary tuberculosis: Evaluation of current diagnostic strategy.

OBJECTIVE: To identify tools that will result in faster diagnosis, making the current pulmonary tuberculosis strategy more efficient. PATIENTS AND METHODS: A 4-year (2015-2018) retrospective study. The gold standard for diagnosis was a positive culture from a respiratory specimen. All sputum, fibroscopy and post-fibroscopy specimens (for smear negative patients) were collected. Each specimen was analyzed through smear examination and culture. All nucleic acid amplification testing results were included. Analyses looked at the incremental yield of positive cases of each successive specimen collection, and time to diagnosis. RESULTS: A total of 354 patients had at least one positive culture. Sputum allowed a diagnosis in 92% of cases (including a gain in sensitivity of around 7% for the third sputum specimen), with 160 smear-positive patients (45%). Among smear-negative patients, 109 underwent a fibroscopy procedure (culture sensitivity of 75%), and 59 had a post-fibroscopy specimen collected, which together identified the rest of the patients (8%). Molecular testing was used in 237 specimens. Median time to diagnosis was 11 days, which was significantly reduced among smear-negative patients when molecular testing was used (P<0.001). Shortening the delay between sputum specimen collections did not alter procedure sensitivity. CONCLUSIONS: We identified several aspects of the French tuberculosis diagnosis algorithm that could be improved, and posed the basis for a prospective study. Centers in higher incidence areas could benefit from a dedicated, predefined procedure exploring suspicions of tuberculosis. A high suspicion score of tuberculosis could drive the reasoned use of molecular testing in such settings.

New guidelines for the prevention of imported malaria in France.

Prevention of malaria is based on personal vector-control measures (PVCMs) to avoid mosquito bites at night and chemoprophylaxis if justified by the risk of contracting the disease. The most effective PVCM is the use of insecticide-treated mosquito nets. The decision to prescribe chemoprophylaxis, mainly to prevent Plasmodium falciparum infection, depends on the benefit-risk ratio. Overall, the risk of contracting malaria is 1,000-fold lower during a stay in the tropical regions of Asia or the Americas than in sub-Saharan Africa. For "conventional" stays (less than one month with nights spent in urban areas) in low-risk settings in tropical Asia and America, the risk of being infected with Plasmodium parasites (≤1/100,000) is equivalent or lower than that of experiencing serious adverse effects caused by chemoprophylaxis. Preventive medication is therefore no longer recommended. By contrast, in other settings and particularly in sub-Saharan Africa, chemoprophylaxis is the most effective measure against malaria. However, it is worth noting that no single preventive measure provides full protection. Regardless of the level of risk or chemoprophylaxis-related indication, protection against mosquito bites and rapid management of febrile illness after returning from an endemic area are also critical to prevent malaria. Finally, migrants of sub-Saharan origin visiting friends and relatives in their country of origin form a high-risk group who should be recommended chemoprophylaxis in the same way as any other travelers-with a preference for the least expensive molecules (doxycycline).

Tuberculous meningitis: Challenges in diagnosis and management.

Tuberculous meningitis (TBM) is the most lethal and disabling form of tuberculosis. In 2017, approximately 10 million people developed TB worldwide, of whom more than 100,000 new cases of TBM are estimated to occur per year. In patients who are co-infected with HIV-1, TBM has a mortality approaching 50%. Diagnosis of TBM is often delayed by the insensitive and lengthy culture technique required for disease confirmation. GeneXpert represents the most significant advance in TBM diagnostics over the past decade, but it lacks sensitivity and cannot be used to rule out the diagnosis. Higher volume of cerebrospinal fluid (CSF) seems to be interesting to improve the diagnosis performances. New rapid and accurate diagnostic tools are necessary. Better advances have been made concerning the anti-tuberculosis chemotherapy of TBM, with the publication of clinical trials and pharmacokinetic studies exploring the use of higher rifampicin doses and fluoroquinolones. The rise of drug-resistant TBM is another challenge for management because TBM caused by multidrug resistant organisms results in death or severe disability in almost all sufferers.

Prediction of methicillin-resistant Staphylococcus aureus bloodstream infection: do we need rapid diagnostic tests?

Staphylococcus aureus (SA) is the leading cause of bloodstream infection (BSI). The incidence of methicillin-resistant SA (MRSA) has decreased in France and Europe since one decade. Early and precise prediction of methicillin susceptibility is needed to improve probabilistic antibiotic therapy of MRSA-BSI. The aim of this study was to identify MRSA-BSI risk factors at admission and evaluate which patients need costly rapid diagnostic tests. A single-center retrospective descriptive study of all diagnosed SA-BSI was conducted in a French University Hospital between January 2015 and December 2016. All medical charts were reviewed. Univariate and multivariate analyses by a logistic regression model were performed on the data. We then build a prediction score of MRSA-BSI by assigning one point for each of the risk factor identified. During the study period, 151 SA-BSI were identified including 32 (21%) MRSA-BSI. In multivariate analysis, three factors were associated with MRSA-BSI: coming from long-term care facility, known previous MRSA colonization and/or infection, and chronic renal disease. Among our population, respectively, 5% and 100% had a MRSA-BSI when no or three risk factors were identified. Therefore, among the PCR performed, 43 (96%) could be avoided according to our clinical score. In our study, methicillin-susceptible SA and MRSA-BSI can be predictable by counting MRSA risk factors. This prediction rule could avoid the use of expensive rapid diagnostic tests. Prospective studies and prediction rules could help physicians to predict SA-BSI susceptibility to improve appropriate empiric therapy choice.

[Pulmonary tuberculosis: Radiological evolution of broncho-pulmonary lesions at the end of treatment]. / Tuberculose pulmonaire : évolution radiologique des lésions broncho-pulmonaires en fin de traitement.

OBJECTIVES: To describe the residual broncho-pulmonary lesions and evaluate the role of CT scanning at the end of treatment of pulmonary tuberculosis. MATERIALS AND METHODS: Analysis of the initial and end of treatment CT scans of 56 patients with pulmonary tuberculosis according to a reading grid including parenchymatous and airways lesions. The CT data at the end of treatment were analysed in relation to the clinical and microbiological data, and the original CT scan. RESULTS: Active lesions (thick walled cavities and/or centrilobular micronodules) persisted in 24 patients (43%) after a mean treatment period of 7 months. The persistence of these signs of activity was correlated with the initial presence of a cavitary syndrome (p=0.027), with predominant sub-segmentary bronchial involvement, with extensive micronodular spread (p=0.024) and with bronchiectasis (p=0.04). These residual lesions were not associated with an increased risk of relapse. CONCLUSION: The persistence of signs of activity on the CT scan at the end of treatment of tuberculosis do not necessarily correspond to an absence of cure but to a radiological delay. This imaging is nevertheless useful to make an assessment of any subsequent changes in the bronchial tree and to estimate the risk of later complications.

Does region of origin influence the timing and outcome of first-line antiretroviral therapy in France?

OBJECTIVES: The aim of the study was to assess whether the timing of combination antiretroviral therapy (cART) initiation, the choice of cART and virological response differ in migrants versus European natives in the north and east of Paris area, after dissemination of French recommendations for universal treatment. METHODS: Antiretroviral therapy-naïve HIV-1-infected adults with at least two follow-up visits at one of 15 participating centres between 1 January 2014 and 31 March 2015 were included in the study. Factors associated with cART initiation before 31 March 2015, with protease inhibitor (PI)-containing cART among individuals initiating cART, and with 1-year virological success after cART initiation were assessed using multivariable logistic regression models. Sex, age, region of origin [Western Europe, sub-Saharan Africa (SSA) or other], HIV transmission group, baseline AIDS status, CD4 cell count and plasma viral load (VL), and hepatitis B and/or C virus infection were considered in the analyses. RESULTS: Among 912 individuals, only 584 (64%) started cART during the study period. After adjustment, migrants from SSA were half as likely to initiate cART and to have a subsequent virological response compared with individuals from Western Europe [adjusted odds ratio (aOR) 0.54; 95% confidence interval (CI) 0.36-0.82; and aOR 0.52; 95% CI 0.28-0.98, respectively]. PI-containing cART was more frequently prescribed in migrants from SSA, in people with lower CD4 cell counts and in people with higher VL. CONCLUSIONS: Even in the context of universal cART recommendations and of free access to care, migrants from SSA still have delayed access to cART and a lower virological response. Efforts are still necessary to provide immediate cART to all people living with HIV.

A descriptive study of advising practices during travel health consultations in France.

BACKGROUND: Recommendations for improving traveler adherence address both the content of the advice given and the structure of the consultation. The objective of this article is to describe how travel health consultations are structured in France. METHODS: A questionnaire based on both theoretical foundations and recommendations in the literature was sent to health professionals who practice in travel clinics, all of them members of France's Société de Médecine des Voyages. RESULTS: The response rate was 78.5% (176/224). One hundred thirty nine respondents (78.9%) reported that treatment (vaccinations, in particular) and advising were done at separate times in the consultation. The majority of respondents questioned the traveler on his wishes, difficulties, expectations, experiences, and previous knowledge. A third explored the traveler's perceptions regarding the seriousness of diseases, the effectiveness of prevention measures and the latter's adverse effects with a difference when health professionals were practicing >5 years and/or had received specific training ( P < 0.05). At the end of the consultation, 92% of the respondents asked the traveler whether he understood the advice given. One hundred thirty seven respondents (77.8%) gave travelers a booklet with additional advice, and 66.5% gave them a website where they could find health advice on their destination. Travelers were almost never offered group consultations or the opportunity to work on real-life situations. When there were language barriers, the respondents were more likely to seek help from a French-speaking member of the traveler's entourage (48.9%) than from an interpreter (22.7%). CONCLUSIONS: While the majority of practitioners follow most of the recommendations regarding the structure of travel health consultations, some of the factors that enhance traveler learning are underutilized, reducing the likelihood that travelers will apply the advice given. The study illustrates the need to develop more educational intervention methods and to evaluate their impact on travelers.

Factors Associated with HIV Status Disclosure in HIV-Infected Sub-Saharan Migrants Living in France and Successfully Treated with Antiretroviral Therapy: Results from the ANRS-VIHVO Study.

To estimate rates and identify correlates of HIV disclosure in migrants from sub-Saharan Africa (SSA) successfully treated, a sub-analysis was conducted in HIV-1 native SSA migrants, living in France with undetectable viral load on antiretroviral, included in the VIHVO adherence study. Logistic regression models assessed factors associated with HIV disclosure. Among 246 individuals (40 % male, median age 41), 79 % of those in a steady heterosexual partnership (n = 167) had disclosed their status to their partner, 55 % of the total 246 to a relative, and 33 % to (an)other person(s). Disclosure to one's steady partner was associated with a follow-up duration since HIV diagnosis of more than 5 years, a higher literacy level, a better social context and marital status. Women were more likely to disclose their HIV status to relatives. Interventions targeting this population should be provided to improve disclosure which in turn ensures better social support, testing of the partner and lower rates of undiagnosed HIV.

MALDI-TOF MS contribution to diagnosis of melioidosis in a nonendemic country in three French travellers.

Melioidosis is an endemic disease in Southeast Asia and northern Australia. An increasing number of cases are being reported in nonendemic countries, making the diagnosis less obvious. We discuss the identification of Burkholderia pseudomallei using matrix-assisted desorption ionization-time of flight mass spectrometry on the occasion of recent cases of imported melioidosis in French travellers.

Active pulmonary tuberculosis: Role for amikacin in early treatment.

OBJECTIVE: To evaluate the efficacy of amikacin on sputum conversion during initial sputum smear positive tuberculosis treatment. MATERIAL AND METHODS: Single-center observational cohort study (2012-2013) evaluating time to sputum smear conversion with standard treatment (ST) versus standard treatment+amikacin (IV 15mg/kg/day) for seven days (STamK). RESULTS: Forty-five patients were included. Median time to smear negative samples was 26.5 days (14-56) for the 30 (66.7%) patients included in the ST group and 48 days (19.5-69.5) for the 15 patients (33.3%) included in the STamK group (P=0.76). Time to negative culture was only known for 27 patients (61.4%): 47.5 days (26-58) for 18 patients in the ST group and 40 days (14-77) for nine patients in the STamK group. CONCLUSION: Despite our small sample size, the addition of amikacin in active tuberculosis treatment did not seem to impact time to smear conversion or period of contagiousness.

Survey of French physician practices in treatment and control of transmission of smear-positive tuberculosis.

OBJECTIVES: To evaluate isolation practices and management of sputum smear-positive tuberculosis (TB) in France. METHODS: A survey was conducted using a questionnaire e-mailed in 2011 and 2012 to physicians of the French Society of Infectious Diseases, the French Respiratory Society and the French National Society of Internal Medicine. RESULTS: Of 311 responders, a quarter stated they treated more than 25 TB cases per year. A total of 87.8% declared they routinely used a four-drug regimen in the initial intensive phase. Of the 311 physicians who responded, 31.9% removed isolation precautions after three negative acid-fast bacilli (AFB) sputum results, 19.0% after 15 days of treatment and 34.1% only in case of clinical improvement. According to 71% of the responders, discharge from hospital despite positive AFB sputum smear results was 'possible'. A routine AFB sputum smear was performed after 2 months of treatment by only 21% of the responders. CONCLUSION: Despite recent national guidelines, the management of isolation precautions for sputum smear-positive TB remains heterogeneous, and a significant proportion of physicians use a three-drug regimen. Further efforts should be made to implement TB guidelines, mainly by raising awareness through national scientific institutions, but also by obtaining better evidence.

Vascular graft infection due to Pasteurella multocida.

BACKGROUND: Vascular graft infections are infrequent complications with important morbidity and mortality rates. Pasteurella multocida, a Gram negative bacillus, is a normal oral commensal of many animals. For mankind, it is a pathogenous bacillus which is rarely implicated in vascular grafts. CASE REPORT: We report hereafter the fourth case introduced in the international literature about vascular graft infections caused by P. multocida. The patient was successfully treated with a combination of a surgical graft change and a 6 weeks bi-antibiotic therapy. DISCUSSION: There is fours case reported in litterature with quite different antibiotic drugs and duration. CONCLUSION: P. multicoda graft infection should be long with initial intravenous drug and mainteance traitement should not be required.

Acquisition of carbapenemase-producing Enterobacteriaceae by healthy travellers to India, France, February 2012 to March 2013.

Healthy travellers to countries where carbapenemases-producing Enterobacteriaceae (CPE) are endemic might be at risk for their acquisition, even without contact with the local healthcare system. Here, we report the acquisition of CPE (two OXA-181, one New Delhi metallo-beta-lactamase 1 (NDM-1)) in three healthy travellers returning from India. The duration of CPE intestinal carriage was less than one month. The results indicate that healthy travellers recently returning from India might be considered as at risk for CPE carriage.