Changing profile of encephalitis: Results of a 4-year study in France.

CONTEXT: In 2007, we performed a nationwide prospective study to assess the epidemiology of encephalitis in France. We aimed to evaluate epidemiological changes 10years later. METHODS: We performed a 4-year prospective cohort study in France (ENCEIF) from 2016 to 2019. Medical history, comorbidities, as well as clinical, biological, imaging, and demographic data were collected. For the comparison analysis, we selected similar data from adult patients enrolled in the 2007 study. We used Stata statistical software, version 15 (Stata Corp). Indicative variable distributions were compared using Pearson's Chi2 test, and means were compared using Student's t-test for continuous variables. RESULTS: We analyzed 494 cases from 62 hospitals. A causative agent was identified in 65.7% of cases. Viruses represented 81.8% of causative agents, Herpesviridae being the most frequent (63.6%). Arboviruses accounted for 10.8%. Bacteria and parasites were responsible for respectively 14.8% and 1.2% of documented cases. Zoonotic infections represented 21% of cases. When comparing ENCEIF with the 2007 cohort (222 adults patients from 59 hospitals), a higher proportion of etiologies were obtained in 2016-2019 (66% vs. 53%). Between 2007 and 2016-2019, the proportions of Herpes simplex virus and Listeria encephalitis cases remained similar, but the proportion of tuberculosis cases decreased (P=0.0001), while tick-borne encephalitis virus (P=0.01) and VZV cases (P=0.03) increased. In the 2016-2019 study, 32 causative agents were identified, whereas only 17 were identified in the 2007 study. CONCLUSION: Our results emphasize the need to regularly perform such studies to monitor the evolution of infectious encephalitis and to adapt guidelines.

Intention to get vaccinations against COVID-19 in French healthcare workers during the first pandemic wave: a cross-sectional survey.

BACKGROUND: Healthcare workers (HCWs) are at the frontline of the COVID-19 pandemic and identified as a priority target group for COVID-19 vaccines. We aimed to determine COVID-19 vaccine acceptance rate in HCWs in France. METHODS: We conducted an anonymous survey from 26th March to 2nd July 2020. The primary endpoint was the intention to get vaccinated against COVID-19 if a vaccine was available. RESULTS: Two-thousand and forty-seven HCWs answered the survey; women accounted for 74% of respondents. Among respondents, 1.554 (76.9%, 95% confidence interval 75.1-78.9) would accept a COVID-19 vaccine. Older age, male gender, fear about COVID-19, individual perceived risk and flu vaccination during previous season were associated with hypothetical COVID-19 vaccine acceptance. Nurses and assistant nurses were less prone to accept vaccination against COVID-19 than physicians. Vaccine hesitancy was associated with a decrease in COVID-19 vaccine acceptance. Flu vaccine rate was 57.3% during the previous season, and 54.6% of the respondents had the intention to get a flu vaccine during the next season. CONCLUSIONS: Intention to get vaccinated against COVID-19 reached 75% in HCWs with discrepancies between occupational categories. COVID-19 pandemic had no positive effect on flu vaccine acceptance rate.

COVID-19 outpatient management: Shorter time to recovery in Healthcare workers according to an electronic daily symptoms assessment.

OBJECTIVES: Our aim is to compare the course of the disease between healthcare workers (HCWs) and non-HCWs suffering from covid-19 and eligible for outpatient management. METHODS: Single-center prospective cohort of outpatients with covid-19, diagnosed between the 10th March and the 2nd April, 2020 with a daily collection of symptoms by an on-line auto-questionnaire. RESULTS: A total of 186 patients were included (median age, 41 years [interquartile range, 19-78 years]; 74.2% female), of whom 132 (71%) were HCWs. The median follow-up after symptom onset was 14 (min 4-max 24) days. HCWs were significantly younger than non-HCWs (median age 40.3 years vs. 47.2 years [P<0.005]), and 81.8% were women. Four patients (2.2%) were hospitalized including one HCW. The median time to recovery was 9 days after symptom onset (95% CI 8-11) in the global population and respectively 8 (95% CI 8-9) and 13 (95% CI 11-15) days in HCWs and in non-HCWs (P<0.005). After adjusting for age, co-morbidities, and gender, the instantaneous risk ratio for symptom absence in HCWs was 1.76 compared with non-HCWs (95% CI [1.16-2.67], P=0.037). CONCLUSION: HCWs suffering from covid-19 had favorable outcomes and had a shorter time to recovery than non HCWs.

[A complex case of miliary pulmonary tuberculosis following intravesical BCG therapy]. / Un cas complexe de miliaire pulmonaire post-BCG thérapie pour carcinome urothélial.

Bladder cancer (urothelial carcinoma in 90 % of cases) is the most common neoplasia of the urinary tract. Superficial carcinoma represents 70-80 % of bladder cancers. The treatment of these tumours includes, after transuretral resection, intravesical Bacillus Calmette-Guerin (BCG) instillation therapy. This treatment constitutes, by its immune-mediated anti-tumoral action, the first step of immunotherapy in cancer. Severe complications (granulomatosis, hypersensitivity pneumonitis or orchitis) are rare (0.5-2 %). Here we report a complex case of pulmonary granulomatosis secondary to BCG therapy. This is a 74-year-old male, treated for superficial bladder carcinoma by transuretral resection (pT1G3) and then endovesical instillations of BCG therapy for two months. Two years later, a new transuretral resection shows an infiltrating urothelial carcinoma pT2G3. The extension balance finds a persistent micro-nodular pulmonary infiltrate. A broncho-alveolar lavage is then realised but no mycobacteria was found. A surgical biopsy of a nodule is performed and revealed a histiocytic reaction without any neoplastic element. Detection of Mycobacterium tuberculosis by Polymerase Chain Reaction (PCR) was finally positive. In the absence of a secondary lesion, the patient had a cysto-prostatectomy and began a tritherapy against tuberculosis. Post-BCG therapy granulomatosis is a rare complication but should remain a differential diagnosis in front of the appearance of pulmonary nodes in patients who have received posttransuretral resection BCG instillations. Mycobacterial DNA PCR research remains the most sensitive examination.

Les carcinomes urothéliaux superficiels de vessies représentent 70 à 80 % des tumeurs de la vessie. Leur traitement comprend, après résection transurétrale, une BCG (Bacille de Calmette et Guérin) thérapie par instillations endovésicales. Les complications sévères (granulomatose, pneumopathie d'hypersensibilité ou orchite) sont rares (0,5-2 %) mais nous rapportons ici un cas complexe de granulomatose pulmonaire secondaire à une BCG thérapie. Il s'agit d'un homme de 74 ans, traité pour un carcinome urothélial superficiel de vessie par résection endo-urétrale (pT1G3) puis instillations endovésicales de BCG thérapie. Deux années après, une nouvelle résection transurétrale objective un carcinome urothélial infiltrant pT2G3. Le bilan d'extension retrouve un infiltrat pulmonaire micronodulaire persistant. Un lavage bronchoalvéolaire ne retrouve pas de bacilles acido-alcoolo-résistants. La biopsie chirurgicale d'un nodule retrouve une réaction histiocytaire sans élément néoplasique. La Polymerase Chain Reaction (PCR) à la recherche de mycobactérie du groupe tuberculosis revient finalement positive. En l'absence de lésion secondaire, le patient a bénéficié d'une cystoprostatectomie et a débuté dans les suites une trithérapie antituberculeuse. La granulomatose post-BCG thérapie est une complication rare, mais doit rester un diagnostic différentiel devant l'apparition de micronodules pulmonaires chez les patients ayant reçu des instillations de BCG post-résection transurétrale. La recherche par PCR d'ADN de mycobactéries reste l'examen le plus sensible.

SARS-CoV-2 infection: advocacy for training and social distancing in healthcare settings.

This article reports the observed rate of infection with severe acute respiratory syndrome coronavirus-2 in healthcare workers (HCWs) who worked on wards dedicated to care of patients with coronavirus disease 2019 (COVID-19) compared with HCWs who worked on non-COVID-19 wards. The infection rate was significantly higher among HCWs who worked on non-COVID-19 wards (odds ratio 2.3, P=0.005), illustrating the need to strengthen social distancing measures and training.

Patient decision aid in vaccination: a systematic review of the literature.

INTRODUCTION: Decision-making for patients and their families in the field of vaccination is difficult, involving many multidimensional factors. The complexity of this process is directly responsible for the phenomenon of vaccine hesitancy. Decision aids are instruments that provide information on a specific subject, explaining the advantages and disadvantages of a decision in a personalized way, thus clarifying the patient's values. AREAS COVERED: A systematic review using PRISMA guidelines was conducted to carry out an inventory of decision aids in the field of vaccination and assess their impact on vaccine coverage and decisional conflict. EXPERT OPINION: Decision aids reduce decision-making conflict and could be good tools to address the phenomenon of vaccine hesitancy. It seems essential to integrate health professionals and patients into the design of future decision aids. This would simplify the use of these tools during the consultation. However, their effect on vaccine coverage remains uncertain. Further studies seem necessary in order to conclude that vaccination coverage is effective.

Health students' knowledge of sexually transmitted infections and risky behaviors before participation to the health promotion program.

OBJECTIVES: We aimed to evaluate knowledge of health students (HS) enrolled in a health promotion program about sexually transmitted infections (STIs) and the frequency of risky behaviors. METHODS: HS answered two anonymous questionnaires, a mandatory one about knowledge of STIs and STI prevention and an optional one about behaviors. RESULTS: Two-hundred and sixteen HS answered the first questionnaire and 183 answered the second one. Eighty-three percent of HS had a good knowledge of HIV transmission, but half of them were aware of pre-exposure and post-exposure prophylaxes for HIV. The role of HPV infection in genital warts and anal cancer was respectively known by 33 (15.3%) and 10 (4.6%) HS. Thirty-six HS (19.7%) reported having unprotected sex in the previous 12 months. CONCLUSION: French HS had a poor knowledge of STIs and STI prevention, and risky behaviors. It is necessary to provide good training on STIs to HS.

Barriers and motivations for participation in preventive vaccine clinical trials: Experience of 5 clinical research sites.

Recruitment in preventive vaccine trials (PVT) is challenging due to common barriers to clinical research and lack of vaccine confidence. Identifying determinants of participation can help to improve recruitment. A prospective survey was conducted in 5 French clinical investigational sites. People asked to participate in a PVT were given a questionnaire whether they decided to participate or not in the trial. A total of 341 people answered the survey: 210 accepting and 131 declining to participate in a PVT. Acceptors were significantly younger (38.5 vs 54.9 years old), more likely to be involved in early phase trials, had a higher level of education (p < 0.005) and a significantly better general opinion concerning vaccines (92.3% versus 72.3%, p < 0.005) compared with those who declined. Factors associated with acceptance or refusal were evaluated in 224 people in the 4 sites where both groups were included. In a multivariate analysis, three factors: older age, having heard about PVT through multiple sources and financial incentives were significantly associated with refusal to participate in the PVT. A generally favourable opinion of vaccines was associated with acceptance. The main motivation for participation was altruism (93.2%) whereas fear of side effects was at the forefront of the barriers (36.6%). Information given by the physician was a key point for decision-making in 70.2% of those who accepted. In brief, vaccine hesitancy may decrease recruitment in PVTs; reinforcing altruism and quality of information given are key points in acceptance of participation in PVT.

Acute kidney injury in infective endocarditis: A retrospective analysis.

BACKGROUND: Acute kidney injury (AKI) is associated with high case fatality in infective endocarditis (IE), but epidemiological data on the frequency of AKI during IE is scarce. We aimed to describe the frequency and risk factors for AKI during the course of IE using Kidney Disease: Improving Global Outcomes consensual criteria. METHODS: Using the French hospital discharge database (French acronym PMSI), we retrospectively reviewed the charts of 112 patients presenting with a first episode of probable or definite IE between January 2010 and May 2015. RESULTS: Seventy-seven patients (68.8%) developed AKI. In univariate analysis, risk factors for AKI were cardiac surgery for IE (n=29, 37.7% vs. n=4, 1.4%, P<0.0005), cardiac failure (n=29, 36.7% vs. n=1, 2.9%, P<0.0005), diabetes mellitus (n=14, 18.2% vs. n=1, 0.9%, P=0.034), and prosthetic valve IEs (n=24, 31.2% vs. n=4, 11.4%). No differences were observed for gentamicin exposure (n=57, 64% vs. n=32, 86.5%, P=0.286). Prosthetic valve IE, cardiac failure, and vancomycin exposure were independently associated with AKI with respective odds ratio of 5.49 (95% CI 1.92-17.9), 4.37 (95% CI 4.37-465.7), and 1.084 (1.084-16.2). Mean length of hospital stay was significantly longer in patients presenting with AKI than in controls (respectively 52.4±22.1 days vs. 39.6±12.6, P<0.005). CONCLUSION: AKI is very frequent during IE, particularly in patients with prosthetic valve IE, cardiac failure, and those receiving vancomycin.

Travel medicine consultation: An opportunity to improve coverage for routine vaccinations.

BACKGROUND: Travelers may be responsible for the spread of vaccine-preventable diseases upon return. Travel physicians and family physicians may play a role in checking and updating vaccinations before traveling. Our aim was to evaluate the vaccine coverage for mandatory and recommended vaccination in travelers attending a travel medicine clinic (TMC). METHODS: Vaccine coverage was measured using the current French immunization schedule as reference for correct immunization, in travelers providing a vaccination certificate during the TMC visit (university hospital of Saint-Étienne), between August 1, 2013 and July 31, 2014. RESULTS: In total, 2336 travelers came to the TMC during the study period. Among the 2019 study participants, only 1216 (60.3%) provided a vaccination certificate. Travelers who provided a vaccination certificate were significantly younger than travelers who did not (mean age: 34.8±17.8 vs. 46±18.4 years, P<0.005) and were less likely to be Hajj pilgrims. Vaccine coverage against Tetanus, Diphtheria, and Poliomyelitis (Td/IPV vaccine) was 91.8%, 78.6% against Measles, Mumps, and Rubella (MMR), and 59.4% against Viral Hepatitis B (HBV). BCG vaccine coverage was 71.9%. Older travelers were less likely to be correctly vaccinated, except against HBV as vaccinated travelers were significantly older than unvaccinated travelers. CONCLUSION: Obtaining information about immunization in travelers is difficult. Coverage for routine vaccines should be improved in this population. Travel medicine consultations could be the opportunity to vaccinate against MMR, HBV, and Td/IPV.

Brugada syndrome revealed by intestinal shigellosis in a patient from Benin at the University Hospital of Saint-Etienne.

This paper is about a Brugada syndrome (BS) of accidental discovery in a patient from Benin during an intestinal shigellosis episode in the infectiology department of university hospital of Saint-Etienne, France. Authors establish a link between these two diseases. After a literature's review, they underline that BS is under-diagnosed in Africa. Furthermore, they highlight socio-cultural characteristics of sudden deaths in West Africa including BS.

CKD-EPI equation: A suitable Glomerular Filtration Rate estimate for drug dosing in HIV-infected patients.

OBJECTIVES: To evaluate concordance between glomerular filtration rate (GFR) estimates (Cockcroft and Gault, modification of diet in renal diseases, chronic kidney disease epidemiology study group equations) for drug dosing in HIV-infected patients. PATIENTS AND METHODS: We performed a monocentric study. GFR was measured using the gold standard method (plasma clearance of iohexol) in 230 HIV-infected patients. Concordance rate was evaluated between measured GFR (mGFR) and estimated GFR (eGFR) for different GFR categories (GFR>90 mL/min, GFR<90 mL/min, GFR>70 mL/min, and GFR<70 mL/min). MDRD and CKD-EPI were used with and without indexation to body surface area (BSA). RESULTS: Mean age was 48±10 years, mean mGFR was 101±26 mL/min. Concordance between mGFR and eGFR estimated with CG, CKD-EPI (indexed and not indexed to BSA), or MDRD equations (not indexed to BSA) was similar (73%, 73%, 74%, and 73% respectively) for a breakpoint value of 90 mL/min for GFR. At this value, the concordance rate between mGFR and MDRD indexed to BSA was significantly lower (65%, P<0.05). Using 70 mL/min of GFR as the breakpoint value, all equations had similar concordance rates with mGFR (with or without indexation to BSA). CONCLUSION: CKD-EPI equation has the same concordance with GFR and with CG when used for drug dosing.

Barriers and motivations to volunteers' participation in preventive vaccine trials: a systematic review.

INTRODUCTION: The recruitment of volunteers in preventive vaccine trials (PVT) is a challenge, since vaccine hesitancy and debates on vaccines are combined to usual difficulties of enrollment in clinical trials. Areas covered: Current knowledge of the reasons leading to the volunteers' participation or non-participation in PVT mainly focuses on data from preventive HIV vaccine trials. A systematic PubMed search was conducted using PRISMA guidelines to identify articles or reviews that reported barriers and motivations to participation in PVT regardless of the targeted disease or population. Expert commentary: In view of the barriers and motivations reviewed here, improvements in recruitment could be made through a better explanation of the prevented disease, of the expected individual and collective benefit and of all ethical protective principles associated to the trials. Use of decision aids as well as patient and public involvement may improve given information and may enhance comprehension of participants and their participation in PVT. Further prospective and interventional studies are needed to analyze if these leads may improve acceptation level in PVT.

Carbapenemase-producing Acinetobacter baumannii: An outbreak report with special highlights on economic burden.

OBJECTIVE: We aimed to describe the management of a carbapenemase-producing Acinetobacter baumannii (CP-AB) outbreak using the Outbreak Reports and Intervention Studies of Nosocomial Infection (ORION) statement. We also aimed to evaluate the cost of the outbreak and simulate costs if a dedicated unit to manage such outbreak had been set-up. METHODS: We performed a prospective epidemiological study. Multiple interventions were implemented including cohorting measures and limitation of admissions. Cost estimation was performed using administrative local data. RESULTS: Five patients were colonized with CP-AB and hospitalized in the neurosurgery ward. The index case was a patient who had been previously hospitalized in Portugal. Four secondary colonized patients were further observed within the unit. The strains of A. baumannii were shown to belong to the same clone and all of them produced an OXA-23 carbapenemase. The closure of the ward associated with the discharge of the five patients in a cohorting area of the Infectious Diseases Unit with dedicated staff put a stop to the outbreak. The estimated cost of this 17-week outbreak was $474,474. If patients had been managed in a dedicated unit - including specific area for cohorting of patients and dedicated staff - at the beginning of the outbreak, the estimated cost would have been $189,046. CONCLUSION: Controlling hospital outbreaks involving multidrug-resistant bacteria requires a rapid cohorting of patients. Using simulation, we highlighted cost gain when using a dedicated cohorting unit strategy for such an outbreak.

International experts' practice in the antibiotic therapy of infective endocarditis is not following the guidelines.

OBJECTIVE: The management of infective endocarditis (IE) may differ from international guidelines, even in reference centres. This is probably because most recommendations are not based on hard evidence, so the consensus obtained for the guidelines does not represent actual practices. For this reason, we aimed to evaluate this question in the particular field of antibiotic therapy. METHODS: Thirteen international centres specialized in the management of IE were selected, according to their reputation, clinical results, original research publications and quotations. They were asked to detail their actual practice in terms of IE antibiotic treatment in various bacteriological and clinical situations. They were also asked to declare their IE-related in-hospital mortality for the year 2015. RESULTS: The global compliance with guidelines concerning antibiotic therapy was 58%, revealing the differences between theoretical 'consensus', local recommendations and actual practice. Some conflicts of interest were also probably expressed. The adherence to guidelines was 100% when the protocol was simple, and decreased with the seriousness of the situation (Staphylococus spp. 54%-62%) or in blood-culture-negative endocarditis (0%-15%) that requires adaptation to clinical and epidemiological data. CONCLUSION: Worldwide experts in IE management, although the majority of them were involved and co-signed the guidelines, do not follow international consensus guidelines on the particular point of the use of antibiotics.

Vaccine hesitancy among general practitioners: evaluation and comparison of their immunisation practice for themselves, their patients and their children.

To gain knowledge about vaccine hesitancy among general practitioners (GPs), we conducted a survey to compare their vaccination attitudes for themselves, their children and their patients. A questionnaire survey was sent to GPs working in private practice in the Rhône-Alpes region, France, between October 2013 and January 2014. GPs' immunisation practices for diphtheria-tetanus-poliomyelitis (DTP), measles-mumps-rubella (MMR), pneumococcal, pertussis, hepatitis B (hepB), human papillomavirus (HPV), seasonal and H1N1 influenza and meningococcal C (menC) vaccines were considered. Divergence was defined by the presence of at least one different immunisation practice between their patients and their children. A total of 693 GPs answered the questionnaire. When considering all investigated vaccines, 45.7 % of divergence was found. Individually, divergence was highest for the newest and more controversial, i.e. HPV (11.8 %), hepB (13.1 %), menC (23.7 %) and pneumococcal (19.8 %) vaccines. Only 73.9 % of GPs declared that they recommended HPV vaccine for their daughters. After multivariate analysis, older age was associated with higher risk of divergence. According to the French 2012 recommendations, GPs were insufficiently immunised, with 88 % for DTP and 72 % for pertussis. GPs declared to recommend vaccination against DTP, pertussis and MMR for their patients and their children in more than 95 % of cases. The declared rates of recommendation were lower than 90 % for other vaccines. These results bring new insight about vaccine hesitancy. GPs have divergent immunisation attitudes toward their relatives and their patients, especially when considering the newest and most controversial vaccines, with HPV vaccine being the main focus of controversies.