Are unknown co-medications, over-the-counter and off-label drug use still problems among people living with HIV? Results from a transversal survey in 23 centres in France.

INTRODUCTION: Polypharmacy can lead to drug-drug interactions (DDIs), especially with ART. The burden of co-medications, including over-the-counter (OTC) drugs and self-medications, could be underestimated. We aimed to investigate the proportion of people living with HIV (PLHIV) with declared and undeclared co-medications, as well as their potential burden. METHODS: We conducted a national, multicentre, 1 week cross-sectional study between 10 December and 16 December 2019 in 23 French hospitals amongst consecutive adult PLHIV presenting for a routine outpatient visit. A standardized questionnaire filled in by the physicians assessed all medications and other active chemical substances taken by the PLHIV. RESULTS: Overall we enrolled 496 participants from 23 centres. Median age was 50.6 years; ART regimens included an integrase inhibitor in 61% (n = 302), an NNRTI in 34% (n = 169) and a PI in 14% (n = 70) of the cases. Co-medications involved 392 (79%) PLHIV, among which 85 (17%) received polypharmacy (≥5 medications). Previously unknown co-medications or other active substances were found for 32% (n = 159) of the participants. Corticosteroids (9%, n = 46) and proton pump inhibitors (10%, n = 50) were frequently administered. These co-medications did not differ according to age range. Illegal drug use was declared by 11% (n = 54) and OTC drugs by 23% (n = 113) of PLHIV. Potential DDIs were discovered for 11% (n = 53), leading to treatment modifications in 47% (25/53) of cases. CONCLUSIONS: Potential DDIs that lead to therapeutic modifications remain significant whatever the age of PLHIV. More devoted time to identify co-medications and OTC treatment is needed in all PLHIV.

A description of a hepatitis A outbreak in men who have sex with men and public health measures implemented in Seine-Maritime department, Normandy, France, 2017.

BACKGROUND: In 2016-2017, a European-wide circulation of genotype IA hepatitis A virus was responsible for hepatitis A outbreaks in men who have sex with men (MSM). This study aimed to describe the outbreak investigation in Seine-Maritime department (France) and the control measures implemented accordingly. METHODS: Outbreak description used data from mandatory reporting and enhanced surveillance of male cases. Confirmed case was genotype IA isolated, possible cases had no reported genotype information. Targeted control measures included communication on sexual practices at risk of hepatitis A transmission and two vaccination campaigns in April 2017 and January 2018. Characteristics of cases and vaccinees were described. We reported the best communication channel for relaying outbreak information and control measures based on the monitoring of social network activities and feedback from vaccinees. RESULTS: During the outbreak period (December 2016 to December 2017), a total of 48 confirmed outbreak cases and 30 possible outbreak cases were notified. Among them, 69 were male (88%). Two epidemic waves were observed. Cases encountered their partners through gay-dating apps (54%) and in one specific sauna (62%). In response to the outbreak, two vaccination campaigns were deployed. A total of 156 MSM were vaccinated, of whom 56 in a truck parked beside the sauna. Most of the vaccinees had been informed about the campaign through dating apps (44%). Community-based organizations involved in sexual health promotion and other gay social media were very proactive in sharing information about the outbreak and promoting the vaccination campaign through their social media account and also on site (gay venues). Vaccinees reported the same sexual practices at risk of hepatitis A transmission as cases. CONCLUSIONS: In response to this massive hepatitis A outbreak that affected mostly MSM in Seine-Maritime department, vaccination campaign remained the cornerstone of prevention. Prevention officers from the community-based organization played a key role in vaccination promotion. Gay-dating apps and outdoor sessions of vaccination allowed to effectively reach MSM. Cost-effectiveness studies might analyze the interest of a continuous sexual health promotion including vaccination against hepatitis A in MSM through dating apps and social networks.

Benefits of a Pre-Treatment Comprehensive Geriatric Assessment in a Rare Case of Gemella Haemolysans Endocarditis in an 86-Year-Old Patient and a Review of the Literature.

Infective endocarditis is a serious condition, which is associated with high mortality in elderly patients. Gemella haemolysans (GH) is a microorganism from the Streptococcus family, rarely involved in infective endocarditis. Here, we present a case of Gemella haemolysans endocarditis in an 86-year-old patient, successfully treated by antibiotics and surgery following a pre-treatment comprehensive geriatric assessment (CGA). This case is discussed in the context of a review of all published cases of Gemella haemolysans endocarditis. We illustrate the benefit of a systematic pre-treatment comprehensive geriatric assessment in elderly patients with infective endocarditis.

Primary bacterial ventriculitis in adults, an emergent diagnosis challenge: report of a meningoccal case and review of the literature.

BACKGROUND: Defined by an infection of the ventricular system of the brain, ventriculitis is usually known as a health-care associated infection. In contrast, primary pyogenic ventriculitis complicating community-acquired meningitis is uncommon, and mainly described in infants. Only seven cases that have occured in adults have been found in the international literature. CASE PRESENTATION: We report here a new case due to Neisseria meningitidis occurring in an 85 year-old-man. The comparison with previous reports allows to drawn several conclusions: (i) cases occurred in relatively old adults (median age: 65 years); (ii) Streptococcus pneumoniae, N. meningitiditis and Staphylococcus aureus are the leading responsible pathogens; (iii) atypical clinical presentation seems the rule in which meningism often lacks; (iv) in absence of clinical or biological specific parameters, modern brain imaging such as magnetic resonance imaging with gadolinium enhancement is of utmost importance for the diagnosis, leading to anticipate an increase of the diagnosis in the near future, thanks to easier access to such exploration; (v) death or serious sequelae commonly occurred; (vi) prolonged antibiotic courses (6 weeks to 3 months) have been used, without strong rational. In the given case, the patient presented with a lack of meningeal irritation signs. The diagnosis was made by MRI considering a lasting confused state. A four-week antibiotic regimen was successful, combining two weeks of intravenous cefotaxime followed by two weeks of oral levofloxacin much easier to administrate and allowing early rehabilitation. CONCLUSION: Primary bacterial ventriculitis is a real diagnosis challenge. Larger indications of MRI for bacterial meningitis, particularly in cases with an atypical presentation or poor evolution would certainly increase the number of diagnosis.

Antiretroviral Therapy as Prevention of Pneumococcal Infections?

BACKGROUND: Despite antiretroviral therapy, it is generally believed that the risk for pneumococcal infections (PnIs) is high among patients infected with human immunodeficiency virus (HIV). However, most studies in this field have been conducted before 2010, and the proportion of virologically suppressed patients has drastically increased in these latter years thanks to larger indications and more effective antiretroviral regimens. This study aimed to re-evaluate the current risk of PnI among adult patients infected with HIV. METHODS: The incidence of PnI was evaluated between 1996 and 2014 in 2 French regional hospitals. The 80 most recent cases of PnI (2000-2014) were retrospectively compared with 160 controls (HIV patients without PnI) to analyze the residual risk factors of PnI. RESULTS: Among a mean annual follow-up cohort of 1616 patients, 116 PnIs were observed over 18 years. The risk factors of PnI among patients infected with HIV were an uncontrolled HIV infection or "classic" risk factors of PnI shared by the general population such as addiction, renal or respiratory insufficiency, or hepatitis B or C coinfection. Pneumococcal vaccination coverage was low and poorly targeted, because only 5% of the cases had been previously vaccinated. The incidence of invasive PnIs among HIV patients with a nonvirologically suppressed infection or comorbidities was 12 times higher than that reported in the general population at the country level (107 vs 9/100000 patients), whereas the incidence among virologically suppressed HIV patients without comorbidities was lower (7.6/100000 patients). CONCLUSIONS: Human immunodeficiency virus infection no longer per se seems to be a significant risk factor for PnI, suggesting a step-down from a systematic to an "at-risk patient" targeted pneumococcal vaccination strategy.

Antineutrophil Cytoplasmic Antibodies Associated With Infective Endocarditis.

To determine the prevalence of antineutrophil cytoplasmic antibodies (ANCA) in patients with infective endocarditis (IE) in internal medicine; and to compare clinical and biochemical features and outcome between patients exhibiting IE with and without ANCA.Fifty consecutive patients with IE underwent ANCA testing. The medical records of these patients were reviewed.Of the 50 patients with IE, 12 exhibited ANCA (24%). ANCA-positive patients with IE exhibited: longer duration between the onset of first symptoms and IE diagnosis (P = 0.02); and more frequently: weight loss (P = 0.017) and renal impairment (P = 0.08), lower levels of C-reactive protein (P = 0.0009) and serum albumin (P = 0.0032), involvement of both aortic and mitral valves (P = 0.009), and longer hospital stay (P = 0.016). Under multivariate analysis, significant factors for ANCA-associated IE were: longer hospital stay (P = 0.004), lower level of serum albumin (P = 0.02), and multiple valve involvement (P = 0.04). Mortality rate was 25% in ANCA patients; death was because of IE complications in all these patients.Our study identifies a high prevalence of ANCA in unselected patients with IE in internal medicine (24%). Our findings further underscore that ANCA may be associated with a subacute form of IE leading to multiple valve involvement and more frequent renal impairment. Because death was due to IE complications in all patients, our data suggest that aggressive therapy may be required to improve such patients' outcome.