[Details of meningitis in the elderly]. / Particularités des méningites du sujet âgé.

PURPOSE: Elderly patients being more at risk for infections than younger people, this study was aimed at defining the epidemiological and clinical features of meningitis in this population, with the objective of improving diagnosis and management. METHODS: Over a period of 10 years, all cases admitted to an infectious diseases unit for acute meningitis were reviewed. Patients infected by human immunodeficiency virus (HIV), fungi meningitis, and who were younger than 15 years of age were excluded from the study. According to age, two groups were constituted (group A: < 65 years and group B: > or = 65 years) and compared. RESULTS: One hundred fifty-two patients were included in the study: 110 (72.4%) in group A (29 with bacterial and 81 with viral meningitis) and 42 (26.7%) in group B (32 with bacterial and ten with viral meningitis); the mean age was, respectively, 32.7 +/- 12.9 years (range: 15-61 years) and 75.9 +/- 7.6 years (range: 65-94 years). Diagnosis was less frequently evoked in the elderly (n = 11; 26%) than in younger patients (n = 78; 71%) (P < 0.001). Streptococcus pneumoniae, Listeria monocytogenes, and herpes simplex virus were the three most common causal agents in group B. Confusion was the most common symptom among the elderly (88 vs. 17%; P < 0.001). The mortality rate was more important in group B than in group A (11.9 vs. 2.7%; P = 0.04). CONCLUSIONS: Diagnosis of acute meningitis is difficult and must be evoked in the presence of any new neurologic sign. Cranial computerized tomography should not delay lumbar puncture, except in the presence of focal neurologic symptoms. Antimicrobial therapy takes into account the bacterial epidemiology.

[Effect of age on the prognosis of infectious endocarditis]. / Influence de l'âge sur le pronostic de l'endocardite infectieuse.

The aim of this study was to evaluate the influence of age on the prognosis of infectious endocarditis. A retrospective study from 1987 to 1997 of 136 patients with infectious endocarditis on native, prosthetic valves or cardiac pacing catheter was performed. The outcome was analysed with the help of general practitioners. Two groups of patients were compared: 87 patients of 65 years of age or more (Group 1) and 49 patients under 65 years of age (Group 2). With a follow-up period of 5 years, the global mortality was 35%, but greater in Group 1 (p = 0.06). Cardiac failure was the main cause of death. The mortality was significantly higher in patients who were not operated (p < 0.002). The authors conclude that age of over 65 does not significantly worsen the prognosis of infectious endocarditis. The absence of surgery seems to be an indirect factor of a poor prognosis. Long-term follow-up of patients is necessary to diagnose and treat cardiac failure at an early stage and to consider referral for surgery.

[Muco-cutaneous colonization and nosocomial infections caused by methicillin-resistant Staphylococcus aureus and Acinetobacter baumanii in intensive care patients]. / Colonisation cutaneo-muqueuse et infections nosocomiales à Staphylococcus aureus meticilline résistant et à Acinetobacter baumanii chez des malades en réanimation médicale.

This study was designed to assess the frequency and risk factors for colonization with MRSA and A. baumanii in the intensive care unit, and to analyse the relationship between colonization and infection with MRSA or A. baumanii. During a 24-day survey period, colonization was studied weekly with nasal, throat and digit skin swabs; nosocomial infections were routinely monitored according to CDC recommendations. Clinical data and invasive procedures were registered during a one-year non-epidemic period; 103 ICU patients hospitalized for more than 7 days were prospectively included. We investigated acquired colonization and nosocomial infection with SAMR or A. baumanii for 87 patients not colonized by SAMR or A. baumanii on admission. The colonization acquisition rate was 56% for MRSA and 27% for A. baumanii. Infection incidence (cases per 1,000 patient-days) was 6.46 for MRSA and 1.61 for A. baumanii. On univariate analysis, acquired MRSA colonization was associated with longer ICU stays, longer mechanical ventilation and longer central venous catheterization. Multivariate analysis only showed an association with longer ICU stay. Acquired A. baumanii colonization was associated with SAPSII, longer mechanical ventilation, and longer central venous catheterization in univariate analysis. Multivariate analysis only showed an association with SAPSII and longer mechanical ventilation. In this study, SAMR or A. baumanii infections were not associated with colonization or clinical setting or invasive procedures.

[Attitude of the clinican toward adverse effects of protease inhibitors]. / Attitude du clinicien face aux effets indésirables des inhibiteurs des protéases.

Since 1996, marketing of new drugs called protease inhibitors has revolutionized the treatment of patients suffering from AIDS. The side-effects of this new therapeutic family are quite well known but we wanted to evaluate the attitude of the clinician: can these adverse effects be corrected by symptomatic treatment, do they regress spontaneously or do they lead to an alternative PI therapy? We therefore carried out a retrospective survey in the Infectious Diseases Department of Poitiers Hospital consisting in research on files of patients (n = 70) treated in this department (hospitalization and consultation) for any clinical or biological abnormality attributable to the PI. For each drug we determined what sort of side-effects could be found and the position adopted by the clinician. For 30 patients the PI was stopped and for 21 of these cases because of drug toxicity (gastrointestinal, neurological, renal and metabolic effects). The biological anomalies are quite well tolerated and regress spontaneously in most cases.

[Infections due to foreign bodies: primary prevention]. / Infections sur corps étrangers: prévention d'abord.

PATHOGENESIS: Subsequent to physico-chemical reactions, foreign bodies, for example catheters, can be colonized by Staphylococcus early at the time of insertion. Once the foreign body has been introduced, germs adhere to the proteins deposited on its surface by the host defense systems. A better understanding of the pathogenesis of these infections should help in developing new strategies for prophylaxis. PREVENTIVE MEASURES: Aseptic insertion with careful skin cleansing, adapted material, and impregnation of the catheter are all essential factors. It would appear that antiseptics are more effective than antibiotics for impregnating catheters. Silver-impregnated venous catheters have given promising results; similar findings have been reported for urinary catheters. EXTERNAL PACEMAKERS: In case of endocarditis, the best treatment is complete ablation of the material and antibiotic therapy. Relapse is inevitable if the material is not removed.

[Pneumococcal infections in the adult population observed at the Poitiers University Hospital. Epidemiologic and clinical study]. / Infections à pneumocoques observées au CHU de Poitiers dans la population adulte. Etude épidémiologique et clinique.

OBJECTIVES: The aim of this study was to assess the prevalence of penicillin-nonsusceptible pneumococcus (PNSP) infections and their clinical and microbiological features among an adult population hospitalized at the Poitiers University Hospital. PATIENTS AND METHODS: A prospective study was conducted between November 1994 and October 1995 and included all pneumococcus infections. RESULTS: Fifty-three adults with one pneumococcal strain were included. The overall rate of PNSP strains was 28%. Infections with PNSP strains were more resistant than penicillin-susceptible pneumococcus to other antibiotics. The most frequent infection was pneumonia (36 infections, 28% PNSP). DISCUSSION: The rate of PNSP in pneumococcal infections was the same in the Poitiers University Hospital as in national surveys in France. The high percentage of multiresistant strains (86.5%) limit the use of antibiotics other than beta-lactams. Surveys of pneumococcal resistance to antibiotics are needed to adapt antibiotic strategies to the local epidemiological situation.

[Distinctive features of tuberculosis in the aged]. / Particularités de la tuberculose chez les sujets âgés.

INTRODUCTION: Current recrudescence of human tuberculosis is ascribed to HIV. Nevertheless, other at-risk individuals, particularly the elderly, have been reported. METHODS: A retrospective study aimed at defining distinctive features of tuberculosis in the elderly was conducted. Eighty-two records of patients aged 18 to 64 years were compared to those of 58 patients of 65 years of age and over. RESULTS: In the French area considered in this study, the elderly represent the most at-risk group. Institutionalization is a significant risk factor for tuberculosis (RR = 4). Despite a past history of tuberculosis and public awareness campaigns, first-intent diagnosis was evoked in only 22% of the older patients. The mean number of infectious localizations was higher in the elderly (1.3/patient) than in younger patients (1.1/patient). Results of tuberculin skin tests are unreliable. Prognosis is poor in the elderly. In the present study, 14 of the 18 encountered deaths occurred in the elderly, of which eight were due to tuberculosis. CONCLUSION: To decrease the current incidence of tuberculosis, evaluations of preventive measures in the elderly should be validated and implemented, especially in institutionalized patients.

High prevalence and usual persistence of serum monoclonal immunoglobulins evidenced by sensitive methods in renal transplant recipients.

BACKGROUND: The occurrence of serum monoclonal immunoglobulins in kidney transplant recipients is well known but their significance and predictive value for the occurrence of lymphoma are a matter of debate. We therefore conducted a study of monoclonal immunoglobulins by a sensitive method during the long-term follow up of grafted patients. METHODS: Monoclonal immunoglobulins were characterized by high-resolution electrophoresis, conventional immunoelectrophoretic analysis, and a sensitive Western blotting procedure in the serum from 84 renal transplant recipients prior to grafting and subsequently, with a 1-8-year follow-up and excluding the patients who developed posttransplant lymphoma. RESULTS: Low abundance monoclonal immunoglobulins were detectable prior to transplantation in 56 cases (66.6%) and after graft in 72 cases (85.5%) (and in 1 case (1.2%) and 18 cases (21.4%) of cases respectively, by immunoelectrophoresis). These abnormalities were often multiple in individual sera. Monoclonal components detected by immunoblotting were transient in 23.8% of patients only (whereas those evidenced by immunoelectrophoresis usually became undetectable by this method) and their pattern was remarkably stable in the majority of cases. The frequency of post-transplant monoclonal immunoglobulins was higher in patients of more than 50 years of age than in younger patients. The appearance of monoclonal components after grafting and their transient character correlated with CMV infections. No correlation was found with various other parameters. The isotypic distribution of monoclonal immunoglobulins with an IgM, IgG3, and IgG1 predominance and an abnormally low kappa/lambda ratio was the same as that observed in various immunodeficiency states. The monoclonal immunoglobulin pattern in three further patients who developed post-transplant lymphoma was unremarkable. CONCLUSION: Monoclonal immunoglobulins hence are not discriminant for lymphoma and their characterization does not appear to be necessary in the evaluation of followed up grafted patients, at least for a prediction of post-transplant lymphoma.

Goals and preparation method for ground operations for the manned space flight Altair.

The mission's success fully depends on the Payload Operations conducted during the space flight. The Ground Team has to be trained to assist the Space Crew, to replan the cosmonaut's activities when contingencies occur onboard and to change or cancel Payload activities when required. In order to act efficiently during the mission, the Ground Team must be prepared in advance of the flight and able to operate special tools for tracking the mission's progress. anticipating problems and taking decisions in realtime. This document sets out the approach for conducting such a preparation for Ground Operation. It will be focused on the Altair mission performed in July 1993 onboard the Russian Mir space station.

Remote assistance experiment during the manned space flight Altair.

This remote assistance trial, performed within the framework of the manned space flight Altair, was carried out by CADMOS (CNES), with the cooperation of the Sub-directorate of CNES Operational Systems, Medes, LBM of Tours and Christol Consultants. It consisted of supplying the cosmonaut performing the Orthostatism experiment (echograph acquisition) on board the Mir station with realtime assistance by an expert (LBM of Tours) working from the ground on the CADMOS premises. The various steps of the approach followed during the preparation phase are described, as well as the technical means of communication used between the Mir station and CADMOS.

Failure of pristinamycin treatment in a case of pneumococcal pneumonia.

A case of pneumonia caused by Streptococcus pneumoniae occurring in a patient receiving pristinamycin is reported. Despite empirical treatment with pristinamycin, 2 g/day for five days, the patient's condition worsened. Protected brush specimen and blood cultures permitted isolation of Streptococcus pneumoniae. MIC testing indicated that the strain was susceptible to pristinamycin and resistant to erythromycin and penicillin. Streptococcus pneumoniae was eradicated by cefotaxime, and pneumonia resolved. This case underlines the fact that pristinamycin may not be suitable for the treatment of multiresistant pneumococcal infections.