In the context of the COVID-19 pandemic, wearing a face mask has become usual and ubiquitous, in both hospitals and community. However, the general public is consuming surgical or filtering facepiece ...(FFP) masks irrespective of their specificity, leading to a global supply shortage for the most exposed persons, who are healthcare workers. This underlines the urgent need to clarify the indications of the different categories of mask, in order to rationalize their use. This article specifies the French position for the rational use of respiratory protective equipment for healthcare workers.
Les anévrismes infectieux de l’aorte sont rares, représentant environ 2 % des anévrismes aortiques. La majorité des cas décrits dans la littérature proviennent de séries chirurgicales et concernent ...l’aorte abdominale. Dans ce travail rétrospectif, nous avons analysé les caractéristiques cliniques, paracliniques et évolutives de patients présentant un anévrisme infectieux de l’aorte thoracique.
Le diagnostic a été porté sur l’association d’une imagerie thoracique évocatrice et d’une documentation microbiologique ou de l’évolution favorable sous traitement anti-infectieux. Étude rétrospective de cas.
Il s’agissait de 6 hommes et une femme, d’âge moyen 66 ans. Tous présentaient au moins un facteur de risque cardiovasculaire ou de l’athérome. La fièvre (71 %) et les douleurs thoraciques (42 %) étaient les signes cliniques les plus fréquents. Les germes identifiés étaient : Salmonella enteritidis (n=3), Staphylococcus aureus (n=1), et Candida albicans (n=1). L’angioscanner montrait un aspect inflammatoire de l’aorte (n=4), un anévrisme supérieur à 50 mm (n=5) ou augmentant rapidement de diamètre (n=5). La prise en charge était médicale et interventionnelle : chirurgie (n=3) ou prise en charge endovasculaire (n=4). L’évolution était favorable pour 6 patients ; le dernier décédait de complications liées à l’anévrisme.
La présentation clinique d’un anévrisme infectieux de l’aorte thoracique est peu spécifique. Il convient d’évoquer ce diagnostic devant un anévrisme volumineux ou augmentant rapidement de diamètre, associé à un syndrome inflammatoire. Le traitement endovasculaire semble une bonne alternative à la chirurgie. La place du TEP-scanner dans le diagnostic et le suivi reste à définir.
Infectious aortic aneurysms are rare conditions, being responsible of 2% of aortic aneurysms. Most published results are surgical case series concerning infected abdominal aorta. In this retrospective study, we assessed clinical features and outcome of patients presenting infectious thoracic aortic aneurysms.
Diagnosis was based upon a combination of imaging evidence for thoracic aorta aneurysm and evidence for an infective aetiology including a culture of a causative pathogen, or a favourable outcome with anti-infective therapy. Retrospective case series.
Six men and one woman were included, with a mean age of 66 years. All the patient presented at least one cardiovascular risk factor or atherosclerosis localisation. Fever (71%) and chest pain (42%) were the most common clinical presenting manifestations. The causative pathogens were: Staphylococcus aureus (N=1), Salmonella enteritidis (N=3) and Candida albicans (N=1). The contrast-enhanced computed-tomography disclosed an aneurysm whose diameter reached more than 50 mm (N=5), that increased rapidly in size (N=5), or presented an inflammatory aspect of the aortic wall (N=4). Management was both medical and interventional: surgery (N=3) or endoluminal repair (N=4). Outcome was favourable in six patients; one patient died from aneurysm-related complications.
Clinical manifestations revealing an infectious thoracic aneurysm are variable. Diagnosis should be considered in patients presenting a rapidly-growing aneurysm, especially in the presence of elevated acute phase reactants. Endoluminal repair constitutes a treatment option. The role of FDG-PET for diagnosis and follow-up remains to be defined.
The high microbiologic diversity encountered in prosthetic joint infection (PJI) makes the choice of empirical antimicrobial therapies challenging, especially in cases of implant retention or ...one-stage exchange. Despite the risk of dysbiosis and toxicity, the combination of vancomycin with a broad-spectrum β-lactam is currently recommended in all cases, even if Gram-negative bacilli (GNB) might be less represented in late PJI. In this context, this study aimed to describe the microbiologic epidemiology of PJI according to the chronology of infection.
This prospective cohort study (2011–2016) evaluated the microbiologic aetiology of 567 PJI according to time of occurrence from prosthesis implantation—early (<3 months), delayed (3–12 months) and late (>12 months)—as well as mechanism of acquisition.
Initial microbiologic documentation (n = 511; 90.1%) disclosed 164 (28.9%) Staphylococcus aureus (including 26 (16.1%) methicillin-resistant S. aureus), 162 (28.6%) coagulase-negative staphylococci (including 81 (59.1%) methicillin-resistant coagulase-negative staphylococci), 80 (14.1%) Enterobacteriaceae, 74 (13.1%) streptococci and 60 (10.6%) Cutibacterium acnes. Considering nonhaematogenous late PJI (n = 182), Enterobacteriaceae (n = 7; 3.8%) were less represented than in the first year after implantation (n = 56; 17.2%; p <0.001), without difference regarding nonfermenting GNB (4.6% and 2.7%, respectively). The prevalence of anaerobes (n = 40; 21.9%; including 32 (80.0%) C. acnes) was higher in late PJI (p <0.001). Consequently, a broad-spectrum β-lactam might be useful in 12 patients (6.6%) with late PJI only compared to 66 patients (20.3%) with early/delayed PJI (p <0.001).
Considering the minority amount of GNB in late postoperative PJI, the empirical use of a broad-spectrum β-lactam should be reconsidered, especially when a two-stage exchange is planned.
The detailed investigation of the broadband flux variability in the blazar 3C 273 allowed us to probe the location and size of emission regions and their physical conditions. We conducted correlation ...studies of the flaring activity in 3C 273, which was observed for the period between 2008 and 2012. The observed broadband variations were investigated using the structure function and the discrete correlation function methods. Starting from the commonly used power spectral density (PSD) analysis at X-ray frequencies, we extended our investigation to characterise the nature of variability at radio, optical, and γ-ray frequencies. The PSD analysis showed that the optical and infrared light-curve slopes are consistent with the slope of white-noise processes, while the PSD slopes at radio, X-ray, and γ-ray energies are consistent with red-noise processes. We found that the estimated fractional variability amplitudes strongly depend on the observed frequency. The flux variations at γ-ray and mm-radio bands are found to be significantly correlated. Using the estimated time lag of (110 ± 27) days between γ-ray and radio light-curves, where γ-ray variations lead the radio bands, we constrained the location of the γ-ray emission region at a de-projected distance of 1.2 ± 0.9 pc from the jet apex. Flux variations at X-ray bands were found to have a significant correlation with variations at both radio and γ-ray energies. The correlation between X-ray and γ-ray light curves indicates two possible time lags, which suggests that two components are responsible for the X-ray emission. A negative time lag of −(50 ± 20) days, where the X-rays are leading the emission, suggests that X-rays are emitted closer to the jet apex from a compact region (0.02–0.05 pc in size), most likely from the corona at a distance of (0.5 ± 0.4) pc from the jet apex. A positive time lag of (110 ± 20) days (γ-rays are leading the emission) suggests a jet-base origin of the other X-ray component at ~4 to 5 pc from the jet apex. The flux variations at radio frequencies were found to be well correlated with each other such that the variations at higher frequencies are leading the lower frequencies, which is expected from the standard shock-in-jet model.
BK virus (BKV) reactivation has been increasingly associated with the occurrence of late-onset hemorrhagic cystitis (HC) after allogeneic hematopoietic SCT (allo-HSCT) resulting in morbidity and ...sometimes mortality. We investigated the incidence, risk factors and outcome of BKV-HC in 323 consecutive adult patients undergoing allo-HSCT over a 5-year period. BK viremia values for HC staging were evaluated, as well as the medico-economic impact of the complication. Forty-three patients developed BKV-HC. In univariate analysis, young age (P=0.028), unrelated donor (P=0.0178), stem cell source (P=0.0001), HLA mismatching (P=0.0022) and BU in conditioning regimen (P=0.01) were associated with a higher risk of developing BKV-HC. In multivariate analysis, patients receiving cord blood units (CBUs) (P=0.0005) and peripheral blood stem cells (P=0.011) represented high-risk subgroups for developing BKV-HC. BK viremia was directly correlated to HC severity (P=0.011) with a 3 to 6-log peak being likely associated with grades 3 or 4 HC. No correlation was found between BKV-HC and acute graft versus host disease or mortality rate. Patients with BKV-HC required a significantly longer duration of hospitalization (P<0.0001), more RBC (P=0.0003) and platelet transfusions (P<0.0001). Over the 5-year study period, the financial cost of the complication was evaluated at \euro2 376 076 ($3 088 899). Strategies to prevent the occurrence of late-onset BKV-HC after allo-HSCT are urgently needed, especially in CBU and peripheral blood stem cell recipients. BK viremia correlates with the severity of the disease. Prospective studies are required to test prophylactic approaches.
Le groupe de travail Secproch (pour sécurité des produits issus du corps humain) a été créé en 2019 au sein du Haut Conseil de la santé publique (HCSP) pour traiter l’ensemble des problématiques ...affectant les produits sanguins labiles, les organes, tissus, cellules (OTC) et gamètes issus du corps humain. Il est notamment en charge de la gestion des alertes en matière d’arboviroses. Ces infections dues à des virus transmis par des arthropodes font l’objet d’émergences ou réémergences, plus particulièrement dans le contexte du réchauffement climatique. Cette revue rapporte les alertes traitées par le groupe Secproch entre 2019 et 2021 suite à trois pathologies dues à des Flaviviridae : dengue, infection à virus West Nile (WNV) et encéphalite à tique. Les alertes « dengue » ont concerné les Antilles où le virus est endémo-épidémique, l’île de la Réunion où la population était naïve jusqu’en 2018 vis-à-vis du virus et la métropole où des foyers de cas autochtones surviennent sporadiquement. L’infection à WNV a touché à la fois des humains et des chevaux en 2019 dans le sud de la France mais avec une intensité beaucoup moindre qu’en 2018. Enfin, le virus de l’encéphalite à tique a été responsable d’un foyer d’une quarantaine de cas dans l’Ain suite à une contamination par du fromage cru non pasteurisé de chèvre. Cette revue est l’occasion de revoir les risques relatifs à ces trois virus en matière de transmission par le sang et les OTC et de préciser les moyens recommandés par le HCSP pour sécuriser ces produits.
The Secproch working group (for “sécurité des produits issus du corps humain”) was created in 2019 within the « Haut Conseil de la santé publique » (HCSP) for addressing all the questions related to labile blood products, organs, tissues, cells (OTC) and gametes issued from human body. It is notably in charge of the management of alerts regarding arbovirus infections. These infections due to arthropod-transmitted viruses are responsible for emergence and reemergence, notably in the context of global warming. This review relates the alerts taken into consideration by the Secproch group between 2019 and 2021 following three pathologies due to Flaviviridae : dengue, West Nile virus (WNV) infection and tick-borne encephalitis (TBE). The dengue alerts have occurred in French Indies where the virus is endemic/epidemic, Reunion Island where the population was naïve until 2018 towards the virus, and the metropole where foci of autochthonous cases are observed sporadically. The WNV infection was responsible of both human and equine cases in 2019 in the South of France but with intensity much less than in 2018. At last, the TBE virus was at the origin of a cluster of about 40 cases in the Ain department following a contamination by crude non-pasteurized goat cheese. This review offers the opportunity to reevaluate the risks linked to these three viruses through blood products and organs/tissues/cells and to precise the means recommended by HCSP to secure these products.
Highlights • A literature review dealing with medical treatment of vascular prosthesis infections was performed. • The microbiological epidemiology of vascular prosthesis infections was highlighted. ...• Indications and modalities of empirical antibiotherapy are proposed. • Documented antibiotherapy of vascular prosthesis infections is described.
Antifungal resistance is a significant and emerging threat. Stewardship programmes (SPs) have been proposed as an opportunity to optimize antifungal use. While examples of antifungal SP ...implementation have been recently described, there is yet to be an overview of interventions and their impacts on performance measures.
We systematically reviewed published articles using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses check-list 2009. MEDLINE was searched using the term 'antifungal stewardship' on 15 February 2017. Eligible studies were those that described an antifungal SP and included an intervention and an evaluation of performance measures.
A total of 97 studies were identified and 14 were included. Only five studies reported an antifungal stewardship team composed of all the recommended members. The main intervention was the formulation of recommendations to change treatment (12 of 14). The main performance measure collected was antifungal consumption (10 of 14), followed by antifungal expenditure (7 of 14), adherence to therapeutic advice (4 of 14) and impact on mortality (4 of 14). Antifungal consumption was reduced by 11.8% to 71% and antifungal expenditure by as much as 50%. Adherence to therapeutic advice ranged from 40% to 88%, whereas antifungal SPs had no impact on mortality.
All antifungal SPs had an impact, in particular on antifungal consumption and antifungal expenditure. Active intervention including a review of prescriptions seems to have more impact than implementation of treatment guidelines only. According to available published studies, antifungal consumption appears to be the most achievable performance measure to evaluate the impact of an antifungal SP.
: In patients undergoing a « debridement, antibiotics, and implant retention » (DAIR) procedure for acute staphylococcal prosthetic joint infection (PJI), post-operative treatment with rifampin has ...been associated with a higher probability of success.(1,2) However, it is not known whether it is the total dose, delay of introduction or length of therapy with rifampin that is most strongly associated with the observed improved outcomes.
: A multicentric, retrospective cohort study of patients with acute staphylococcal hip and knee PJI treated with DAIR between January 2011 and December 2016. Failure of the DAIR procedure was defined as persistent infection, need for another surgery or death. We fitted logistic and Cox regression multivariate models to identify predictors of DAIR failure. We compared Kaplan-Meier estimates of failure probability in different levels of the 3 variables of interest - total dose, delay of introduction or length of therapy with rifampin - with the log-rank test.
: 79 patients included (median age 71 years 63.5-81; 55 men 70%), including 54 (68%) DAIR successes and 25 (32%) DAIR failures. Patients observed for a median of 435 days IQR 107.5-834. Median ASA score significantly lower in DAIR successes than in DAIR failures (2 vs. 3, respectively
= 0.011). Bacterial cultures revealed 65 (82.3%)
and 16 (20.3%) coagulase negative staphylococci, with 2 patients being infected simultaneously with
and CNS. Among
isolates, 7 (10.8%) resistant to methicillin; 2 (3.1 %) resistant to rifampin. Median duration of antimicrobial therapy was 85 days IQR 28.5-97.8. Fifty-eight patients (73.4%) received rifampin at a median dose of 14.6 mg/kg/day |IQR 13-16.7, started at a median delay of 8.5 days IQR, 4-7.5 after debridement surgery. Twenty-one patients (26.6%) developed a drug-related adverse event, leading to rifampin interruption in 6 of them (7.6% of total cohort). Determinants of DAIR failure were rifampin use (HR 0.17, IC 0.06, 0.45, p-value <0.001), association of rifampin with a fluoroquinolone (HR 0.19, IC 0.07, 0.53, p-value = 0.002) and duration of rifampin therapy (HR 0.97, IC 0.95, 1, p-value = 0.022). We did not observe a significant difference between DAIR successes and failures in rifampin use, dose and delay of introduction. In a multivariate Cox model, only duration of rifampin therapy was significantly associated with DAIR failure. Kaplan Meier estimate of DAIR failure probability was significantly higher in patients receiving less than 14 days of rifampin in comparison with those receiving more than 14 days of rifampin (
= 0.0017).
: Duration of rifampin therapy is a key determinant of improved outcomes in early-onset acute prosthetic joint infection due to
treated with DAIR.
The use of piperacillin/tazobactam with vancomycin as empirical antimicrobial therapy (EAT) for prosthetic joint infection (PJI) has been associated with an increased risk of acute kidney injury ...(AKI), leading us to propose cefepime as an alternative since 2017 in our reference centre.
To compare microbiological efficacy and tolerance of these two EAT strategies.
All adult patients with PJI empirically treated with vancomycin+cefepime (n = 89) were enrolled in a prospective observational study and matched with vancomycin+piperacillin/tazobactam-treated historical controls (n = 89) according to a propensity score including age, baseline renal function and concomitant use of other nephrotoxic agents. The two groups were compared using Kaplan-Meier curve analysis, and non-parametric tests regarding the proportion of efficacious empirical regimen and the incidence of empirical therapy-related adverse events (AE).
Among 146 (82.0%) documented infections, the EAT was considered efficacious in 77 (98.7%) and 65 (98.5%) of the piperacillin/tazobactam- and cefepime-treated patients, respectively (P = 1.000). The rate of AE, particularly AKI, was significantly higher in the vancomycin+piperacillin/tazobactam group n = 27 (30.3%) for all AE and 23 (25.8%) for AKI compared with the vancomycin+cefepime n = 13 (14.6%) and 6 (6.7%) group (P = 0.019 and <0.001, respectively), leading to premature EAT discontinuation in 20 (22.5%) and 5 (5.6%) patients (P = 0.002). The two groups were not significantly different regarding their comorbidities, and AKI incidence was not related to vancomycin plasma overexposure.
Based on the susceptibility profile of bacterial isolates from included patients, microbiological efficacy of both strategies was expected to be similar, but vancomycin + cefepime was associated with a significantly lower incidence of AKI.
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