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In French Guiana, community-acquired pneumonia (CAP) represents over 90% of Coxiella burnetii acute infections. Between 2004 and 2007, we reported that C. burnetii was responsible for 24.4% of the 131 CAP hospitalized in Cayenne. The main objective of the present study was to determine whether the prevalence of Q fever pneumonia remained at such high levels. The secondary objectives were to identify new clinical characteristics and risk factors for C. burnetii pneumonia. A retrospective case-control study was conducted on patients admitted in Cayenne Hospital, between 2009 and 2012. All patients with CAP were included. The diagnosis of acute Q fever relied on titers of phase II IgG ≥ 200 and/or IgM ≥ 50 or seroconversion between two serum samples. Patients with Q fever were compared with patients with non-C. burnetii CAP in bivariate and multivariate analyses. During the 5-year study, 275 patients with CAP were included. The etiology of CAP was identified in 54% of the patients. C. burnetii represented 38.5% (106/275; 95% CI: 31.2–45.9%). In multivariate analysis, living in Cayenne area, being aged 30–60 years, C-reactive protein (CRP) > 185 mg/L, and leukocyte count < 10 G/L were independently associated with Q fever. The prevalence of Q fever among CAP increased to 38.5%. This is the highest prevalence ever reported in the world. This high prevalence justifies the systematic use of doxycycline in addition to antipneumococcal antibiotic regimens.

BackgroundThe diffusion of the SARS-CoV-2 delta (B.1.617.2) variant and the waning of immune response after primary Covid-19 vaccination favoured the breakthrough SARS-CoV-2 infections in vaccinated subjects. To assess the impact of vaccination, we determined the severity of infection in hospitalised patients according to vaccine status.MethodsWe retrospectively analysed data from patients hospitalised in 10 centres with a SARS-CoV-2 infection (delta variant) from July to November 2021: i) all patients who had completed their primary vaccination at least 14 days before hospital admission; and ii) the same number of completely unvaccinated patients. We assessed the impact of vaccination and other risk factors through logistic regression.FindingsWe included 955 patients (474 vaccinated and 481 unvaccinated). Vaccinated patients were significantly older, more frequently males, and with more comorbidities. They were less often admitted for Covid-19 (59·3% vs. 75·1%, pConclusionsAmong patients hospitalised with a delta variant SARS-CoV-2 infection, vaccination was associated with less severe forms, even in the presence of comorbidities.

Dengue virus is endemic in French Guiana with occurrence of cyclical outbreaks. There is a need for rapid tests allowing dengue laboratory diagnosis in healthcare centers scattered throughout this wide Amazonian territory. Our objective was to evaluate the real-life performance of the SD BIOLINE Dengue Duo (IgG/IgM + NS1 Ag) rapid test (RDT) during the 2012-2013 dengue epidemics. The RDT was evaluated in parallel with routine laboratory tests, PlateliaTM Dengue NS1 Ag and Focus Diagnostics Dengue Fever Virus IgM Capture DxSelect. A total of 3,347 patients with suspected dengue acute infection were evaluated. The diagnostic performances of the SD BIOLINE NS1 Ag were equivalent to Platelia NS1, 471 patients (14.1%) were NS1 Ag positive with the RDT and 14.2% with Platelia. The Cohen's Kappa coefficient was 0.86 [95%CI: 0.83-0.88], indicating an almost perfect agreement. Moreover, the sensitivity of SD BIOLINE NS1 Ag relative to the RT-PCR method was 87% [95%CI: 80-93%] and the specificity was 92% [95% CI: 87-97%]. However, the SD BIOLINE IgM test was found positive in 6.3% of the samples in comparison to 10.7% with Dx Select IgM. The Cohen's Kappa coefficient was 0.53 [95%CI: 0.47-0.58] indicating a moderate agreement. This raised concern about the SD BIOLINE IgM for the diagnostic of dengue in endemic areas. When considering only NS1 Ag results and not IgM, the RDT could be a viable solution to manage dengue outbreaks in healthcare centers where no laboratory services are available, in the early phase of the disease.

Q fever in French Guiana : a specific epidemiological context. During the last 15 years, several studies have been conducted to describe the epidemiology of animal and human Q fever in French Guiana. The main findings highlight disease specificity in this area associated with a unique and hypervirulent strain of Coxiella burnetii, suburban and close to forested area of transmission, pneumonia as primary manifestation of acute Q fever, wild animal reservoir and ticks as putative vector of the bacterium. Prevalence of the disease in French Guianese population remains unknown. A comprehensive health strategy is needed to prevent the disease. We present recent acquired knowledge and outstanding issues, in a “One Health” approach., Les études scientifiques menées sur la fièvre Q en Guyane au cours des quinze dernières années ont permis de répondre à de nombreuses interrogations sur l’épidémiologie humaine et animale de cette maladie. Les résultats observés démontrent une réelle spécificité locale de la fièvre Q, avec une souche de Coxiella burnetii unique et hypervirulente, une transmission suburbaine et en bordure de forêt, principalement sur la ville de Cayenne et ses alentours, des formes pulmonaires prédominantes, un réservoir sauvage de la bactérie et la possibilité d’une transmission vectorielle par les tiques. La prévalence réelle de la maladie dans la population guyanaise reste inconnue et conditionne la mise en oeuvre d’une stratégie de santé publique dédiée. Cette communication se propose de faire une synthèse sur l’ensemble des connaissances acquises et sur les questions qui demeurent, dans une approche One Health., Pommier de Santi Vincent, Marié Jean-Lou, Briolant Sébastien, Mahamat Aba, Djossou Félix, Epelboin Loïc, Lamour Thierry, Thoisy Benoît de, Raoult Didier, Edouard Sophie, Davoust Bernard. Spécificités épidémiologiques de la fièvre Q en Guyane. In: Bulletin de l'Académie Vétérinaire de France tome 169 n°2, 2016. pp. 148-154.

International audience; A Q fever epidemic occurred in 2013 in a small military residential area in Cayenne, French Guiana. A retrospective cohort study was conducted to identify Q fever risk factors. Confirmed acute Q fever case was defined as positive serology (IgM >= 50 and phase II IgG >= 200) and/or positive qPCR on serum or blood. In addition, wild mammals were captured at the study site and tested by serology and real-time PCR performed on blood, vaginal swabs and ticks. The attack rate was 20 percent (11/54). All the cases were symptomatic with fever > 38.5 degrees C and community-acquired pneumonia for four cases. Log binomial multivariate models identified two independent risk factors associated with Q fever: to clean the house (RRa = 7.5 CI95% [1.03-55.3]) and to carry a three-toed sloth in arms (RRa = 2.6 CI95% [1.1-5.8]). Eighteen marsupial individuals were captured, all PCRs were negative but 17% (3/18) had a positive serology. Another study conducted after the epidemic found only one (1/4) three-tooth sloth (Bradypus tridactylus) with feces highly infectious for C. burnetii MST17. The same strain C. burnetii genotype 17 has been laboratory-confirmed in this mammal and in human cases. These results support the implication of three-toed-sloth in this epidemic. Human contamination mainly occurs through inhalation of infectious aerosols as suggested by high relative risk associated with house cleaning activities and pulmonary forms of the disease, and through direct contact with three- toed-sloth. Positive serological results among marsupials confirm wildlife exposure and suggest a more complex sylvatic transmission cycle among wild mammals.

Rationale: The pathway of Nontyphoid Salmonella meningitis, especially in exclusive breastfeeding infants, has not been well characterized. Patient concerns: We analyzed data related to nontyphoid Salmonella meningitis in 4 infants. Diagnoses: No diarrhea was observed and the coproculture was negative for all patients. Interventions: Early diagnosis and treatment with combination of third-generation cephalosporins plus quinolones for a minimum of 3 weeks is necessary to avoid severe sequelae and death. Outcomes: The first 3 patients had a good evolution, whereas the last patient had multiple brain abscesses and hydrocephalus requiring treatment with a ventriculoperitoneal shunt. Lessons: The highlights of our study are that all infants were exclusively breastfed, no diarrhea observed and the negative coproculture for all the 4 patients, which is relatively rare for Salmonella infection.

Background. Calendar trends in virologic failure (VF) among human immunodeficiency virus (HIV)-infected patients can help to evaluate the performance of healthcare systems and the need for new antiretroviral therapy (ART). We examined the time trend in the rate of VF beyond 6 months of ART between 1997 and 2011 in France. Methods. We included patients from the French Hospital Database on HIV who received at least 6 months of ART. VF was defined as 2 consecutive plasma HIV-RNA values >500 copies/mL or as 1 value >500 copies/mL followed byatreatment switch. We adjusted for patients’ characteristics by fitting a multivariable generalized estimating equation logistic regression model with an exchangeable covariance matrix. Results. A total of 81738 patients were enrolled, and median follow-up was 112.4 months. Median CD4 count was 333 cells/µL, and 23% of patients had HIV infection classified as Centers for Disease Control and Prevention stage C. Overall, 29.3% of patients received single/dual-drug ART initially, and 45.4% of patients experienced at least 1 episode of VF during follow-up. The percentage of patients with VF fell from 61.5% in 1997–1998 to 9.7% in 2009–2011 (P

Coxiella burnetii, the causative agent of Q fever, is present worldwide. Recent studies have shown that this bacterium is an emerging pathogen in French Guiana and has a high prevalence (24% of community-acquired pneumonia). In this review, we focus on the peculiar epidemiology of Q fever in French Guiana. We place it in the context of the epidemiology of the disease in the surrounding countries of South America. We also review the clinical features of Q fever in this region, which has severe initial presentation but low mortality rates. These characteristics seem to be linked to a unique genotype (genotype 17). Finally, we discuss the issue of the animal reservoir of C. burnetii in French Guiana, which is still unknown. Further studies are necessary to identify this reservoir. Identification of this reservoir will improve the understanding of the Q fever epidemic in French Guiana and will provide new tools to control this public health problem.

Q fever is an emergent disease in French Guiana. We compared the incidence clinical and serologic profiles between patients from Cayenne, French Guiana and Marseille in metropolitan France during a four-year period. The annual incidence of diagnosed acute Q fever was significantly higher in Cayenne (17.5/100,000) than in Marseille (1.9/100,000) (P = 0.0004), but not the annual incidence of endocarditis (1.29 versus 0.34/100,000). Most patients had fever (97%) and pneumonia (83%) in Cayenne versus 81% and 8% in Marseille (P < 0.0001 and P < 0.0001, respectively) but transaminitis was more common in patients from Marseille (54% versus 32%; P < 0.0001). The proportion of patients with cardiovascular infections was significantly lower in Cayenne (7%) than in Marseille (17%) (P = 0.017), although they showed a stronger immune response with higher levels of phase I IgG (P = 0.024). The differing epidemiology, clinical, and serologic responses of patients from Cayenne and Marseille suggest a different source of infection and a different strain of Coxiella burnetii.

International audience; The French Hospital Database on HIV (FHDH) is a hospital-based multicentre open cohort with inclusions ongoing since 1989. The research objectives focus mainly on mid- and long-term clinical outcomes and therapeutic strategies, as well as severe AIDS and non-AIDS morbidities, and public health issues relative to HIV infection. FHDH also serves to describe HIV-infected patients receiving hospital care in France. FHDH includes data on more than 120,000 HIV-infected patients from 70 French general or university hospitals distributed throughout France. Patients are eligible for inclusion if they are infected by HIV-1 or HIV-2 and give their written informed consent. Standardized variables are collected at each outpatient visit or hospital admission during which a new clinical manifestation is diagnosed, a new treatment is prescribed or a change in biological markers is noted, and/or at least every 6 months. Since its inception, variables collected in FHDH include demographic characteristics, HIV-related biological markers, the date and type of AIDS and non AIDS-defining events, antiretroviral treatments and the date and causes of death, as reported in the medical records. Since 2005, data have also been collected on: co-infection with hepatitis B or C virus; alcohol and tobacco use; and non HIV-related biomarkers. Anyone can submit a research project by completing a standardized form available on the FHDH website (http://www.ccde.fr/_fold/fl-1385734776-429.pdf) or from the corresponding author, describing the context and objectives of the study. All projects are reviewed by the scientific committee.

Q fever in French Guiana is correlated with the rainy season. We found a 1- to 2-month lagged correlation between Q fever incidence and the number of births of three-toed sloth. This result strengthens the hypothesis that the three-toed sloth is the wild reservoir of Q fever in French Guiana.

Elderly people are at increased risk of influenza and pneumococcal diseases. Influenza increases clinical pneumococcal disease incidence. Pneumococcal vaccination could therefore be a supplement to influenza vaccination. This study evaluated all-cause mortality and antibiotic consumption according to elderly people’s influenza and pneumococcal vaccination status. Its goal was to demonstrate that vaccination with both Influenza and pneumococcal vaccines decrease all-cause mortality and antibiotic consumption. From 2004-10-01 to 2004-12-31 (3 mo), elderly people (≥ 65 y) who lived in the Gard department (South of France) were offered both vaccinations. Among the 68,897 subjects followed-up one year after this vaccination campaign, 21,303 (30.9%) were vaccinated with both vaccines, 18,651 (27.1%) with influenza vaccine alone, 3,769 (5.5%) with pneumococcal vaccine alone; 25,174 (36.5%) subjects were unvaccinated. Mortality rate (per 1,000 inhabitants-year) adjusted on gender, age and prior underlying chronic disease was 17.9 (95% CI: 16.3–19.6), 20.8 (19.0–22.8), 22.5 (19.0–26.6) and 24.7 (22.7–26.8), respectively. It was 42.1 (38.8–45.8) in elderly people with underlying chronic disease who received both vaccines vs. 58.1 (53.7–62.9) in unvaccinated elderly people. The decrease in mortality rate was 27.0% (20.0–34.0) in subjects who received both vaccines and 16.0% (6.0–24.0) in those who received influenza vaccine. No significant reduction in mortality rate was seen with the pneumococcal vaccine alone. Influenza and/or pneumococcal vaccinations did not decrease antibiotic consumption that drastically increases during the winter period. An additive effect was observed in the prevention of all-cause mortality with influenza and pneumococcal vaccines given together in elderly people, including in those with underlying chronic disease.

Background Identifying patients at risk of developing severe dengue is challenging. The objective of the present study was to determine the incidence of hypotension and its predictive factors during the Dengue 2 epidemic in 2013. Methods In 2013, a longitudinal study was performed using data from all confirmed cases of dengue seen in Cayenne General Hospital. The analysis used Cox proportional modeling to obtain adjusted hazards ratios for hypotension. Results A total of 806 confirmed patients were included 78 (9.6%) of whom developed hypotension. Extensive purpura, cutaneomucous hemorrhage, serous effusion and age 1-15 years were associated with subsequent hypotension whereas 'aches' and a rash were associated with a lower incidence of hypotension. The biological variables independently associated with hypotension were: increase of hematocrit, low protein concentrations, low sodium concentration and lymphocytes over 1400/ml. A risk score was computed from the scaled Cox model coefficient. Conclusions From a clinician's perspective, extensive purpura, cutaneomucous hemorrhage, serous effusion, age 1-15 years, hematocrit increase, low protein, low sodium, lymphocytosis and the absence of aches or of a rash, may be important warning signs to predict subsequent hypotension and shock. Over half of the patients with the highest risk score subsequently developed hypotension. The prognostic score had a 48.2% sensitivity with less than 10% of false positives. This score requires external validation before its impact on clinical practice is evaluated.

International audience; Q fever is a cosmopolitan zoonosis caused by an intracellular bacterium, Coxiella burnetii. Since its discovery in 1935 in Australia, its presence has been reported almost worldwide in animals and humans [1]. In most developed countries, this infection has been widely described, and its life cycle, exposure factors, and clinical and biological pictures are well known. The incidence of Q fever is generally quite low, and most of the cases are diagnosed during short outbreaks related to direct or indirect contact of humans with cattle, sheep, or goats, which are the main reservoirs. In developing countries, information on endemicity is generally scarce and limited to seroprevalence studies in exposed populations or case reports. This presumably reflects misdiagnosis, rather than lower incidence. The diagnosis of acute Q fever mostly relies on the elevation of anti-C. burnetii antibodies by 15 to 21 days after the onset of the symptoms, detected by Immunofluorescence Assay, which is the gold standard for C. burnetii detection. However, these diagnostic techniques are often not available in tropical areas and, apparently, in numerous Latin American settings. Indeed, an exhaustive review of the literature in English, French, Spanish, and Portuguese showed that publications on Q fever in Latin America are scarce despite the worldwide presence of the disease (Table 1). Seven countries have never reported any cases of Q fever according to the available literature (Belize, Costa Rica, Guatemala, Guyana, Honduras, Paraguay, Suriname); three haven't reported any since 1990, but some older studies do exist (Bolivia, Pan-ama, Venezuela); seven countries reported one or two publications since 1990 (Argentina, Chile, Ecuador, El Salvador, Peru, Trinidad, Uruguay); and Colombia, Mexico, and Brazil published several publications, including mostly case reports of chronic Q fever, one case of acute Q fever, several seroprevalence studies in exposed populations, and some studies based on an acute febrile or acute respiratory syndrome approach. Recently, Q fever was confirmed in patients and animals in parts of the Brazilian Atlantic Forest. Thus, there are no publications on Q fever in the Amazon region except in French Guiana and Ecuador.

International audience; This study investigated the clinical epidemiology and resistance mechanisms of Acinetobacter baumannii and characterised the clonal diversity of carbapenem-resistant A. baumannii (CRAB) during an ICU-associated outbreak at Cayenne Hospital, French Guiana. All non-duplicate A. baumannii isolates from 2008 to 2014 were tested for antibiotic susceptibility by disk diffusion. Multilocus sequence typing, pulsed-field gel electrophoresis (PFGE) and characterisation of carbapenemase-encoding genes were performed on CRAB. Of the 441 A. baumannii isolates, most were from males (54.0%) and were detected mainly from the ICU (30.8%) and medicine wards (21.8%). In the ICU, strains were mainly isolated from the respiratory tract (44.1%) and bloodstream (14.0%), whereas in medicine wards they mainly were from wound/drainage (36.5%) and bloodstream (25.0%). A. baumannii showed the greatest susceptibility to piperacillin/tazobactam (92.7%), imipenem (92.5%), colistin (95.6%) and amikacin (97.2%), being lower in the ICU and medicine wards compared with other wards. An outbreak of OXA-23-producing CRAB occurred in the 13-bed ICU in 2010. CRAB strains were more co-resistant to other antimicrobials compared with non-CRAB. Molecular genetics analysis revealed five sequence types [ST78, ST107 and ST642 and two new STs (ST830 and ST831)]. Analysis of PFGE profiles indicated cross-transmissions of CRAB within the ICU, between the ICU and one medicine ward during transfer of patients, and within that medicine ward. This study provides the first clinical and molecular data of A. baumannii from French Guiana and the Amazon basin. The ICU was the highest risk unit of this nosocomial outbreak of OXA-23-producing CRAB, which could subsequently disseminate within the hospital.

Background Community-acquired pneumonia (CAP) is the major manifestation of Q fever, an emerging disease in French Guiana. Consequently, the empirical antibiotherapy used for the treatment of CAP combines doxycycline and the recommended amoxicillin. Our objectives were to estimate the prevalence of Q fever pneumonia and to build a prediction rule to identify patients with Q fever pneumonia for empirical antibiotic guidance. Methods A retrospective case-control study was conducted on inpatients admitted with CAP in the Department of Infectious Diseases of Cayenne Hospital from 2004 to 2007. Serodiagnosis for Coxiella burnetii was performed for all patients. Risk factor analysis was performed using multivariate logistic regression, and a prognostic score was computed using bootstrap procedures. The score performance characteristics were used to choose the best prediction rule to identify patients with Q fever pneumonia. Results One hundred thirty-one patients with CAP were included and the Q fever pneumonia prevalence was 24.4% (95% confidence interval [CI], 17.1-31.9). In multivariate analysis, male sex, middle age (age, 30-60 years), headache, leukocyte count 185 mg/L were independently associated with Q fever pneumonia. Patients with a predictive score ≤3 had a low risk of Q fever pneumonia with a negative predictive value of 0.97 (95% CI, .90-1) and a sensitivity of 0.97 (95% CI, .89-1). Conclusions The prediction rule described here accurately identifies patients with low risk of Q fever pneumonia and may help physicians to make more rational decisions about the empirical use of antibiotherapy. Further prospective studies should be performed to validate this score.

Resume Objectifs Evalue lors d’un audit prospectif, la compliance aux recommandations des pratiques d’antibioprophylaxie (ATBP) chirurgicale et identifier les facteurs predictifs de non-conformite. Patients et methode Etude prospective entre le 1 er fevrier et le 30 avril 2008 des conformites de l’indication (recommandee et prescrite ou non recommandee et non prescrite), de l’administration (molecule, dose, horaire et duree) ainsi que la conformite globale (indication et administration) des ATBP pour l’ensemble des patients admis pour une chirurgie propre ou propre-contaminee. Les facteurs predictifs de non-conformite globale ont ete estimes a partir d’analyse de regression logistique multivariee. Resultats Au total, 481 pratiques ont ete evaluees. La conformite de l’indication a ete de 83 %, celle de l’administration a ete de 56 %. La conformite globale n’a ete que de 37 %. Apres analyse multivariee, la prescription par un chirurgien (RR = 3,4, IC 95 % : 1,6–7,5), la chirurgie propre-contaminee (2,2 ; 1,4–3,7), la chirurgie traumatologique (1,87 ; 1,1–3,3), la chirurgie digestive (3,7 ; 1,8-7,5) et la chirurgie de la tete et du cou (11,4 ; 2,3–56,3) etaient predicteurs de non-conformite globale. Conclusion Cet audit a confirme la variabilite de la conformite aux pratiques d’ATBP selon le type de chirurgie et la classe de contamination. Plus pedagogique, il a estime, un risque plus eleve de non-respect du protocole en cas de prescription par les chirurgiens. Des plans d’actions specifiques ont ete mis en œuvre suite a la restitution des resultats a l’ensemble des acteurs concernes.

We conducted this prospective randomized study to compare the success rate and the onset time between 3 intensities of stimulation threshold (0.5, 0.5-0.64, and 0.65-0.8 mA) when using a peripheral nerve stimulation at the midhumeral level.Sixty-nine adult patients undergoing elective hand surgery were studied. Blocks were performed using conventional nerve stimulation technique. Needle advance began at 2 mA (1 Hz, 0.1 millisecond). When motor response (MR) occurred at less than 0.5 mA, needle position was fixed for "group0.5 mA." For "group 0.5-0.64 mA," the needle was withdrawn until MR occurred at greater than 0.5 mA and disappeared at less than 0.5 mA. For "group0.65 mA," the needle was withdrawn until MR occurred at greater than 0.65 mA and disappeared at less than 0.65 mA. For each group, patients received 8 mL of ropivacaine 7.5 mg/mL on the 4 nerves (radial, median, ulnar, and musculocutaneous). Primary end point was the number of failed radial nerve sensory blocks at 30 mins.The time to perform the block was not different between the 3 groups (17 mins [SD, 7 mins] vs 13 mins [SD, 8 mins] and 13 mins [SD, 4 mins], respectively). The time required to obtain a complete sensory block was shorter for the 4 nerves in group0.5 mA, with a statistical significance for radial and musculocutaneous nerves in group0.5 mA versus group 0.5-0.64 mA and group0.65 mA. Patients in group0.5 mA had a greater success rate for complete sensory radial nerve compared with those of group 0.5-0.64 mA and group0.65 mA at any interval times between 5 and 30 mins (P = 0.0001). Supplemental local anesthesia was provided for the 3 groups more frequently for the median nerve, with no difference between groups. Group0.65 mA required 5 general anesthesias (20%) as compared with 1 (4%) in group0.5 mA (P0.05). No adverse event (dysesthesia) occurred after 48 hrs and 45 days.We conclude that intensity of stimulation influenced onset time and success rate.

Background and objectives As B-type Natriuretic Peptide (BNP) is a marker of ventricular wall stress, the present study was aimed at determining whether plasma BNP concentration could predict fluid responsiveness in critically ill patients with acute circulatory failure. Methods This prospective and non randomized interventional study included 33 sedated, mechanically ventilated patients, with acute circulatory failure requiring cardiac output measurement and fluid challenge. Plasma BNP concentration was measured before and after fluid challenge (250 to 500 ml with infusion rate = 999 ml/h). An increase in stroke index (SI) greater than or equal to 15% allowed separation of responders from nonresponders. Receiver operating characteristic (ROC) curves were generated for BNP and compared to that of central venous pressure (CVP) that is routinely considered as a marker of cardiac preload. Results Among 33 patients, there were 24 responders. At baseline, BNP plasma values were less in responders (328 [35–1190] pg/ml versus 535 [223–5000] pg/ml, p Conclusion In critically ill patients with acute circulatory failure, BNP does not accurately predict fluid responsiveness.

Mixtures of lidocaine with a long-acting local anesthetic are commonly used for peripheral nerve block. Few data are available regarding the safety, efficacy, or pharmacokinetics of mixtures of local anesthetics. In the current study, we compared the effects of bupivacaine 0.5% or ropivacaine 0.75% alone or in a mixed solution of equal volumes of bupivacaine 0.5% and lidocaine 2% or ropivacaine 0.75% and lidocaine 2% for surgery after femoral-sciatic peripheral nerve block. The primary end point was onset time.In a double-blind, randomized study, 82 adults scheduled for lower limb surgery received a sciatic (20 mL) and femoral (20 mL) peripheral nerve block with 0.5% bupivacaine (200 mg), a mixture of 0.5% bupivacaine 20 mL (100 mg) with 2% lidocaine (400 mg), 0.75% ropivacaine (300 mg) or a mixture of 0.75% ropivacaine 20 mL (150 mg) with 2% lidocaine (400 mg). Each solution contained epinephrine 1:200,000. Times to perform blocks, onset times (end of injection to complete sensory and motor block), duration of sensory and motor block, and morphine consumption via IV patient-controlled analgesia were compared. Venous blood samples of 5 mL were collected for determination of drug concentration at 0, 5, 15, 30, 45, 60, and 90 min after placement of the block.Patient demographics and surgical times were similar for all four groups. Sciatic onset times (sensory and motor block) were reduced by combining lidocaine with the long-acting local anesthetic. The onset of bupivacaine-lidocaine was 16 +/- 9 min versus 28 +/- 12 min for bupivacaine alone. The onset of ropivacaine-lidocaine was 16 +/- 12 min versus 23 +/- 12 for ropivacaine alone. Sensory blocks were complete for all patients within 40 min for those receiving bupivacaine-lidocaine versus 60 min for those receiving bupivacaine alone and 30 min for those receiving ropivacaine-lidocaine versus 40 min for those receiving ropivacaine alone (P0.05). Duration of sensory and motor block was significantly shorter in mixture groups. There was no difference among groups for visual analog scale pain scores and morphine consumption during the 48 h postoperative period, except for bupivacaine alone (median: 9 mg) versus bupivacaine-lidocaine mixture (15 mg), P0.01. There was no difference in the incidence of adverse events among groups. Plasma concentrations of bupivacaine and ropivacaine were higher, and remained elevated longer, in patients who received only the long-acting local anesthetic compared to patients who received the mixture of long-acting local anesthetic with lidocaine (P0.01).Mixtures of long-acting local anesthetics with lidocaine induced faster onset blocks of decreased duration. Whether there is a safety benefit is unclear, as the benefit of a decreased concentration of long-acting local anesthetic may be offset by the presence of a significant plasma concentration of lidocaine.

Molecular methods have become essential in the diagnosis of visceral leishmaniasis (VL) in patients who have AIDS. The present study aimed at (1) identifying relapse risk factors for VL and (2) assessing the value of long-range routine polymerase chain reaction (PCR) monitoring in such patients (3) with a view to proposing decision-making elements for discontinuing specific secondary prophylaxis. A cohort of 27 HIV-positive patients was prospectively followed up during a period of 5 months to 9 years (median = 51 months) after a first episode of VL. The clinical and biologic follow-up protocol included routine Leishmania detection using peripheral blood and a previously validated PCR method. Quantitative and qualitative variables were statistically analyzed. Sixteen patients relapsed for a total of 38 relapses. CD4 counts less than 100 cells/microL and absence of highly active antiretroviral therapy at primary diagnosis and CD4 counts less than 100 cells/microL during follow-up were the major predictive factors for relapse. No relapse occurred when CD4 counts were greater than 200 cells/microL. The Leishmania PCR assay was positive in all clinical relapses and its negative predictive value was 100%. The PCR assay used here proved extremely useful for routine follow-up of VL in patients who had AIDS. Considering CD4 cell counts and Leishmania PCR assays these results allow defining proposals for discontinuing secondary prophylaxis and thus optimizing the clinical care of VL in these patients. (authors)

Background. The benefits of continuing antiretroviral therapy are questionable in human immunodeficiency virus (HIV) type 1-infected patients with profound immunodeficiency and multiple treatment failure due to viral resistance. Methods. From the French Hospital Database on HIV, we selected 12,765 patients with a CD4 + cell count

Contains fulltext : 70499.pdf (Publisher’s version ) (Closed access) OBJECTIVE: To determine whether differences in short-term virologic failure among commonly used antiretroviral therapy (ART) regimens translate to differences in clinical events in antiretroviral-naive patients initiating ART. DESIGN: Observational cohort study of patients initiating ART between January 2000 and December 2005. SETTING: The Antiretroviral Therapy Cohort Collaboration (ART-CC) is a collaboration of 15 HIV cohort studies from Canada, Europe, and the United States. STUDY PARTICIPANTS: A total of 13 546 antiretroviral-naive HIV-positive patients initiating ART with efavirenz, nevirapine, lopinavir/ritonavir, nelfinavir, or abacavir as third drugs in combination with a zidovudine and lamivudine nucleoside reverse transcriptase inhibitor backbone. MAIN OUTCOME MEASURES: Short-term (24-week) virologic failure (>500 copies/ml) and clinical events within 2 years of ART initiation (incident AIDS-defining event, death, and a composite measure of these two outcomes). RESULTS: Compared with efavirenz as initial third drug, short-term virologic failure was more common with all other third drugs evaluated; nevirapine (adjusted odds ratio = 1.87, 95% confidence interval (CI) = 1.58-2.22), lopinavir/ritonavir (1.32, 95% CI = 1.12-1.57), nelfinavir (3.20, 95% CI = 2.74-3.74), and abacavir (2.13, 95% CI = 1.82-2.50). However, the rate of clinical events within 2 years of ART initiation appeared higher only with nevirapine (adjusted hazard ratio for composite outcome measure 1.27, 95% CI = 1.04-1.56) and abacavir (1.22, 95% CI = 1.00-1.48). CONCLUSION: Among antiretroviral-naive patients initiating therapy, between-ART regimen, differences in short-term virologic failure do not necessarily translate to differences in clinical outcomes. Our results should be interpreted with caution because of the possibility of residual confounding by indication.

Hospitals in the northeast of Scotland have experienced methicillin-resistant Staphylococcus aureus (MRSA) outbreaks since 1997. Several infection control measures were introduced sequentially to control MRSA, and antibiotic use has been monitored. From January 1997 to December 2004, data on the monthly percentage of non-duplicate MRSA infections (%MRSA) were collated from an intervention hospital (IH) and a control hospital (CH). Both hospitals introduced the use of alcohol hand gel in November 2002. Furthermore, the IH introduced an environmental MRSA swabbing programme in March 2001, chlorine disinfection of the environment in September 2001, discharge screening in December 2001, admission screening in November 2003 and environmental audits in March 2004. Multivariate dynamic regression analysis was used to evaluate the longitudinal effects of these interventions as measured by new clinical cases of MRSA. At the IH, the %MRSA increased between January 1998 and January 2001 and then decreased. At the CH, the %MRSA increased from January 1997 to December 2004. Introduction of alcohol hand gel was associated with an absolute decrease in %MRSA of 21% and 30%, respectively, for the IH and CH. At the IH, introduction of chlorine disinfection and environmental swabbing were, respectively, associated with a decrease in %MRSA of 27% immediately and 32% 3 months later. Discharge screening and environmental audit did not significantly affect %MRSA, whereas admission screening was associated with a 22% decrease in %MRSA 4 months later. Increasing macrolide use was associated with increasing %MRSA in both hospitals, and increasing quinolone use was associated with increasing %MRSA in the CH. Implementation of stepwise infection control measures was associated with a decrease in %MRSA in the IH. Introduction of an alcohol gel for hand hygiene was associated with a decrease in %MRSA in both hospitals. Antibiotic use also affects %MRSA, in particular that of macrolides and quinolones.

Resume Introduction Le bloc tronculaire du nerf femoral a ete propose comme technique analgesique simple et efficace apres fracture du col du femur. Cette modalite d'analgesie administree en continue par catheter femoral (CF) est comparee a deux procedures d'analgesie classique : morphine sous-cutanee (s.c.) (M) et propacetamol intraveineuse (i.v.) (P). Methode Les patients (n = 62) operes sous anesthesie spinale etaient inclus et randomises en trois groupes en postoperatoire : groupe CF (catheter femoral : voie inguinale paravasculaire, injection d'un bolus initial et entretien par injection continue de ropivacaine 0,2 %), groupe P (propacetamol i.v. 2 g/6 heures), groupe M (Morphine s.c. : 0,05 mg/kg toutes les quatre heures). Une analgesie additionnelle etait standardisee : titration morphine intraveineuse puis relais par voie sous-cutanee par quatre heures. La consommation morphinique etait le critere principal de jugement. Les criteres secondaires etaient colliges : en effets adverses (morphine), morbidite, mortalite et score EVA. Resultats Les caracteristiques chirurgicales et anesthesiques etaient similaires pour les trois groupes. Apres titration morphinique, les scores EVA etaient similaires entre les groupes de 0 a 48 heures. La consommation totale de morphine etait plus elevee dans le groupe CF : 26 mg (5–42) versus P : 8 mg (3–12) (p = 0,0001) ou M : 19 mg (8–33) (p Conclusion L'analgesie par catheter femoral continu apres fracture du col du femur ne montre pas de reel benefice pour un cout financier significativement plus eleve.

International audience; Background - Chronic kidney disease (CKD) is frequent in individuals infected with human immunodeficiency virus (HIV). Progression to end-stage renal disease can be slowed by appropriate medical management. Methods - To assess whether active promotion of guidelines improves CKD management, we conducted a cluster randomized controlled trial within the French Hospital Database on HIV (FHDH-ANRS CO4). We randomized 46 centers participating in the FHDH to either simple information on guideline availability or active promotion with a multifaceted and repeated intervention comprising reminders and audit feedback and targeting of local opinion leaders carried out between April 2009 and April 2010. Outcome measure was CKD management adequacy assessed before and 2 years after the beginning of the intervention in HIV-infected patients with moderate to severe CKD. CKD management was considered adequate in case of referral to a nephrologist or if proteinuria, blood pressure, low-density lipoprotein cholesterol level, and glycemia had been measured during the previous year and medications had been prescribed when necessary. Results - Three hundred six patients were enrolled, of whom 238 (78%) completed the 2 years of follow-up. During the study period, the percentage of patients receiving adequate CKD management improved from 64.1% to 70.4% (+6.3%) in the active arm and from 68.3% to 75.6% (+7.3%) in the control arm (adjusted mean difference, -0.7 percentage points [95% confidence interval: -9.2 to 7.9]; P = .95). The biggest impact of active promotion was on the management of proteinuria and blood pressure. Conclusions - Adequate compliance with CKD management guidelines improved slightly between 2009 and 2011, with no difference between the simple information and active promotion arms. Clinical trials registration - CCTIRS 10.150 and CNIL DR-2010-379.

Current clinical guidelines consider regimens consisting of either ritonavir-boosted atazanavir or ritonavir-boosted lopinavir and a nucleoside reverse transcriptase inhibitor (NRTI) backbone among their recommended and alternative first-line antiretroviral regimens. However, these guidelines are based on limited evidence from randomized clinical trials and clinical experience.We compared these regimens with respect to clinical, immunologic, and virologic outcomes using data from prospective studies of human immunodeficiency virus (HIV)-infected individuals in Europe and the United States in the HIV-CAUSAL Collaboration, 2004-2013. Antiretroviral therapy-naive and AIDS-free individuals were followed from the time they started a lopinavir or an atazanavir regimen. We estimated the 'intention-to-treat' effect for atazanavir vs lopinavir regimens on each of the outcomes.A total of 6668 individuals started a lopinavir regimen (213 deaths, 457 AIDS-defining illnesses or deaths), and 4301 individuals started an atazanavir regimen (83 deaths, 157 AIDS-defining illnesses or deaths). The adjusted intention-to-treat hazard ratios for atazanavir vs lopinavir regimens were 0.70 (95% confidence interval [CI], .53-.91) for death, 0.67 (95% CI, .55-.82) for AIDS-defining illness or death, and 0.91 (95% CI, .84-.99) for virologic failure at 12 months. The mean 12-month increase in CD4 count was 8.15 (95% CI, -.13 to 16.43) cells/?L higher in the atazanavir group. Estimates differed by NRTI backbone.Our estimates are consistent with a lower mortality, a lower incidence of AIDS-defining illness, a greater 12-month increase in CD4 cell count, and a smaller risk of virologic failure at 12 months for atazanavir compared with lopinavir regimens.? The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.

Resume But de l'etude Analyser l'evolution de la resistance des souches urinaires de Proteus mirabilis du 1er janvier 1999 au 31 decembre 2005 au CHU de Nimes. Patients et methodes Nous avons collige retrospectivement les souches non redondantes issues des infections et colonisations urinaires de l'ensemble des services sauf des urgences. Resultats Parmi 1008 souches, 63,1 % ont ete isolees chez les femmes et la moyenne d'âge etait de 76 ans. Le taux moyen de resistance etait de 59,0 % pour l'amoxicilline (AMX), 48,0 % pour la piperacilline (PIP), 3,9 % pour le cefotaxime, 33,9 % pour l'amoxicilline + acide clavulanique (AMC) et 2,8 % pour l'association piperacilline + tazobactam (TZP). Une augmentation significative de la resistance a ete notee pour AMC et TZP. Ce taux moyen de resistance etait de 35,0 % pour la norfloxacine, 34,8 % pour ofloxacine et 23,5 % pour la ciprofloxacine. Aucune augmentation de la resistance aux fluoroquinolones (FQ) n'a ete constatee a l'exception de la ciprofloxacine tandis qu'une hausse significative a ete notee pour les aminosides. Une tendance a la baisse de la resistance au cotrimoxazole a ete constatee avec un taux de 33,2 %. Conclusion L'augmentation de la resistance pour AMC et TZP pourrait s'expliquer par l'emergence des β-lactamases particulierement a spectre etendu (10 %). La resistance aux FQ est preoccupante. En revanche, P. mirabilis reste sensible aux cephalosporines de troisieme generation ainsi qu'a TZP malgre la tendance significative a l'augmentation de resistance. L'amikacine est l'aminoside le plus efficace. Ces donnees pronent pour un maintien de la surveillance afin d'optimiser l'usage des antibiotiques.

Purpose To study the impact of different potent combined antiretroviral treatment (cART) on the incidence of HIV-associated Kaposi's sarcoma (KS) with and without visceral involvement. Patients and Methods Patients were selected from the French Hospital Database on HIV, a large hospital cohort. The risk of KS was estimated by using Cox proportional hazards models adjusting for age, the CD4 cell nadir, the HIV exposure category, prior AIDS, cART, and the type of cART regimen. cART regimens were distinguished according to whether they contained protease inhibitor (PI), non-nucleoside analog (NNRTI), both, or only nucleoside analog (NRTI). Separate analyzes were conducted according to the initial visceral involvement of KS. Results Among the 54,999 patients included in this study (182,756 person-years of follow-up), 1,634 patients were diagnosed with KS during follow-up, of whom 421 had visceral involvement at diagnosis. The KS incidence rate fell from 32 per 1,000 person-years in 1993 to 1994 to 3 per 1,000 person-years after 1999. PI-containing and NNRTI-containing cART regimens were associated with similar reductions in the risk of KS (hazard ratio, 0.68; 95%CI, 0.61 to 0.75; HR, 0.62; 95% CI, 0.54 to 0.71, respectively). The risk of visceral KS fell more strongly than the risk of cutaneous KS (> 50% and < 30%, respectively). Conclusion The incidence of KS, and especially visceral KS, has fallen sharply since the advent of cART. This effect is likely due to immune restoration rather than to a specific effect on the tumoral process, as PI-containing and NNRTI-containing regimens had similar preventive efficacy.

The emergence of Escherichia coli (E. coli) resistance to fluoroquinolones (FQs) increased and spread gradually worldwide since the early 1990s. The selective pressure of FQs is the main mechanism responsible for the emergence of FQ resistance as shown by in vitro studies. Clinical trials are required to prove the causality between exposure to FQs and emergence of resistance. But this would not be ethical in humans. Non experimental studies must answer several principles to establish causality: association, anteriority, and directional change. We described and compared the contribution of observational and quasi-experimental studies implemented to answer several of these principles. Quasi-experimental studies using interventional models (ARIMA models with transfer function), can answer several of these principles, unlike observational studies. Thus, in addition to assessment of the association, they were able to show that the exposure to FQs precedes the emergence of FQ resistance to E. coli. They were also able to estimate the time necessary for the emergence of resistance and the dose effect, and to show if this association was reversible.

Escherichia coli urinary tract isolates were collected in 1997–2003 from NîmesUniversity Hospital in order to investigate long-term trends in antibiotic resistance and to explore the relationship between antibiotic use and the emergence of resistance. Time-series analysis (ARIMA models) and dynamic regression models were used to investigate relationships between antibiotic use and resistance to ofloxacin and ciprofloxacin. Significant increases were seen in the frequency of ofloxacin (8.9 to 16.7%) and ciprofloxacin resistance (6.2 to 10.1%) (p < 0.001). Using multivariate dynamic regression analysis, it was found that an increased use of one defined daily dose (DDD)/1000 patient-days for ofloxacin, ciprofloxacin and norfloxacin induced average increases of 0.81%, 0.65%and 0.53%in E. coli ofloxacin resistance (p < 0.01), with average delays of 4, 4 and 6 months, respectively. An increase of 1 DDD/1000 patient-days of ciprofloxacin, ofloxacin and norfloxacin use induced increases of 0.73%, 0.82% and 0.63% in E. coli ciprofloxacin resistance (p < 0.01), with average delays of 4, 4 and 5 months, respectively. The use of nalidixic acid was not associated significantly with an increase in resistance to fluoroquinolones by multivariate analysis.

Acute Q fever is an emergent and severe disease in French Guiana. We obtained 5 Coxiella burnetii isolates from samples of patients from Cayenne and found an epidemic clone circulating in Cayenne. This clone has caused pneumonia and endocarditis and seems to be more virulent than previously described strains.

In 2002, 80 isolates of Enterobacteriaceae producing extended-spectrum β-lactamases (ESBLs) were collected from infected patients in our hospital. Enterobacter aerogenes was the most common bacterium isolated from all specimens (36.5%). The ESBLs were predominantly (90%) TEM derivatives (TEM-24, TEM-3). Pulsed-field gel electrophoresis highlighted that E. aerogenes , Klebsiella pneumoniae , and Citrobacter koseri had a clonal propagation.

A case-control study was conducted in a university hospital to determine the risk factors for nosocomial infection with multidrug-resistant Pseudomonas aeruginosa (MDR-PA) among all hospitalized patients and among those with a nosocomial infection due to P. aeruginosa. Eighty patients infected with MDR-PA, 75 infected with a non-MDR phenotype and 240 random controls were included in the 12-month study. Among all hospitalized patients, age, severity index, having a bedridden condition, transfer from other units, nasogastric feeding, urinary catheterization and exposure to beta-lactams (OR=2.5) or fluoroquinolones (OR=4.1) in the seven days before infection were linked to nosocomial infection due to MDR-PA. Among patients infected by P. aeruginosa, exposure to fluoroquinolones (OR=4.7) or surgery (OR=0.5) were linked to the isolation of MDR-PA. This study showed that, in addition to urinary catheterization, nasogastric feeding is an important risk factor in MDR-PA infection. Indeed, an imbalance in gut flora, modifications to the mucous membranes due to the use of nasogastric feeding and the selection pressures exerted by antibiotics were implicated in the occurrence of this infection.

Resume Objectif. – Evaluer les effets hemodynamiques de 250 ml de serum sale hypertonique (SSH) a 7,5 % chez des patients de reanimation en sepsis severe ou choc septique. Type d'etude. – Descriptive. Patients. – Douze patients ventiles en choc septique ou sepsis severe monitores par catheter arteriel pulmonaire necessitant une epreuve de remplissage. Methodes. – Deux cent cinquante millilitres de SSH ont ete administres en 15 minutes. Parametres etudies : frequence cardiaque (FC), pression arterielle moyenne (PAM), pression moyenne de l'artere pulmonaire (PAPm), pression de l'oreillette droite (POD), index cardiaque (IC), resistances vasculaires systemiques et pulmonaires indexees (RVSI, RVPI), natremie, chloremie, protidemie, hemoglobine, lactates arteriels. Ces parametres sont mesures avant traitement (Temps 0 = T0), a 5 (T20) et 105 (T120) minutes apres la fin de la perfusion. Resultats. – La PAM, la FC et la POD etaient inchangees. Le SSH a augmente la PAPm (25 ± 5 to 30 ± 6mmHg), la PAPO (13 ± 3 to 18 ± 4 mmHg) et l'IC (3,5 ± 1,2 to 4,6 ± 1,1 l/minute par m2) a T20 (p Conclusion. – Chez des patients en sepsis severe ou en choc septique, l'administration de 250 ml de SSH 7,5 % induit une augmentation transitoire (2 heures) de l'IC et de la PAPO associee a une hemodilution et une elevation de la natremie et de la chloremie.

Background The purpose of this study was to evaluate the efficacy and safety of episcleral single-injection anesthesia in a large number of patients. Methods Over a period of 5 yr, in four institutions, anesthesiologists involved in this prospective study completed a standardized form to evaluate single-injection medial canthus high-volume episcleral anesthesia. The success rate of the block was rated according to an akinesia score. The study parameters included demographic data, surgical procedure, and anesthetic management. All patients were followed up at least until postoperative day 1, and all complications, pain, and discomfort were noted. Statistical analysis was done to assess the risk factors for complications. Results A total of 2,031 patients were included in the study. The most frequent surgical procedures performed were phacoemulsification and posterior chamber artificial lens implantation (91.0%). A total of 66 complications (3.3%) occurred in 60 patients. One patient had a retrobulbar hemorrhage, and 59 had one or two more minor incidents or pain/discomfort with the procedure. The complications consisted of subconjunctival hematoma (1.3%), ocular hypertonia (0.4%), and chemosis (0.30%). Statistical analysis revealed that inexperience in the technique represented a risk factor for complications. Conclusions This is the first survey of a large experience in episcleral single-injection anesthesia, a form of anesthesia that does not preclude sharp-needle complications and does require training. Only one complication occurred among 2,031 patients; however, a larger number of patients is needed to definitively evaluate the safety of episcleral single-injection anesthesia.

The aim of the present study was to assess the joint contribution of hypertension and body mass index to coronary heart disease risk. DESIGN Prospective study on men aged 50-59 years free of coronary heart disease at entry recruited in three regions of France (n = 7359) and in Northern Ireland (n = 2399).The recruitment frame was based on industry and various employment groups, on health screening centers and general practice.Incident cases of effort angina, unstable angina, myocardial infarction and coronary death were recorded over a 5-year follow-up.Compared with the reference group [body mass index (BMI) 25 kg/m2], the relative risk of coronary event was higher in the second (25or =BMI 27.6) and third BMI tertiles: 1.27 (95% confidence interval 0.94-1.70) and 1.14 (0.84-1.56) after adjustment for confounders and covariates, including diabetes, hypertension and lipoprotein levels. Further analyses revealed a significant interaction between hypertension and BMI on coronary disease risk (P0.05), suggesting that hypertension modifies coronary heart disease (CHD) risk attributable to BMI. Among hypertensive men, the relative risk of coronary heart disease was 1.34 (0.85-2.11) and 1.61 (1.04-2.50) in the second and third BMI tertiles, respectively. In normotensive men, BMI was not associated with CHD risk; relative risk 1.25 (0.85-1.85) and 0.66 (0.40-1.09) in the second and third BMI, respectively.These results indicate that hypertension and overweight jointly increase coronary heart disease risk.

BACKGROUND The X-linked hyper-IgM (XHIM) syndrome is a rare form of primary immunodeficiency disorder characterized by hypogammaglobulinemia and impaired cell immunity. OBSERVATION We report history of Guianese family affected by XHIM syndrome. The eldest boy died at 7 months from pneumonia. The 5-month-old youngest boy presented with a potentially fatal episode of Pneumocystis jiroveci pneumonia. The diagnosis was done in the Pediatric Unit of Immunohematology of Hopital Necker in Paris. CONCLUSIONS This report points to the importance of diagnosis of XHIM to allow early treatment to minimize serious infections and to detect carriers in XHIM families for genetic counseling.

International audience; Objective: To describe characteristics and outcomes of HIV-infected patients with Pneumocystis jirovecii pneumonia (PCP) over 2004–2011 in France, in particular in those previously enrolled (PE) in the French Hospital Database on HIV (FHDH). Methods: PE patients with an incident PCP were compared with patients with an inaugural PCP revealing HIV infection (reference). Adequate adherence to care was defined as a CD4 measurement at least every 6 months. Immune reconstitution (CD4$200/mm 3) and risk of death were studied using Kaplan-Meier estimates and multivariable Cox proportional hazards models. Results: In a context of a decreasing incidence of PCP, 1259 HIV-infected patients had a PCP diagnosis, and 593 (47%) were PE patients of whom 161 (27%) have had a prior history of AIDS-defining clinical illness (prior ADI). Median time since enrolment was 8 years for PE patients; 74% had received cART. Median proportion of time with adequate adherence to care was 85% (IQR, 66–96) for all FHDH enrollees, but only 45% (IQR, 1–81) for PE patients during the 2 years before PCP. Median CD4 cell count (38/mm 3) and HIV viral load (5.2 log10 copies/ml) at PCP diagnosis did not differ between PE patients and the reference group. Three year mortality rate of 25% was observed for PE prior ADI group, higher than in PE non-prior ADI group (8%) and the reference group (9%) (p,0.0001). In the PE prior ADI group, poor prognosis remained even after adjustment for virological control and immune reconstitution (HR, 2.4 [95%CI, 1.5–3.7]). Conclusion: Almost 50% of PCP diagnoses in HIV-infected patients occurred presently in patients already in care, mainly with a previous cART prescription but with waning adherence to care. Having repeated ADI is contributing to the risk of death beyond its impact on immune reconstitution and viral suppression: special efforts must be undertaken to maintain those patients in care.

We described hepatitis B surface antigen (HBsAg) prevalence among 2,347 pregnant women having delivered at the Cayenne hospital in 2007 according to ethnicity. With 11.0% HBsAg prevalence, Asian women (Hmong and Chinese) were the group with the highest risk of hepatitis B virus (HBV) perinatal transmission compared with other ethnic groups.