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A growing literature shows an improvement of chronic hepatitis C virus (HCV)-related depression after successful treatment with direct-acting antivirals. However, depression after HCV cure remains insufficiently documented in people living with HIV (PLWH) and HCV, a population with specific mental health challenges. This study aimed to (i) document the prevalence of moderate-to-severe depression (PHQ-9 score ≥10) across different age classes in HCV-cured PLWH; (ii) identify associated socio-behavioral correlates.Descriptive analyses were performed on data collected during a cross-sectional survey (February 2018 - May 2019) nested in a prospective, multicenter cohort of individuals living with HIV and HCV (ANRS CO13 HEPAVIH). Socio-behavioral correlates of moderate-to-severe depression were identified using logistic regression.Among the 398 HCV-cured individuals in the study sample (median age [IQR]: 56 [53-59] years; 73.1% men), 23.9% presented with moderate-to-severe depression (PHQ-9 score ≥10). Depressive symptom prevalence rates were as follows: anhedonia: 52.3%; feeling 'down' or feelings of hopelessness: 48.3%; sleeping problems: 65.7%; lack of energy: 70.3%; eating disorders: 51.2%; lack of self-esteem: 34.3%; difficulty concentrating: 34.9%; sluggishness (in movement and voice) or restlessness: 24.6%; suicidal ideation: 17.1%. No significant difference was detected across age classes. Female sex, unhealthy alcohol use, sedentary lifestyle, and unhealthy eating behaviors were associated with increased odds of moderate-to-severe depression.Depressive symptoms were common in this sample of HCV-cured PLWH. Unlike findings for the French general population, the prevalence of depression did not decrease with age class. Mental health remains a key issue for HIV-HCV-coinfected individuals, even after HCV cure, especially in women and in individuals with unhealthy behaviors.Despite potential improvements in mental health after successful treatment with direct-acting antivirals, many people living with HIV (PLWH) and hepatitis C virus (HCV) - even in older age classes - still face depressive symptoms after HCV cure. In this population, women and people reporting unhealthy alcohol use, sedentary lifestyle, or unhealthy eating behaviors are more prone to report depressive symptoms after HCV cure. Mental health and lifestyle-related issues should be integrated in a global care model for PLWH living with or having a history of hepatitis C.

International audience; Objectives - Studies evaluating the efficacy and safety of the fixed-dose combination ledipasvir (LDV)/sofosbuvir (SOF) in patients coinfected with HIV-1 and hepatitis C virus (HCV) have mainly included treatment-naïve patients without cirrhosis. We aimed to evaluate the efficacy and safety of this combination in treatment-experienced patients with and without cirrhosis.Methods - We conducted a multicentre, open-label, double-arm, nonrandomized study in patients coinfected with HIV-1 and HCV genotype 1 with and without cirrhosis, who had good viral suppression on their antiretroviral regimens. All patients were pretreated with a first-generation NS3/4A protease inhibitor (PI) plus pegylated interferon/ribavirin. Patients received a fixed-dose combination of LDV/SOF for 12 weeks, or for 24 weeks if cirrhosis was present. The primary endpoint was a sustained virological response (SVR) 12 weeks after the end of therapy. Secondary endpoints included safety, pharmacokinetics and patient-reported outcomes.Results - Of the 68 patients enrolled, 39.7% had cirrhosis. Sixty-five patients [95.6%; 95% confidence interval (CI): 87.6-99.1%; P < 0.0001] achieved an SVR, with similar rates of SVR in those with and without cirrhosis. Tolerance was satisfactory, with mainly grade 1 or 2 adverse events. Among patient-reported outcomes, only fatigue significantly decreased at the end of treatment compared with baseline [odds ratio (OR): 0.36; 95% CI: 0.14-0.96; P = 0.04]. Mean tenofovir area under the plasma concentration-time curve (AUC) at week 4 was high, with mean ± SD AUC variation between baseline and week 4 higher in cirrhotic than in noncirrhotic patients (3261.57 ± 1920.47 ng/mL vs. 1576.15 ± 911.97 ng/mL, respectively; P = 0.03). Mild proteinuria (54.4%), hypophosphataemia (50.0%), blood bicarbonate decrease (29.4%) and hypokalaemia (13.2%) were reported. The serum creatinine level was not modified.Conclusions - LDV/SOF provided a high SVR rate in PI-experienced subjects coinfected with HCV genotype 1 and HIV-1, including patients with cirrhosis.

Resume Malgre les mesures preventives, l’infection osteo-articulaire reste une complication rare mais grave de la chirurgie des protheses de hanche ou de genou avec un retentissement psycho-socio-economique majeur. Son diagnostic peut etre parfois difficile et necessite alors des examens complementaires. Aucun d’entre eux ne presente de valeur diagnostique absolue. Seule leur association apportera au clinicien un faisceau de presomption. Parmi les techniques d’imagerie, les examens isotopiques peuvent apporter une aide appreciable. La scintigraphie aux polynucleaires marques in vitro ou in vivo reste l’examen de reference en association avec la scintigraphie osseuse avec d’excellentes performances diagnostiques. Associee a l’imagerie scanner grâce aux imageurs hybrides, elle permet de guider les prelevements qui, seuls, realises dans des conditions strictes, pourront affirmer le diagnostic en isolant les germes et decider de la prise en charge optimale. La TEP au [ 18 F]-FDG notamment semble aussi une methode prometteuse, mais dont les criteres d’interpretation meritent d’etre affines afin de pouvoir l’evaluer de facon reproductible entre les etudes. Enfin, de nouveaux traceurs en TEP sont a l’etude afin de rechercher une specificite accrue vis-a-vis de l’infection qui permettrait de poser un diagnostic definitif dans les cas d’infections osteo-articulaires complexes.

International audience; EASL International Liver Congress, APR 13-17, 2016, Barcelona, SPAIN

Objectives Data on the natural selection of isolates harbouring mutations within the NS3 protease, conferring resistance to hepatitis C virus (HCV) protease inhibitors (PIs), are limited for HIV/HCV-coinfected patients. The aim of this study was to describe the natural prevalence of mutations conferring resistance to HCV PIs in HIV/HCV-coinfected patients compared with HCV-monoinfected patients. Methods The natural prevalences of HCV PI resistance mutations in 120 sequences from HIV/HCV-coinfected patients (58 genotype 1a, 18 genotype 1b and 44 genotype 4) and 501 sequences from HCV-monoinfected patients (476 genotype 1 and 25 genotype 4), retrieved from GenBank as a control group, were compared. Results Of 76 sequences from HIV/HCV genotype 1-coinfected patients, six (7.9%) showed amino acid substitutions associated with HCV PI resistance (V36L, n=1; V36M, n=2; T54S, n=2; R155K, n=1). In 31 of 476 (6.5%) HCV genotype 1 sequences retrieved from the GenBank database, HCV PI resistance mutations were found. The difference was not statistically significant (P=0.6). All of the sequences from HIV/HCV genotype 4-coinfected patients and those retrieved from the GenBank database had amino acid changes at position 36 (V36L). Conclusion Our study suggests that the natural prevalence of strains resistant to HCV PIs does not differ between HCV-monoinfected and HIV/HCV-coinfected patients. Further studies on larger cohorts are needed to confirm these findings and to evaluate the impact of these mutations in clinical practice.

Introduction Le bon usage des antibiotiques (ATB) est une preoccupation mondiale. L’emergence et la diffusion de bacteries hautement resistantes aux ATB sont des consequences de leur mesusage. En etablissement de sante (ES) le referent ATB anime le programme de bon usage des anti-infectieux. Une enquete a ete realisee en Nouvelle-Aquitaine afin de decrire le profil des referents ATB ainsi que leurs missions, outils, besoins et attentes. Materiels et methodes Enquete de deux semaines en fevrier 2017 en ligne validee par un groupe de travail regional. Les donnees recueillies (profession, formation, temps dedie a l’activite, missions, outils a disposition, ressenti, attentes) etaient saisies dans un tableur pour analyse a l’aide de statistiques descriptives. Resultats Le taux de participation etait de 46 % avec 101 reponses. Les referents ATB (55 cliniciens, 37 pharmaciens, 9 biologistes) exercaient en centre hospitalier (n = 38), en clinique privee (n = 31) et etablissement de soins de suite et de readaptation (n = 23). Seul 1 referent sur 2 avait une formation en ATB. Plus de 80 % des referents n’avaient pas de temps dedie pour assurer leurs missions. Les plus citees etaient : emission d’avis sur le choix du traitement ATB (n = 79), redaction de referentiels sur le bon usage des ATB (n = 62), suivi de l’evolution des consommations d’ATB (n = 78) et de l’evolution des resistances bacteriennes (n = 64). La distribution de ces missions differait selon la profession du referent : le clinicien emettant principalement des avis, le pharmacien en charge du suivi de l’evolution des consommations ATB et le biologiste suivant particulierement l’evolution de la resistance bacterienne. Les referents disposaient tous d’outils d’aide a la decision. Les plus cites etaient le guide d’antibiotherapie de l’ES (n = 76) et le site web de la SPILF (n = 64). Les referents ATB avaient le sentiment de manquer de temps (n = 82), de formation continue (n = 70), d’outils et de methodes (n = 66), de reconnaissance dans leurs missions (n = 57), d’une mauvaise valorisation de leurs actions (n = 66) et d’etre isoles dans leur role de referent (n = 63). Leurs principales attente etaient la formation continue (n = 94) en particulier en antibiotherapie (n = 83) et l’apport de documents et referentiels communs (n = 79). Conclusion On constate qu’en Nouvelle-Aquitaine seule la moitie des referents ATB dispose d’une formation adequate notamment en antibiotherapie et peu disposent de temps dedie. Ils eprouvent un manque de reconnaissance dans leurs missions et sont demandeurs en formation continue notamment en antibiotherapie. Pourtant des formations en presentiel existent (DU infectiologie, antibiotherapie, hygiene ; journees d’infectiologie ; congres) mais gagneraient a etre declinees en formation a distance ou e-learning dans la region la plus vaste de France.

The aims of the present study were to estimate the prevalence of renal impairment (RI) among HIV-infected adult patients and to investigate the associated factors.A cross-sectional survey was conducted in a French hospital-based cohort. Clearance of creatinine (CC) was calculated using the Cockcroft-Gault formula. Four stages of RI were defined: mild (60-90 mL/min), moderate (30-60), severe (15-30) and end stage (15). Logistic regression models were used to investigate factors associated with RI.The male/female ratio of the 2588 patients enrolled was 3:1 and the median age was 42 years. At the time of assessment of CC, the median CD4 count was 430 cells/microL and HIV plasma viral load (VL) was50 copies/mL in 60%. The overall prevalence of RI was 39.0%: 34.2% mild, 4.4% moderate, 0.3% severe and 0.2% end-stage. Mild RI was associated with female gender [odds ratio (OR)=3.3: 95% CI 2.6-4.3)], age50 years (OR=9.8: 7.4-13.0) and 40-50 years (OR=1.9: 1.5-2.4), body mass index (BMI)22 kg/m(2) (OR=3.3: 2.7-4.3) and tenofovir exposure (OR=1.4: 1.0-1.9 for1 year and OR=1.5: 1.2-2.0 for1 year). Advanced RI (CC60 mL/min) was associated with age50 years (OR=5.6: 2.9-10.9) and 40-50 years (OR=2.2: 1.1-1.4), BMI22 kg/m(2) (OR=1.5: 1.0-2.4), hypertension (OR=2.5: 1.4-2.5) and indinavir (IDV) exposure1 year (OR=2.3: 1.5-3.6).This survey confirms the high prevalence of RI in HIV-infected patients and indicates the importance of the investigation of renal function especially in women, older patients, those with a low BMI or treated with tenofovir or IDV.

The compensation of the inoculation accidents evolved after the law of August 9th, 2004 which stated the conditions of a complete repair of the attributable damages in a compulsory inoculation in conformance with the National Solidarity. The Office National d'Indemnisation des Accidents Medicaux, des Affections Iatrogenes et des Infections Nosocomiales (ONIAM) ensures this repair. For the not compulsory inoculations, the medical responsibility can be called only in conformance with a fault committed by the doctor. In spite of the absence of link scientifically established as in the inoculation of the hepatitis B and the induction of a multiple sclerosis at the end of 2008, the jurisprudence in vaccinal accidents varies according to the civil, social, administrative jurisdictions. The appreciation of the link of causality between the inoculation and its consequences is more rigorous in front of the civil jurisdictions than in front of the administrative or social jurisdictions.

Resume La tomographie par emission monophotonique couplee a la tomodensitometrie (TEMP-TDM) represente une nouvelle technique d’imagerie hybride qui offre des capacites diagnostiques nouvelles dans la pratique quotidienne des medecins nucleaires. Non seulement, elle permet d’obtenir des informations anatomiques et fonctionnelles fusionnees lors de la meme acquisition, mais aussi, elle accroit la sensibilite et la precision diagnostique de la TEMP par les corrections d’attenuation et de diffuse obtenues grâce a l’imagerie de transmission. Utilisee initialement pour les explorations en oncologie et en cardiologie, son interet se porte aujourd’hui vers de nombreux types de scintigraphie et, notamment vers les pathologies infectieuses. Dans les maladies inflammatoires et infectieuses de l’intestin, la TEMP-TDM semble ameliorer les performances diagnostiques et modifier la prise chez un certain nombre de patients. Dans la suspicion de sepsis vasculaire, la technique va permettre d’augmenter la sensibilite de la scintigraphie aux polynucleaires marques (SPM) mais aussi la specificite grâce a la resolution spatiale de la TDM. Dans les infections osteoarticulaires, son interet reside dans sa capacite a distinguer les atteintes osseuses et/ou des parties molles et de guider les prelevements biopsiques. Neanmoins, a la lumiere des travaux realises en TEP-TDM, le developpement de la TEMP-TDM va probablement modifier les pratiques de la medecine nucleaire et de nombreuses etudes seront necessaires pour etablir un consensus sur des recommandations de bonnes pratiques de son utilisation.

Objective The aim of the study was to characterize the causes, trends and determinants of severe morbidity in a large cohort of HIV-infected patients between 2000 and 2004. Method Severe morbid events were defined as medical events associated with hospitalization or death. Epidemiological and biological data were recorded at the time of the morbid event. Trends were estimated using Poisson regression. Results Among 3863 individuals followed between 2000 and 2004, 1186 experienced one or more severe events, resulting in 1854 hospitalizations or deaths. The severe events recorded included bacterial infections (21%), AIDS events (20%), psychiatric events (10%), cardiovascular events (9%), digestive events including cirrhosis (7%), viral infections (6%) and non-AIDS cancers (5%). Between 2000 and 2004, the incidence rate of AIDS events decreased from 60 to 20 per 1000 person-years, that of bacterial infections decreased from 45 to 24 per 1000 person-years, and that of psychiatric events decreased from 26 to 14 per 1000 person-years (all P

Resume Objectif Evaluer en Aquitaine les pratiques de prescription et d'administration de l'antibioprophylaxie pour implantation de prothese de hanche et de genou. Methodes Etude descriptive et retrospective realisee par les praticiens conseils sur un echantillon d'interventions programmees en 2003 dans tous les etablissements de la region. L'etude a porte sur les pratiques de l'antibioprophylaxie a partir des dossiers medicaux des patients. L'analyse a ete effectuee sur un effectif redresse pour tenir compte du poids de chaque etablissement. Resultats Sur 51 etablissements, 58,8 % utilisaient des protocoles conformes aux recommandations. L'echantillon correspondait a un effectif redresse de 9651 patients. Une antibiopropylaxie a ete prescrite chez 99,3 % des patients, la duree de l'antibioprophylaxie etait adaptee chez 77,4 % des patients, le choix de la molecule et le dosage dans 85,4 % des cas. Le delai entre l'injection de l'antibiotique et l'incision chirurgicale a ete le principal critere de non-conformite (56,3 %). Le delai etait inferieur a 30 minutes pour 43,7 % des injections de cephalosporines. En postoperatoire, l'administration respectait la prescription chez 76,4 % des patients et la posologie etait adaptee chez 60,0 %. Selon les variables etudiees, 3 a 23,5 % des donnees etaient manquantes dans les dossiers medicaux. Conclusion Pour ameliorer la qualite des soins et des pratiques, il apparait necessaire de generaliser les protocoles d'antibioprophylaxie ecrits et valides, une meilleure tenue des dossiers medicaux, une coordination renforcee entre les professionnels en amont, au cours et apres l'intervention.

Background The K65R HIV-1 reverse transcriptase (RT) mutation is a multidrug resistance mutation which may be correlated with specific antiretroviral combinations and with the presence or absence of other RT resistance mutations. Objectives The aims of this study were: (i) to determine the prevalence of the K65R mutation in a cohort of antiretroviral-treated patients; (ii) to study genotypic patterns and treatment characteristics in patients in whom the K65R mutation was present. Study design We included in the study all antiretroviral-experienced patients followed up at the Bordeaux University Hospital in 2003 and 2004 for whom an HIV-1 genotypic resistance analysis was available. Information on RT resistance mutations was reported from a hospital database including therapeutic and biological parameters. The prevalence of K65R was investigated for all patients. Genotypic patterns and treatment characteristics were examined at the time of detection of the K65R mutation. Results The prevalence of K65R was 1.9% (26 of 1404 patients). K65R was associated with nucleoside RT inhibitor-based regimens in 22 patients, and with tenofovir disoproxil fumarate, lamivudine, didanosine and abacavir in 23, 17, 17 and eight patients, respectively. The M184V and Q151M mutations were the most commonly co-selected substitutions. Thymidine analogue mutations (TAMs) were rarely co-selected with K65R and inversely associated with K65R. Conclusion The K65R mutation may emerge preferentially in the absence of zidovudine and TAMs, suggesting the possibility of an antagonistic interaction between K65 and TAMs.

HIV-infected patients are at risk of atherosclerosis and cardiovascular diseases. In a 12-month follow-up study, we aimed to investigate changes in carotid intima-media thickness (IMT), a surrogate marker of atherosclerosis, and its determinants in HIV-1-infected patients.Our multicentre prospective longitudinal cohort study included 346 HIV-infected patients, for each of whom two IMT measurements were taken by B-mode ultrasonography at baseline (M0) and 1 year later (M12).We observed a significant but moderate increase in the common carotid artery (CCA) median IMT, from 0.54 to 0.56 mm (P10(-4)), i.e. an increase of 0.020 mm (95% confidence interval 0.012-0.029). There was a significant association between cross-sectional CCA IMT measures at M12 and conventional cardiovascular risk factors (higher CCA IMT with older age, P10(-4); male gender, P=0.02; tobacco consumption, P=0.05), as well as higher CD4 cell count at M12 (median 455 cells/microL, P=0.01). Only CD4 cell count at M0 was strongly and positively associated with the variation in IMT between M0 and M12 (P=4 x 10(-3)). IMT progression was +0.0020 mm for the lowest quartile of CD4 cell count distribution at M0, i.e. 3-253 cells/microL, +0.010 mm for 253-402 cells/microL, +0.043 mm for 402-590 cells/microL, and +0.028 mm for 590-2270 cells/microL. No association was found with type or duration of antiretroviral exposure.Conventional cardiovascular risk factors are major determinants of IMT evolution. The link between immunological status and carotid IMT requires further study.

Radiographic diagnosis plays an important role in bone and joint infection management but the techniques used do not all present the same interest. Conventional radiography may not be informative during the first weeks and ultrasonography is especially useful to show accumulation of intra articular fluid or edematous soft-tissue. Computed tomography, magnetic resonance imaging, bone scintigraphy are the best exams for this diagnosis. According to the type of infection (septic arthritis, osteomyelitis, spondylodiskitis, diabetic foot, prosthetic joint infection), and to anatomical localization, the examination is chosen depending on its sensitivity and its specificity for bone and joint infection management.

Levels of triglycerides (TG), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-c), and high-density lipoprotein cholesterol (HDL-c), as well as the TC:HDL-c ratio, were compared in patients receiving different antiretroviral therapy regimens. Patients receiving first-line regimens including protease inhibitors (PIs) had higher TC and TG levels and TC : HDL-c ratios than did antiretroviral-naive patients; patients receiving 2 PIs had higher levels of each lipid. Ritonavir-containing regimens were associated with higher TC and TG levels and TC : HDL-c ratios than were indinavir-containing regimens; however, receipt of nelfinavir was associated with reduced risk of lower HDL-c levels, and receipt of saquinavir was associated with lower TC : HDL-c ratios. Patients receiving nonnucleoside reverse-transcriptase inhibitors had higher levels of TC and LDL-c than did antiretroviral-naive patients, although the risk of having lower HDL-c levels was lower than that in patients receiving a single PI. Efavirenz was associated with higher levels of TC and TG than was nevirapine.

Objective The effects on T-lymphocyte populations of two interferon-alfa-2a (IFN) regimens associated with ribavirin were evaluated in 36 HCV-HIV co-infected patients with chronic hepatitis C, T-CD4 cell count > 250 cells/µL and a plasma viral load of

Resume La cause la plus frequente de l'infection de prothese articulaire est la contamination peroperatoire. Dans d'autres cas, il s'agit d'une contamination par une bacteriemie symptomatique ou non, raison pour laquelle la denomination d'infection secondaire est preferable. Les facteurs de ce diagnostic sont : long intervalle libre de symptomes entre la pose de la prothese et l'episode infectieux, bacterie non habituellement responsable d'infection peroperatoire, foyer infectieux a distance, hemoculture positive, prelevement bacteriologique positif au niveau de la prothese, au(x) meme(s) germe(s) que celui ou ceux isoles a distance ou des hemocultures. L'infection peut etre aigue, voire chronique, se traduisant par un dysfonctionnement de la prothese. L'interrogatoire retrouve souvent un episode aigu transitoire neglige. Le diagnostic bacteriologique est imperatif avant la mise en route du traitement antibiotique. Sur le plan chirurgical, le lavage avec synovectomie est realise a ciel ouvert avec excision des tissus suspects. Le maintien du materiel doit etre tente. L'interet d'une antibiotherapie locale n'est pas prouve. Passes 21 jours, il faut recourir a l'ablation de la prothese avec un nettoyage de l'interface avec l'os et une repose en un ou deux temps. La recherche et le traitement de la porte d'entree sont a realiser sans delai. La prevention de l'infection secondaire repose sur la recherche et le traitement de toutes les infections focales. Tous les actes invasifs avec ou sans pose de materiel sont incriminables. Le benefice/risque d'une antibioprophylaxie n'est pour l'instant pas documente.

Per-operative contamination is the most frequent cause of prosthetic joint infection. In other cases, hematogenous contamination, which may be symptom-free, is responsible for secondary infection, which is the best-suited designation. Several factors, either isolated or combined, are important in establishing this diagnosis: prolonged symptom-free interval, bacterial agent not usually encountered in per-operative infections, remote focal infection site, positive blood cultures, identical bacteria isolated from both the prosthesis and the remote focal infection site or blood cultures. Infection may be acute or chronic and leads to mechanical failure. Patient history often reveals a neglected acute transient episode. Bacterial diagnosis is mandatory before initiating antibiotic therapy. Surgical management includes open irrigation, synovectomy, and debridement of any suspect tissue. Preserving the prosthesis should be attempted. Local antibiotic treatment has not been proven effective. After a lapse of 21 days, prosthetic material should be removed, bone interface should be scrubbed, and one- or two-stage re-implantation should be performed. Investigation and treatment of portal of entry should be initiated without delay. Prevention of secondary infection consists mainly in investigating and treating all focal infections. Any invasive procedure, with or without implantation of foreign devices, may be incriminated. The benefits versus risks provided by an antibiotic prophylaxis have not been documented.

The aim of the present study was to better characterize the expansion of double-negative (DN) T cells in vivo in AIDS patients and to ascertain the discrepant response of an immunodepressed immune system towards two distinct mycobacterial infections. In a large cohort of HIV-1 seropositive patients with low CD4(+) T cell counts (

The purpose of this investigation was to evaluate the microbiological diagnosis yield of post-biopsy blood cultures (PBBCs) and second percutaneous needle biopsy (PNB) following an initial negative biopsy in vertebral osteomyelitis (VO) without bacteremia. A retrospective multicenter study was performed. Patients with VO, pre-biopsy negative blood culture(s), ≥1 PNB, and ≥1 PBBC (0-4 h) were included. One hundred and sixty-nine PNBs (136 first and 33 following initial negative biopsy) were performed for 136 patients (median age = 58 years, sex ratio M/F = 1.9). First and second PNBs had a similar yield: 43.4 % (59/136) versus 39.4 % (13/33), respectively. Only two PBBCs (1.1 %) led to a microbiological diagnosis. The strategy with positive first PNB and second PNB following an initial negative result led to microbiological diagnosis in 79.6 % (74/93) of cases versus 44.1 % (60/136) for the strategy with only one biopsy. In the multivariate analysis, young age (odds ratio, OR [95 % confidence interval (CI)] = 0.98 [0.97; 0.99] per 1 year increase, p = 0.02) and >1 sample (OR = 2.4 ([1.3; 4.4], p = 0.007)) were independently associated with positive PNB. To optimize microbiological diagnosis in vertebral osteomyelitis, performing a second PNB (after an initial negative biopsy) could lead to a microbiological diagnosis in nearly 80 % of patients. PBBC appears to be limited in microbiological diagnosis.

Objective: To evaluate the prevalence of antibodies to hepatitis C virus and serological markers for hepatitis B virus infection in patients with HIV. Design: Cross sectional survey. Setting: Aquitaine, southwestern France, 1991-94. Subjects: 1935 HIV positive patients seen at least once since June 1991. Main outcome measures: Presence of antibodies to hepatitis C virus were detected by second or third generation enzyme linked immunosorbent assay (ELISA) and recombinant immunoblot assay (RIBA) and markers for hepatitis B virus detected by ELISA. Results: The prevalence was 42.5% (823) for antibodies to hepatitis C virus, 56.4 (507) for antibodies to hepatitis B core antigen, 6.9% (133) for hepatitis B surface antigen, 30.2% (584) for antibodies to hepatitis B core and surface antigen with no detectable surface antigen, 26.2% (507) for antibodies to core antigen only, and 4.8% (92) for antibodies to surface antigen only. The prevalence of antibodies to hepatitis C virus was 86.1% (726/843) in subjects who had bloodborne HIV infection and 7.3% (66/899) in those with sexually acquired infection. The prevalence of markers for hepatitis B was higher among homosexuals than in the other groups of patients, except for antibodies to surface antigen alone. The relation between markers for hepatitis B and hepatitis C virus was negative among men but positive among women. Conclusions: The results favour the hypothesis that hepatitis C virus is sexually transmitted much less commonly than either HIV or hepatitis B virus.

Resume Les tuberculoses extra-pulmonaires representent 15 a 30 % de l'ensemble des tuberculoses. Leur incidence avait moins diminue que celle de la tuberculose pulmonaire dans les pays industrialises avant l'apparition de l'infection a VIH. A l'heure actuelle cependant elles concernent plus particulierement les malades contamines par ce virus et atteints d'immunodeficience. Les formes disseminees ou miliaires et les meningites restent encore grevees d'un taux de mortalite d'environ 20 % malgre les progres diagnostiques et therapeutiques. A cote de ces 2 entites qui restent graves, les 4 localisations les plus courantes sont dans l'ordre : les ganglions, la plevre, le systeme genito-urinaire et l'appareil locomoteur. Compte-tenu de leur polymorphisme anatomo-clinique, des donnees de la litterature, il n'apparait pas qu'actuellement les delais d'intervention therapeutique se soient ameliores de facon evidente.

The improvement of survival of AIDS patients allowed the emergence of disseminated Mycobacterium avium Complex infections (D.MAC). Here we report the experience of the group of "Epidemiologie clinique du sida en Aquitaine (GECSA)" about 100 patients. There were no differences according to sex, age and route of acquisition of HIV. Clinical and biological characteristics of the infections were not specific. The mean TCD4+ lymphocytes count was 18/mm3. The diagnostic was generally established by systematic blood culture on Septi-Chek in patients with TCD4+ lymphocytes count below 75/mm3. The recommendations on therapy for D.MAC are to use regimen containing azithromycin or clarithromycin, ethambutol and one of the following drugs, rifabutin, clofazimine, amikacin, or ciprofloxacin. Rifabutin is recommended for prophylaxis in patients with lymphocytes TCD4+ count below 100/mm3.

An increased use of peripherally inserted central catheters (PICC) in French hospitals has been observed in recent years. We report complications having occurred following the placement of PICC in a teaching hospital. Patients and methods A prospective study was made for 7 months, between October 2010 and April 2011, including all patients having undergone PICC placement in interventional radiology. Results Two hundred and sixty-seven PICC were inserted in 222 patients for intravenous antibiotic therapy (68%), parenteral nutrition (13%), or chemotherapy (9%). The median duration of PICC use was 17 days (min–max: 1–140) for the 200 PICC monitored until removal. The most common complication was obstruction ( n = 41), 16 of which motivated PICC removal (8%). Five cases of vein thrombosis (2.5%) and 20 infectious complications (10%) led to removal. There were 14 accidental removals (7%). The overall infection rate was 2.3 per 1000 catheter-days with 0.86 per 1000 catheter-days for central line-associated bloodstream infection. Thirty-four percent of PICC were removed without any complications without any difference according to use. Conclusion PICC are a simple alternative to standard central venous catheter but the rate of complications is high and could be decreased by a stringent management and training for this type of catheter.

The pharmacokinetics of piperacillin and vancomycin used intravenously as antibioprophylaxis were measured in the plasma and bile during orthotopic liver transplantation. Piperacillin (4 g and then 2 g every 4 h) and vancomycin (1 g and then 0.5 g every 6 h) were infused in 10 patients. During vascular clamping without venovenous bypass, clearance of both antibiotics decreased in relation to renal insufficiency. During the surgical procedure, volume of distribution of both drugs increased because of fluid redistribution. The peaks of piperacillin after first, second and third administrations were respectively 314, 265 and 210 mg.l-1, while trough levels were 46.5, 55.2 and 54.5 mg.l-1. The peaks of vancomycin were 54.4, 49.6 and 40.9 mg.l-1, while first and second trough levels were 9.5 and 12 mg.l-1. These plasma concentrations were quite similar to levels reported in healthy subjects despite large blood loss and fluid replacement. However, piperacillin trough concentrations (64 mg/l) were too low in relation to its concentration-dependent antibacterial activity and vancomycin peak concentrations (or = 40 mg/l) were slightly too high in relation to its toxicity.

Resume De juin a novembre 1991, une enquete concernant la prescription de pefloxacine en prise unique (2 comprimes a 400 mg) a ete realisee dans le departement de la Dordogne par les praticiens conseils de l'Assurance Maladie. Un echantillon de 118 ordonnances a ete recueilli ; 23 (19 %) concernaient des hommes et 95 (81 %) des femmes. L'evaluation de la pertinence de la prescription a ete effectuee apres avis des experts infectiologues d'apres les indications de l'AMM et d'apres les recommandations de la conference de consensus sur l'antibiotherapie des infections urinaires (SPILF, Paris, 16 novembre 1990). Pour les hommes, aucune prescription n'etait motivee par une urethrite gonococcique, 6 prescriptions concernaient la prophylaxie d'un acte urologique ; au total, les 23 prescriptions n'etaient pas conformes. Pour les femmes, 60 ordonnances concernaient des femmes âgees de 50 ans ou moins ; toutes sauf une etaient motivees par une cystite mais dans 10 cas, il y avait prescription de 2 boites ; au total 11 prescriptions etaient non conformes. Trente cinq ordonnances concernaient des femmes âgees de plus de 50 ans dont 30 avaient plus de 60 ans avec dans un cas une prescription motivee par une infection oculaire ; de plus dans 5 cas, il y avait prescription de 2 boites et dans 5 cas, l'ordonnance faisait suite a la prescription d'un autre antibiotique ; ces 35 ordonnances ont ete jugees non conformes. Finalement, 69 sur 118 prescriptions (58,5 %, intervalle de confiance a 95 % : 49,6 − 67,4 %) ont ete jugees non conformes. Ces resultats amenent a faire une analyse critique de l'impact des conferences de consensus sur le comportement des prescripteurs et de l'activite promotionnelle des laboratoires pharmaceutiques. Cette enquete qui a debouche sur une information locale aupres des praticiens, met en evidence la necessite d'une concertation plus large entre l'industrie pharmaceutique, les medecins praticiens, universitaires, les medecins conseils de l'Assurance Maladie et les experts des commissions (AMM).

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 43 - N° 6 - p. 480-481

We observed a prolonged shedding of virus 14 and 28 days after symptom onset in two patients with pandemic H1N1 influenza, who did not have immunodepression and were treated with neuraminidase inhibitor. This prolonged shedding was not associated with the emergence of resistance mutation H275Y in the viral neuraminidase gene.

We observed a prolonged shedding of virus 14 and 28 days after symptom onset in two patients with pandemic H1N1 influenza, who did not have immunodepression and were treated with neuraminidase inhibitor. This prolonged shedding was not associated with the emergence of resistance mutation H275Y in the viral neuraminidase gene.

The compensation of the inoculation accidents evolved after the law of August 9th, 2004 which stated the conditions of a complete repair of the attributable damages in a compulsory inoculation in conformance with the National Solidarity. The Office National d'Indemnisation des Accidents Médicaux, des Affections Iatrogènes et des Infections Nosocomiales (ONIAM) ensures this repair. For the not compulsory inoculations, the medical responsibility can be called only in conformance with a fault committed by the doctor. In spite of the absence of link scientifically established as in the inoculation of the hepatitis B and the induction of a multiple sclerosis at the end of 2008, the jurisprudence in vaccinal accidents varies according to the civil, social, administrative jurisdictions. The appreciation of the link of causality between the inoculation and its consequences is more rigorous in front of the civil jurisdictions than in front of the administrative or social jurisdictions.

Resume Trente et une personnes âgees de 60 ans ou plus et infectees par le virus de l'immunodeficience humaine type 1 (VIH1) ont ete suivies de facon retrospective et prospective au CHRU de Bordeaux. Elles representent 2,3 p 100 de l'ensemble des patients infectes par le VIH suivis par le groupe d'epidemiologie clinique du SIDA en Aquitaine (GECSA). Le sex-ratio homme/femme est de 1,4/1. La contamination est post-transfusionnelle dans 58p 100 des cas. Le diagnostic a ete effectue avec retard, revele par une pathologie indicative du SIDA dans 45,2 p 100 des cas. Les signes cliniques les plus frequents sont la candidose, le zona ou les manifestations neurologiques; celles-ci posent un probleme de diagnostic differentiel difficile avec les demences seniles. Le pronostic de cette affection est severe avec une probabilite de survie a 18 mois de 39,7 p 100 (intervalle de confiance a 95 p 100: 18,6 p 100-60, 8p 100). Ce pronostic pourrait etre ameliore par un diagnostic plus precoce et une prise en charge therapeutique specifique a la personne âgee.

Resume Nous avons etudie les infections documentees severes survenues chez 51 patients âges de 4 a 67 ans qui ont recu une greffe hepatique entre juillet 86 et decembre 89. 18 patients sont decedes (35,3 % des cas) dont 6 cas en relation directe avec une infection (33,3 % des deces); 4 patients ont ete retransplantes dont une fois pour recidive d'une infection par le virus de l'hepatite B. Tous les patients avaient recu une antibiotherapie prophylactique (piperacilline ± teicoplanine pendant 48 h en I.V. ± nystatine ± norfloxacine per os pendant 15 jours). 38 greffes ont presente un episode infectieux severe, 14 a un type de germe, 20 a deux types de germes et 4 a trois types de germes (bacterienne ± virale ± fongique). 66 % des episodes infectieux ont ete diagnostiques dans le premier mois et 97 % dans les trois premiers mois apres la greffe. Sur 112 infections, 69 (61,6 %) etaient d'origine bacterienne : 28,6 % dues a des germes a Gram positif (dont 23,2 % dues a des staphylocoques), 29,4 % dues a des germes a Gram negatif (dont 9,8 % dues a des Pseudomonas) et 3,6 % dues a des anaerobies. 37 infections (33 %) etaient d'origine virale dont 14,3 % dues au cytomegalovirus et 6 (5,4 %) etaient d'origine fongique. Parmi les 139 localisations relevees, 42 (30,2 %) etaient des septicemies, bacteriemies, viremies ou fongemies, 18 (12,9 %) concernaient les tissus mous, 15 (10,8 %) etaient des hepatites, 13 (9,3 %) etaient des pneumonies, 12 (8,6 %) etaient des infections des voies biliaires, 11 (7,9 %) concernaient les voies aeriennes superieures ou la bouche, 10 (7,2 %) etaient des peritonites et 6 (4,3 %) concernaient les voies aeriennes superieures ou la bouche, (10 (7,2 %) etaient des peritonites et 6 (4,3 %) concernaient le tractus digestif.

Des etudes cliniques ont demontre pour les patients atteints d'infections compliquees de la peau et des tissus mous fortement suspectees a Staphylococcus aureus resistant a la methiciline (SARM) et traites par le linezolide (versus la vancomycine), des taux de guerison similaires et des durees de sejour plus courtes. Objectif. - Determiner le ratio cout-efficacite du linezolide versus la vancomycine selon la perspective du systeme de sante francais. Methodes. - Un modele de decision analytique a ete applique a un patient-type, de l'initiation du traitement empirique jusqu'a guerison, mort ou echec du traitement de deuxieme ligne. Les probabilites cliniques provenaient des essais cliniques. Les donnees d'utilisation de ressources (incluant la duree de traitement et la duree de sejour) et les taux de prevalence SARM etaient fournis par un panel d'expert. Les couts etaient apprecies a partir de publications. Resultats. ― Le taux de guerison en premiere ligne etait de 90,7 % pour le linezolide versus 85,5 % pour la vancomycine (apres deux lignes de traitement 98,5 % et 98 %, respectivement). Le cout total moyen etait de 7778 ?pour le linezolide versus 8777 ?pour la vancomycine pour une duree de sejour moyenne de 10,7 jours et 13,3 jours, respectivement. La prescription de linezolide etait la strategie dominante. La conclusion ne changeait pas apres realisation des analyses de sensibilite. Conclusion. ― Le linezolide peut etre considere comme une strategie cout-efficace en France dans le traitement des infections compliquees de la peau et des tissus mous suspectees a SARM.

Management of febrile neutropenic patients is described in guidelines. Each cancer center can adapt these according to its local bacterial ecology. We present a retrospective study made in a cancer center from 2001 to 2003.Three hundred and fifteen febrile neutropenic episodes after chemotherapy (66% for solid tumor) were analysed.For 279 episodes, no antibiotic therapy was given before admission. Clinical or radiological manifestations occurred in 46%; microbiologically documented infections by hemocultures in 28% (Gram positive: 42%; Gram negative: 51%) and by puncture in 14% (Gram negative: 58%). The length of pyrexia was inferior to 7 days in 88% and neutropenia inferior 7 days in 80.8%. 79.7% of episodes were treated with one of the three antibiotic therapy recommended by the center (ceftriaxone+tobramycin; ceftriaxone+ciprofloxacin; ceftriaxone+ofloxacin); 13.3% were treated with an other therapy; 7% received no antibiotic therapy. 68.5% of patients treated with one of the three antibiotic therapies, became afebrile without changing the antibiotic protocol.In our study, there were a majority of Gram negative bacteria except for Pseudomonas aeruginosa. The three antibiotic therapy recommended by the center (third generation cephalosporin+aminoglycosides or fluoroquinolones) were effective and glycopeptide was not necessary in first intention treatment.

The aim of the study was to estimate the prescription and administration of antibioprophylaxis for hip and knee replacement in Aquitaine (SouthWestern France).In 2003, "Social Security" medical experts performed a descriptive and retrospective study on a sample of scheduled surgical operations in all the Aquitaine public and private hospitals. Antibioprophylaxis, protocols, and practice were assessed by studying the patients' medical files. The analysis was made on adjusted numbers to take into account the size of every institution.In 51 hospitals, 58.8% of antibioprophylaxis protocols followed French guidelines. The sample corresponded to an adjusted number of 9,651 patients. Antibiopropylaxis was prescribed for 99.3% of patients, the course of antibioprophylaxis followed guidelines for 77.4% of the patients, the choice of the molecule and the dosage in 85.4% of the cases. Interval between antibiotic injection and surgical section was the main criterion of nonconformity (56.3%); it was under30 minutes for 43.7% of cephalosporin injections. In the post-operative period, administration complied with the medical prescription for 76.4% of the patients and dosage was adapted for 60.0% of the patients. According to the studied variables, 3 to 23.5% of data was missing in the medical files.If the quality of care and practice must be improved, it is mandatory to implement written and confirmed antibioprophylaxis protocols, to better document medical files, to insure an improved coordination among professionals before, during, and after surgery.

The spread of multiresistant Staphylococcus and Enterococcus strains required the development of new drugs. Linezolid is the first molecule of a new antibiotic family, oxazolidinones, with an original mechanism of action. In this general review, the authors first present its antibacterial activity, its pharmacokinetic properties, its therapeutic uses in serious Gram-positive infections, pneumonia, skin and soft tissue infections, and also in other indications. They then explain the rules for administration and tolerability.

International guidelines recommend prescription of inhaled corticosteroids to improve asthma control. Chronic secondary adrenal suppression due to inhaled corticosteroids has been described. We report a case of acute adrenal suppression due to drug interaction between Fluticasone and antiretroviral therapy in a HIV patient. Seeing an increased prevalence of hyperresponsiveness among HIV-infected men, we conclude that coprescription of Fluticasone and highly active antiretroviral therapy must be carefully controlled.

Radiographic diagnosis plays an important role in bone and joint infection management but the techniques used do not all present the same interest. Conventional radiography may not be informative during the first weeks and ultrasonography is especially useful to show accumulation of intra articular fluid or edematous soft-tissue. Computed tomography, magnetic resonance imaging, bone scintigraphy are the best exams for this diagnosis. According to the type of infection (septic arthritis, osteomyelitis, spondylodiskitis, diabetic foot, prosthetic joint infection), and to anatomical localization, the examination is chosen depending on its sensitivity and its specificity for bone and joint infection management.

Background Since the inception of highly active antiretroviral therapy (HAART), mortality among HIV-infected patients has decreased, but this has been accompanied by the appearance of several complications. Objectives To estimate the incidence of symptomatic bone disorders in HIV-infected patients of the Aquitaine cohort (from south-west France) for the period 1999–2002, and to describe cases. Methods We retrospectively studied the records of 2700 patients of the Aquitaine cohort, which was derived from a hospital-based surveillance system of HIV infection in France. All cases of symptomatic bone disorders diagnosed from 1 January 1999 to 30 June 2002 were reviewed. Results Fourteen cases of bone disorders were diagnosed, eight cases of aseptic osteonecrosis and six cases of severe osteoporosis, representing incidences of 0.3/1000 patient-years [95% confidence interval (CI): 0.14–0.62] and 0.22/1000 patient-years (95% CI: 0.09–0.52), respectively. All patients with aseptic osteonecrosis were male, while all but one with osteoporosis were female. The ages of patients ranged from 36 to 54 years for osteonecrosis and from 39 to 50 for severe osteoporosis. At the time of clinical diagnosis, all patients were treated with nucleoside reverse transcriptase inhibitors (duration of treatment ranging from 19 to 123 months for osteonecrosis and from 46 to 132 months for severe osteoporosis). Ten patients were treated with nonnucleoside reverse transcriptase inhibitors [duration of treatment ranging from 6 to 31 months for osteonecrosis (n=6) and from 4 to 29 months for severe osteoporosis (n=4)]. Thirteen patients were treated with protease inhibitors [duration of treatment ranging from 12 to 62 months for osteonecrosis (n=8) and from 3 to 44 months for severe osteoporosis (n=5)]. All osteonecrosis and five osteoporosis patients had at least one known risk factor or comorbidity associated with the bone disorder occurrence. Conclusions In our study, the aetiology of clinical bone disorders seemed to be multifactorial, as almost all the patients had at least one possible risk factor in addition to HAART exposure.

Staphylococcal toxic shock replies to precise clinical-biological criteria; but can be difficult to diagnose. Today, the nonmenstrual form of shock is the most frequent. The incidence of menstrual shock is low but their potential severity must be recalled.A young 14 year-old girl and a 33 year-old woman presented with menstrual shock that was treated successfully. A relapse in the form of staphylococcal scarlet fever occurred in the second patient. In both cases, the strain Staphylococcus aureus, which produces the TSST-1 toxin, had been identified.The possibility of the occurrence of a menstrual staphylococcal shock in the year 2002 must be known. The polymorphism of the clinical and biological manifestations must be underlined. The search for a toxin can be conducted in an appropriate centre.

Symptomatic lactic acidosis requiring intensive care is a rare and severe adverse event related to the mitochondrial toxicity of the nucleoside analog reverse transcriptase inhibitors (NRTIs).We retrospectively investigated the clinical and biological features of HIV-infected patients who developed severe lactic acidosis syndrome at the University teaching hospital of Bordeaux and the regional community hospital, during 1996-2000.Nine patients were identified (incidence: 0,9/1000 NRTI treated patient-years), 4 men and 5 women with a median age of 36 years. They had a moderate immunodeficiency (median CD4+ T lymphocyte counts: 197/mm(3)) and only one of them presented a virological failure. The causes of hospital admission were abdominal pain (n = 6), dyspnea (n = 6), asthenia (n = 5), jaundice (n = 4), and vomiting (n = 2). Hepatomegaly was present in 6 patients. Lactic acidosis was found in all cases: median pH: 7.28, bicarbonate: 12 mmol/l, anion gap: 27 mEq/l, plasma lactic acid: 13 mmol/l. Cytolysis (n = 8), cholestasis (n = 6), hepatic failure (n = 4), rhabdomyolysis (n = 4) and pancreatitis (n = 2), were also present. Despite medical intensive care, seven patients died. The only two post-mortem examinations revealed severe hepatic steatosis. Median duration of NRTI therapy was 4 years. At presentation, five patients were receiving lamivudine, five didanosine, four stavudine and three zidovudine. Six patients were coinfected by HCV and/or HBV, four had chronic renal failure and five an immediately preceding infectious disease.The prognosis of lactic acidosis is severe. Nucleosid-analog therapy needs clinical and biological monitoring, specially in patients with comorbidities.

Serum and intrahepatic hepatitis C virus (HCV) RNA were measured in 37 HIV-HCV co-infected patients with controlled human immunodeficiency virus (HIV) infection and correlated with clinical, biological, and histological parameters. Thirty-seven interferon-naive patients underwent liver biopsy. HCV-induced activity (A) and fibrosis (F) were evaluated with METAVIR score. The 37 patients included had HIV plasma loads10,000 copies/ml, CD4(+) count250/microl. All the patients but two were receiving antiretroviral treatment. Liver tissue and sera were used for measurement of HCV RNA by the Cobas Amplicor HCV Monitor. All patients had serum and liver HCV RNA, and both levels were correlated (r = 0.47; P = 0.003). Intrahepatic HCV load did not depend on age, sex, duration of HCV infection, CD4(+), HCV genotype, or fibrosis. AST levels correlated with intrahepatic HCV load (r = 0.52; P = 0.001). Patients with METAVIR A1/A2 had significantly lower levels of liver HCV-RNA than were found in patients with METAVIR A3 (P = 0.026). Highly active antiretroviral therapy (HAART) including protease inhibitors(PI)-treated patients had significantly lower intrahepatic HCV load (P = 0.04). A weak but significant correlation between serum and liver HCV RNA was found. The amount of hepatic HCV RNA was correlated with AST levels, histological activity, but not with HCV genotype or fibrosis. The immune improvement associated with PI regimens could help reduce HCV load, supporting a protective effect of PI-induced immune restoration.

Peroperative contamination is the most frequent cause of infection after arthroplasty. For other cases of infection subsequent to bacteremia or a neighboring focus, it would be more appropriate to use the term "secondary" infections rather than hematogeneous infections. Arguments favoring secondary infection include long symptom-free interval between prosthesis implantation and the infectious episode, a causal germ not generally responsible for peroperative infection, presence of a distant infectious focus, positive blood culture, and a positive bacteriological sample from the prosthesis level showing the same strain as grown from the distant focus or blood samples. Both acute and chronic infections are observed, leading to prosthesis dysfunction. History taking generally identifies a neglected acute but transient episode. Search for a bacteriological diagnosis must be completed before initiating an antibiotic regimen. If detected very early, washing with open synovectomy and resection of suspicious tissue should be attempted in order to maintain the implant if possible. Local antibiotics have proven efficacy. Beyond a certain delay, treatment for chronic infection usually requires removing the prosthesis, cleaning the bone interface, and new arthroplasty delayed or not. Search for the portal must be undertaken early in order to initiate appropriate local treatment. The causal event may be any invasive procedure, with or without material implantation. The risk-benefit ratio for antibiotic prophylaxis remains to be determined.