Elisabeth Bouvet

Predictors of Virologic Failure and Resistance in HIV-Infected Patients Treated with Nevirapine- or Efavirenz-Based Antiretroviral Therapy

Resistance to nonnucleoside reverse transcriptase inhibitors (NNRTIs) increases with the wider use of this class of antiretroviral therapy. The association between adherence and resistance to NNRTI-based regimens is poorly understood. Predictors of virologic failure and resistance according to a baseline evaluation of nonadherence risk factors were determined in a cohort of 71 human immunodeficiency virus (HIV)-infected patients with early virologic response who received an NNRTI-based regimen. During the median follow-up of 29 months, 20 (28%) of 71 patients experienced virologic failure with an NNRTI-based regimen. Virologic failure was associated with repeated drug holidays (> or =48 h of unplanned drug cessation), depression, younger age, and low adherence to therapy during baseline evaluation. Moreover, repeated drug holidays was the only risk factor for developing a major mutation conferring cross-resistance to the NNRTI class (hazard ratio, 22.5; 95% confidence interval, 2.8-180.3; P<.0001). Patients previous adherence to therapy and drugs genetic barriers, not only the number of pills or doses involved, should be taken into consideration in the decision to simplify highly active antiretroviral therapy.

Moyens de protection au bloc opératoire et risques d’exposition au sang. Résultats d’une enquête nationale

Resume Une enquete nationale a ete realisee aupres de 5u2008000 chirurgiens tires au sort pour connaitre les moyens de protection utilises au bloc operatoire contre le risque d’exposition au sang. Le taux de vaccination complete contre l’hepatite B etait de 79,2xa0%. Le port de la double paire de gants etait constant pour 72xa0% des orthopedistes, mais seulement pour 28,2xa0% dans l’ensemble de la population chirurgicale ; 46,1xa0% des casaques utilisees etaient en tissu alors que la qualite barriere de ce type de materiel humidifie est tres aleatoire. La protection au bloc operatoire contre l’exposition au sang peut encore etre amelioree.

Occupational Malaria Following Needlestick Injury

To the Editor: A 24-year-old female nurse was admitted to the emergency room at Bichat University Hospital in Paris, France, on July 4, 2001, with fever, nausea, and general malaise. She had no notable medical history, except spontaneously regressive Schonlein-Henloch purpura at 9 months of age. On admission, after she was given paracetamol, her axillary temperature was 37.6°C. She was slightly jaundiced and reported a mild headache but showed no resistance to head flexion. Her abdomen was depressible but tender. Urinalysis did not show hematuria or signs of urinary infection. Biologic tests indicated normal values except the following: platelets 47.4 x 103/µL, aspartate aminotransferase 307 U/L (normal value <56), alanine aminotransferase 239 U/L (normal value <56), total bilirubin 58 µmol/L (normal value <24), and γ-glutamyl transpeptidase 57 U/L (normal value <35). Results of an abdominal echogram were normal. Result of a blood film to identify Plasmodium falciparum was positive for parasitemia at 0.038 per 100 erythrocytes. The patient was given 500 mg of oral quinine three times daily; intravenous quinine was administered 15 hours after admission because she became nauseated. Her malaise persisted for 3 days, but she did not show any signs of malaria. She recovered completely and was discharged on day 6 of hospitalization. n nThe patient had not traveled outside France except to the United Kingdom years earlier. She did not live near an airport, nor had she been to one recently. She had vacationed in the south of France from June 23 to June 26 but had traveled by car. She had been certified as a registered nurse on May 28 and had been working as a substitute employee at various hospitals in the greater Paris area. On June 21, 2001, she sustained an accidental needlestick injury while taking a blood sample with an 18-gauge, peripheral venous catheter that had no safety feature. She removed the catheter stylet and stuck herself as she crossed her hands to discard the stylet in a sharps container. The needlestick pierced the nurses glove and caused a deep, blood-letting injury on the anterior aspect of the left wrist. She had no previous history of needlestick injury. She notified the hospital occupational medicine department of her injury on the day it occurred and was given a postexposure interview. In accordance with national postexposure management guidelines, she was tested for HIV and hepatitis C virus (HCV) antibody, and results were negative at baseline; her immunization against hepatitis B virus (HBV) was confirmed. The risk of infection by pathogens other than HBV, HCV, or HIV following a needlestick injury was not discussed during her postexposure interview, and the nurse was not made aware of that risk. The injured nurse did not inform the managing physician that the injury had occurred while she was drawing blood from a patient to determine if the patient was infected with malaria. n nBy July 1, 10 days after exposure, fatigue, malaise, and fever developed; her temperature was lowered to 38.6°C by taking paracetamol. Her condition returned to normal on July 2 before a second bout of fever and myalgia occurred during the night. She had to leave work early on July 3 because of generalized pain and a temperature of 39°C. The patients mother is a biologist and was aware that her daughter had sustained a needlestick injury while drawing blood from a patient in whom malaria was suspected. The mother insisted that a blood smear be performed at a private laboratory in Paris. The smear was qualitatively determined positive for P. vivax. Subsequently, the patient was admitted to Bichat-Claude Bernard University Hospital with suspected malaria. A repeat blood smear conducted there identified P. falciparum. n nThe source patient was a 28-weeks pregnant, 30-year-old woman of Kenyan origin who resided in France; she had visited Kenya and returned to France on June 1, 2001. On June 21, she was admitted to the gynecology-obstetrics emergency room at a greater Paris area hospital with fever and malaise. Blood sampling and thin and thick blood smears were performed by the nurse. The source patients level of parasitemia was estimated at 0.05 per 100 erythrocytes, and oral quinine was initiated. The physician who interviewed the nurse after the needlestick injury verified that the source patient was HIV- and HCV-antibody negative and that the nurse was immunized against HBV. On June 23, although the results of her test for Plasmodium were negative, she was transferred to another tertiary care center where IV quinine was administered for nausea and vomiting, and she could be monitored more closely. She recovered fully and was discharged on June 27. Unfortunately, all blood samples or smears from the source patient had been discarded by the time the injured nurse became ill. n nP. falciparum is a bloodborne pathogen, and malaria is a well-documented complication of transfusion (1). Malaria has also been diagnosed after intravenous drug use (2,3) and breaches in infection control procedures (4–6), as well as occupational exposures (1–5). Occupational P. falciparum infection after a needlestick injury may be rare; however, such an injury can be potentially severe in nonimmune healthcare workers in countries where malaria is not endemic, especially if the occupationally infected person is pregnant. This situation may also become more common as malaria spreads and as increasing international travel brings potential source patients to hospitals in malaria-endemic countries. n nHBV, HCV, and HIV are the pathogens most often transmitted in documented cases of occupational infection following needlestick injuries in industrialized countries. Testing for infection by these pathogens does not include all the possible infections that can result from occupational exposure (1,7,8). Although conducting a thorough investigation of the circumstances surrounding any needlestick injury is a challenge in the daily clinical setting, an investigation should always be carried out. As in this case-patient, the treatment of occupational P. falciparum infection may be delayed because physicians do not immediately consider malaria as a possible diagnosis. Furthermore, healthcare workers with neurologic symptoms caused by P. falciparum malaria may be too ill to tell the treating physician about their occupational exposure. Such infections must be diagnosed promptly as they are potentially lethal, and presumptive treatment is readily available and well tolerated. Clinicians managing healthcare or laboratory workers with a febrile illness or in a postexposure setting should consider the probability of occupational P. falciparum malaria.

Paradoxical emergence of humerus osteomyelitis during treatment of pulmonary and lymph-node tuberculosis.

A transient worsening of a pre-existing lesion (or emergence of new lesions) under appropriate antituberculous therapy has been described mainly for adenitis, intracranial tuberculoma and the lung (1). Although paradoxical expansion (PExp) is not uncommon for osteoarticular tuberculosis (TB), the emergence of tuberculous osteomyelitis under appropriate treatment is rare. We report a case of tuberculous osteomyelitis emerging under antimycobacterial therapy. A 35-y-old Sri Lankan male who had been residing in France for 1 month, was admitted for pulmonary TB and lymphadenitis. Mycobacterium tuberculosis, susceptible to all antimycobacterial agents, was isolated from sputum smears and cervical node puncture. A human immunode® ciency virus (HIV) test was negative. Antimycobacterial therapy was initiated. One month later, he complained of fever (37°C) and in ̄ ammatory pain from the lower extremity of the left humerus without local swelling or erythema. Tenderness was increased by local palpation. The C-reactive protein (CRP) level had risen from 42 to 86 mg:l. An X-ray of the left humerus was normal. A computed tomographic (CT) scan showed increased density of the lower third of the left humerus. Magnetic resonance imaging (MRI) of the left humerus performed after 40 d of appropriate treatment showed signs of osteomyelitis, i.e. a cyst-like cavity with periostal reaction. A chest CT scan revealed enlargement of the mediastinal lymph node. The occurrence of these complications despite adequate therapy and good compliance suggested PExp. Steroid therapy was therefore initiated (prednisone 60 mg:d). The abscess enlarged and was ultimately drained. Pathological examination showed an epithelioid and gigantocellular granuloma. No acid-fast bacilli were found and cultures remained negative. The pain resolved completely within 3 weeks and the patient remained symptom free. Corticosteroid therapy was then progressively reduced. PExp generally appears during the ® rst few months of therapy (1) and may vary widely in localization. It is mostly observed in haematogenous dissemination, but can also be seen in pulmonary TB. In lymph-node TB, up to 30% of patients may present with enlargement under treatment (1). A relatively high frequency of extrapulmonary disease in Asian immigrants may explain the more frequent occurrence of PExp in this population (1, 2). Several unusual localizations of PExp such as subcutaneous abscess (3) or hand tenosynovitis (4) have been reported. Tibial osteomyelitis emerging under antituberculous therapy in a 17-y-old Indian girl has also been described (2). In these cases, however, the initial lesion (miliary TB) was haematogenous. A few cases of multifocal osteoarticular PExp have also been described (5). Long-bone tuberculous osteomyelitis is generally rare compared with spine or joint involvement (6). The present case was unusual with respect to several points. PExp involved a long bone which was previously apparently unaffected. Furthermore, osteomyelitis occurred without obvious initial osteoarticular TB localization. The emergence of a new lesion in spite of appropriate antituberculous therapy should suggest the presence of PExp, the localization of which may be variable. Corticosteroid therapy may be useful in such a situation, but requires further evaluation since evidence of ef® cacy is lacking.Bacterial pili have been shown to be an important virulence factor for urinary tract infections. In this report we relate the results of studies which evaluated the influence of antipili antibody on the susceptibility of rats to ascending pyelonephritis and on several antibody-mediated antibacterial mechanisms. Rats immunized with E. coli type 1 pili, and animals infected with E. coli developed antipili antibodies in their serum. Active or passive immunization of rats with pili protected the animals from ascending pyelonephritis. Antipili antibody did not mediate complement-dependent bacteriolysis, opsonophagocytosis or promote more rapid intravascular clearance of injected E. coli. Humoral immunity to pili did, however, effectively inhibit bacterial adherence to epithelial cells. These studies indicate that type 1 E. coli pili are immunogenic and that antipili antibodies afford protection from ascending pyelonephritis. They suggest further that a mechanism of protection is inhibition of bacterial adherence.

Nosocomial bacteremia in HIV patients: the role of peripheral venous catheters.

A retrospective case-control study compared 40 human immunodeficiency virus (HV)-infected patients with 43 nosocomial bacteremias (NB) to 77 HIV-infected patients without NB. Presence of a peripheral venous catheter (PVC) was associated with occurrence of NB and was significantly more frequent in NB without an identified source. PVCs probably are an underestimated source of NB in HIV-infected patients.