J. Courjon

Direct-acting antiviral treatment in adults infected with hepatitis C virus: Reactivation of hepatitis B virus coinfection as a further challenge.

Use of direct-acting antiviral drugs (DAAs) greatly improves management of adults infected with hepatitis C virus (HCV) whether patients are treatment-naive or unsuccessfully pre-treated. Several inhibitors of viral nonstructural proteins (NS3/4A protease, NS5A and NS5B polymerase) allow a rapid HCV clearance and increase rates of sustained virological response. Both the EASL and AASLD guidelines have recently published up-to-date recommendations for their use, addressing each HCV genotype and particular situations. However, management of patients coinfected with hepatitis B virus (HBV) has been developed by these guidelines with reference to cases of HBV reactivation reported during previous anti-HCV regimens containing interferon known active against both HBV and HCV. In the setting of the interferon-free HCV therapies with DAAs only, the possibility of HBV reactivation during treatment of hepatitis C is raised due to viral interferences in HCV/HBV coinfected persons. Herein, we report a case of early HBV reactivation during DAAs-based anti-HCV treatment (ledipasvir/sofosbuvir) in a patient having a resolved HBV infection and chronically infected with HCV genotype 4 and HIV. Moreover, we review similar recent cases of HBV reactivation in patients infected with HBV and HCV genotype 1 during treatment of hepatitis C by regimen incorporating other combination of DAAs (sofosbuvir/simeprevir or daclatasvir/asunaprevir). Due to the potential risk of early HBV reactivation in HCV/HBV-coinfected patients during interferon-free DAAs-based HCV therapies, altogether these cases highlight the necessity to closely monitor HBV coinfection, regardless its stage (chronic, occult, resolved), whatever HCV genotype or class of DAAs used.

The impact of bacteremia on the outcome of bone infections

UNLABELLED We have used a medical database to analyze our activity since 2005. We observed a frequent association between bone and joint infection (BI) and bacteremia. Our aim was to characterize patients with BI and bacteremia, and focus on the outcome. PATIENTS AND METHOD Our database includes the prospective recording of 28 characteristics of all hospitalized patients, including diagnosis, comorbid conditions, microbiological data, therapy, and outcome. We selected patients presenting with BI in this database, from July 2005 to December 2012. Fever before blood culture was retrospectively documented from the patients chart. Chronic BI was defined as a disease lasting more than 1 month. An unfavorable outcome was defined by the need for intensive care or death. RESULTS Six hundred and thirty-two patients presented with BI and 125 with bacteremia (19.8%). We used a stepwise logistic regression analysis and determined that bacteremia was associated with vertebral osteomyelitis, OR, 3.97, P<0.001; alcohol abuse, OR, 2.51, P=0.010; fever, OR, 2.43, P<0.001; neurological and/or psychiatric diseases, OR, 2.41, P ≤ 0.001; and Staphylococcus aureus infection, OR, 2.32, P<0.001. The outcome was unfavorable in 23 cases (3.6%), associated with bacteremia, OR, 8.00, P<0.001, age> 60 years, OR, 4.78, P=0.018, and S. aureus infection, OR, 3.96, P=0.010. No single comorbid condition was significantly associated with an unfavorable outcome. CONCLUSION Bacteremia occurred in nearly 20% of the patients presenting with BI, and was associated with identifiable comorbid conditions; it was the main risk factor for an unfavorable outcome.

Medical table: A major tool for antimicrobial stewardship policy

Infectious diseases are unpredictable, with heterogeneous clinical presentations, diverse pathogens, and various susceptibility rates to anti-infective agents. These features lead to a wide variety of clinical practices, which in turn strongly limits their evaluation. We have been using a medical table since 2005 to monitor the medical activity in our department. The observation of heterogeneous therapeutic practices led to drafting up our own antibiotic guidelines and to implementing a continuous evaluation of their observance and impact on morbidity and mortality associated with infectious diseases, including adverse effects of antibiotics, duration of hospital stay, use of intensive care, and deaths. The 10-year analysis of medical practices using the medical table is based on more than 10,000 hospitalizations. It shows simplified antibiotic therapies and a reduction in infection-related morbidity and mortality. The medical table is a major tool for antimicrobial stewardship, leading to constant benefits for patients.

Safety of antibiotics combinations against Staphylococcal bone and joint infections

Joint Bone Spine - In Press.Proof corrected by the author Available online since dimanche 22 juin 2014

Managing ESBL-producing Enterobacteriaceae-related urinary tract infection in primary care: a tool kit for general practitioners

In Southern France, approximately 4% of E. coli isolates from community-acquired urinary tract infections are extended spectrum beta-lactamase producers, while carriage rates for enterobacteriaceae (ESBL-E) range from 3 to 6%. General practitioners (GP) are unfamiliar with the management of patients harboring ESBL-E. Providing them with a specific tool kit should assist in their therapeutic approach and optimize antimicrobial prescription an ESBL-E tool kit was developed by a multidisciplinary team: infectious diseases (ID) specialists, microbiologists, pharmacologists, and nursing home staff. This tool kit includes treatment protocols, GP and patient information leaflets, a list of infection control measures, and contact details of ID physicians for specialized advice. A community-based (including nursing homes) prospective study was conducted in 2012 in Southeastern France to test the tool kit in the context of ESBL-E-related urinary tract infections (UTI). ESBL-E-related UTI were identified in 88 patients, 66 GPs were contacted by the microbiology laboratory, 56 stated they were offered the tool kit, 48 said they had received it, and 41 stated they had read its contents. Use of the tool kit was significantly correlated with appropriate antibiotic prescription, which concerned 36/39 tool kit users versus 13/20 non-users (p = 0.0125) and 40 GPs expressed an average satisfaction rate of 4.2 on a scale of 0 to 5. Availability of a specific tool for managing patients harboring ESBL-E, now completed with a website, can assist community-based GPs and improve antimicrobial prescription.

Fast track consultation in the infectious diseases department of a French university hospital: evaluation of the service delivered to the general practitioner

Abstract Purpose: Since 2010, the Infectious Diseases (ID) department of the Nice university hospital (France) has implemented a fast track consultation (FTC): it allows General Practitioners (GP) to directly reach an ID specialist through a dedicated phone number for initial advice. Depending on the first observation, a formal consultation can be planned within 48 h. Our aim was to evaluate in a pilot study, the contribution of the FTC regarding the management of patients 28 days after the first phone contact. Methods: This prospective current care study was conducted between November 2014 and January 2015 in our ID department. The GP indicates the most likely diagnosis, the therapeutic strategy and the patient’s management he would have applied. After the formal consultation, ID specialist provides his diagnosis, therapeutic strategy and patient’s management. An adjudicative committee has evaluated the benefit of the FTC after 28 days of follow-up. Results: Fifty-one patients referred by 49 GP were included. ID specialists modified the diagnosis in 22 (43%) patients, antibiotic treatment in 35 (68%) and treatment plan in 30 patients (59%). FTC provided at least one service for 41/51 patients (94%): antibiotic treatment was reassessed for 11 (22%) patients, averted for 9 (18%) patients, unnecessary hospitalization was avoided for 8 (16%) of them and emergency room visit averted for 5 (10%) patients. Conclusions: FTC can provide significant improvement in the management of the patients in terms of decrease in unnecessary hospitalization, emergency room visit averted and appropriate use of antibiotics.

Antimicrobial stewardship policy: time to revisit the strategy?

Recent data indicate that both the overall numbers of antibiotic prescription and the frequency of multidrug-resistant bacteria are increasing significantly. These threatening features are observed, despite national antimicrobial stewardship (AMS) policies aimed at decreasing antibiotic use. AMS should also focus on the initial steps leading to antibiotic prescription. Physicians and their patients should benefit from the structured clinical pathways, the latter being adapted to regional epidemiological data and resources. Continuous evaluation of these predefined clinical paths through a computerized medical dashboard will allow a critical review and finally the optimization of medical practices. These innovative behavioural approaches for clinicians will supply precise information on the relationship among the diagnosis, therapeutics and outcome. This changing environment will carry out the adapted therapeutic procedures, and appropriate antibiotic use will inherently improve.

G-06: Évaluation de l’association fluoroquinolone + clindamycine au cours des infections ostéo-articulaires (IOA) à staphylocoques

Introduction – objectifs Au cours des infections osteo-articulaires (IOA) a staphylocoques une bi-antibiotherapie est recommandee. Les lincosamides et les fluoroquinolones sont des antistaphylococciques a bonne diffusion osseuse pouvant etre administres per os. L’efficacite de l’association de ces deux molecules est mal connue et merite d’etre mieux documentee pour justifier son utilisation. Materiels et methodes Les patients pris en charge pour IOA dans notre centre sont inclus dans une base de donnees specifique dans laquelle tous les antibiotiques prescrits ainsi que les effets indesirables (EI) associes sont references. Nous avons selectionne entre 2007 et 2013 les patients ayant recu l’association clindamycine + fluoroquinolone (C + F) pour une IOA a staphylocoque. L’efficacite therapeutique a ete determinee retrospectivement lorsque l’association C + F avait ete prescrite durant au moins la moitie de la duree d’antibiotherapie programmee. Resultats Les etapes de selection permettaient d’identifier 47 patients : 16 spondylodiscites (34 %), 13 IOA sur materiel (28 %), 11 arthrites (23 %) et 7 osteites (15 %). S. aureus et les staphylocoques a coagulase negative etaient impliques dans respectivement 78 % et 22 % des cas. Les F utilisees etaient la levofloxacine (60 %), l’ofloxacine (36 %) et la pefloxacine (4 %). La duree d’antibiotherapie etait de 48 jours en moyenne ; 7 patients (15 %) presentaient un EI imposant l’arret du traitement : 3 lies aux F et 4 lies a la C. Aucune diarrhee a C. difficile n’etait enregistree. L’association F + C avait ete administree durant 79 % de la duree totale d’antibiotherapie. Avec un recul median post-antibiotherapie de 26 mois, la guerison etait observee dans 87,5 % des cas, un echec dans 7,5 % des cas, 5 % des patients etant perdu de vue. Conclusion Au cours des IOA a staphylocoques l’association antibiotique F + C apparait efficace et bien toleree.