Karolina Griffiths

The inevitable Hajj cough: Surveillance data in French pilgrims, 2012-2014.

Summary Background Respiratory tract infections are the most common infection affecting Hajj pilgrims, and the ‘‘Hajj cough’’ is considered by pilgrims almost de rigueur. Methods French pilgrims were recruited between January 2012–December 2014 and information on demographics, medical history, compliance with preventive measures and health problems during travel were collected. Results A total of 382 pilgrims were included with 39.3% aged ≥65 years and 55.1% suffering from a chronic disease, most frequently hypertension and diabetes. The prevalence of cough was 80.9% and a high proportion presented with associated sore throat (91.0%), rhinitis (78.7%) and hoarseness (63.0%). Myalgia was reported in 48.3% of cases and subjective fever in 47.3%. The incubation time of respiratory symptoms was 7.7 days (range 0–25 days) and 51.9% of pilgrims presenting with a cough during their stay were still symptomatic on return. Among pilgrims with a cough, 69.4% took antibiotics. The prevalence of cough was significantly higher among females than men, but age, chronic conditions and preventive measures had no significant effect. Conclusions The Hajj cough is highly common, likely a result of crowded conditions at religious places. Pilgrims should be advised to carry symptomatic relief for the Hajj cough such as cough suppressant, soothing throat lozenges and paracetamol. Use of antibiotics should be discouraged.

Acquisition of a High Diversity of Bacteria during the Hajj Pilgrimage, Including Acinetobacter baumannii with blaOXA-72 and Escherichia coli with blaNDM-5 Carbapenemase Genes

ABSTRACT Pilgrims returning from the Hajj (pilgrimage to Mecca) can be carriers of multidrug-resistant bacteria (MDR). Pharyngeal and rectal swab samples were collected from 98 pilgrims before and after they traveled to the Hajj in 2014 to investigate the acquisition of MDR bacteria. The bacterial diversity in pharyngeal swab samples was assessed by culture with selective media. There was a significantly higher diversity of bacteria in samples collected after the return from the Hajj than in those collected before (P = 0.0008). Surprisingly, Acinetobacter baumannii strains were isolated from 16 pharyngeal swab samples (1 sample taken during the Hajj and 15 samples taken upon return) and 26 post-Hajj rectal swab samples, while none were isolated from samples taken before the Hajj. Testing of all samples by real-time PCR targeting blaOXA-51 gave positive results for only 1% of samples taken during the Hajj, 21/90 (23.3%) pharyngeal swab samples taken post-Hajj, and 35/90 (38.9%) rectal swab samples taken post-Hajj. One strain of A. baumannii isolated from the pharynx was resistant to imipenem and harbored a blaOXA-72 carbapenemase gene. Multilocus sequence typing analysis of 43 A. baumannii isolates revealed a huge diversity of 35 sequence types (STs), among which 18 were novel STs reported for the first time in this study. Moreover, we also found one Escherichia coli isolate, collected from a rectal swab sample from a pilgrim taken after the Hajj, which harbored blaNDM-5, blaCTX-M-15, blaTEM-1, and aadA2 (ST2659 and ST181). In conclusion, pilgrims are at a potential risk of acquiring and transmitting MDR Acinetobacter spp. and carbapenemase-producing Gram-negative bacteria during the Hajj season.

Melioidosis as a travel-associated infection: Case report and review of the literature

BACKGROUND Increasing numbers of sporadic cases of melioidosis in returning travelers have been reported from non-endemic regions. METHODS We report a new case and undertook a literature review. RESULTS Eighty-two travelers with melioidosis infection were included. The mean age was 50.95 years, with only one case <15 years. A male predominance was noted, with 66 males (80.5%). Type of travel included tourism (51.2%), family visits (15.8%) and business (14.6%). The most common destinations were Asia (80.5%), America (9.7%) and Africa (7.3%). No cases were documented from Oceania. Underlying conditions were documented in 68 patients, showing a strong association with diabetes (37.8%). Exposure risks were documented in 32 patients, including contact with water. Pulmonary involvement was seen in 41 patients, cutaneous in 23, abdominal in 14, and urogenital in 10 cases. Blood cultures posed the diagnosis in 43 cases. Fifty-seven patients fully recovered, 12 died, and three relapsed. The mortality rate (14.6%) was close to that observed in Australia but lower than series in Southern Asia. CONCLUSION Melioidosis should not only be considered in travelers returning from classically considered endemic areas (Australia and South-East Asia) but also from America and Africa, especially in diabetic patients or after contact with water.

Antibiotic prophylaxis of endocarditis.

We read with interest the Comment by John Chambers and colleagues on antibiotic prophylaxis of endocarditis. The authors questioned the conclusions of the recently updated NICE clinical guidelines, which do not recommend antibiotic prophylaxis for people undergoing dental procedures. Historical arguments for prophylaxis included transient streptococcal bacteraemia following teeth extraction. The most unexpected finding in seminal studies was that, in several patients, streptococci were isolated from blood samples taken before the operation. Subsequently, investigators related endocarditis, mostly documented with oral streptococci, to oral sepsis of pyorrheal nature in several patients and autopsies. These results correctly suggested that oral sepsis, rather than dental procedures on their own, might be causally associated with streptococcal bacteraemia and endocarditis. Endocarditis was also reported following cleaning and fi lling of teeth. Only by deduction, some authors and health authorities of several countries recommended onedose antibiotic prophylaxis before dental procedure in at-risk patients. However, well-designed studies never validated this attitude. Failures of antibiotic prophylaxis occurred in several cases, in which the infecting microorganism was later found to be sensitive to the antibiotic used for prophylaxis. The causal link between oral sepsis and endocarditis, highlighting the critical importance of dental hygiene, the causal link between dental procedures and endocarditis, and the efficacy of antibiotic prophylaxis before dental procedures should be considered completely diff erent issues. Studies assessing efficacy of antibiotic prophylaxis in this context are very heterogeneous, including studies mixing dental, urological, oropharynx, and gynaecological virus detection in saliva within the first days post symptoms onset for symptomatic infections (appendix). For a mother with a positive result for RT-PCR in blood, we also recommend collection of a second blood sample 2–4 weeks after the fi rst. Detection of Zika virus RNA in the second sample would reflect prolonged maternal viraemia, which might be an alarming sign of fetal infection. Knowledge of prolonged maternal viraemia might be particularly useful when termination of pregnancy is considered. Zika virus RNA detection in any clinical specimen is laboratory evidence of maternal infection; however, clinicians should remain aware that a negative PCR does not exclude an infection, and clinical decisions should not be made on this result alone.

Patient-prosthesis mismatch in new generation trans-catheter heart valves: a propensity score analysis

Aims When compared with the former Sapien XT (XT-THV), the Sapien 3 trans-catheter heart valve (S3-THV) embeds an outer annular sealing cuff to prevent para-valvular regurgitation (PVR). The consequences of this new feature on valve haemodynamics have never been evaluated. We aimed to compare both types of prostheses regarding patient-prosthesis mismatch (PPM). Methods and results Patients who underwent a TAVR for aortic stenosis were retrospectively included. Regression adjustment for the propensity score was used to compare 50 XT-THV patients with 71 S3-THV. At the 1-month follow-up, the mean indexed effective orifice area (iEOA) was 1.12 ± 0.34 cm2/m2 with XT-THV and 0.96 ± 0.27 cm2/m2 with S3-THV. The mean gradient was 11 ± 5 mmHg and 13 ± 5 mmHg, respectively. Nine patients had moderate PPM, and two exhibited severe PPM with XT-THV. Nineteen patients had moderate PPM, and seven demonstrated severe PPM with S3-THV. There was a five-fold increased risk of PPM with S3-THV (OR = 4.98; [1.38-20.94], P = 0.019). S3-THV decreased the iEOA by 0.21 cm2/m2 [-0.21; (-0.38 to - 0.05); P = 0.012] and increased the mean gradient by 4.95 mmHg [4.95; (2.27-7.64); P < 0.001]. The risk of PPM was increased 15.24-fold with 23 mm S3-THV [15.24; (2.92-101.52); P = 0.002] in comparison with the 23 mm XT-THV. PVR were reduced by 98% with S3-THV. Conclusion There is an increased risk of PPM with 23mm S3-THV in comparison with 23 mm XT-THV. This may be attributable to the additional sub-annular cuff that avoids the risk of PVR. Regarding the increased vulnerability of younger patients to PPM, we provide essential information on the extension of TAVR indication to the younger population.

Surveillance of travel-associated diseases at two referral centres in Marseille, France: a 12-year survey

Abstract Background With increasing international travel and historically high numbers of residents visiting friends and relatives overseas, travel-associated illnesses are frequent in Marseille, France. We report the changing epidemiology of travel-related illnesses over a 12-year period. Methods A single site GeoSentinel surveillance analysis was undertaken for 3460 ill returned travellers presenting to two public hospitals in Marseille, France from March 2003 to October 2015, with travel-related illnesses. Demographic characteristics, travel history, presenting symptoms and information on pre-travel consultations were collected. Results There was a predominance of travel to sub-Saharan Africa, in particular to Comoros archipelago. Tourism was the main reason for travel (1591/3460, 46%), followed by visiting friends or relatives (VFR) (895/3460, 26%), with a mean duration of 29 days; 35% (1212/3460) of travellers reported a pre-travel health consultation. The most common syndromic diagnoses were febrile systemic illness (1343, 39%), dermatologic (716, 21%), gastrointestinal (340, 10%) and respiratory/ear–nose–throat (331, ENT) (10%). Hospitalization rates were highest amongst travellers from sub-Saharan Africa (858/ 1632, 53%), and VFR (573/ 895, 64%, P < 0.001). Frequent diagnoses included malaria (797, 23%), dengue (96, 2.77%) and chikungunya (75, 2.17%), reflecting global trends. Comparison of two periods (2003–10 to 2011–15) demonstrated an increase in chikungunya and decrease in malaria and influenza-like illness. We report an increase in ill travellers from the Caribbean, Middle East and South-East Asia. Conclusion Surveillance of travellers provides relevant sentinel information on the changing epidemiology of infectious diseases across the globe, most notably for malaria, dengue and chikungunya. We demonstrate the use of travel surveillance in improving pre-travel consultation needs and to address autochthonous vector-borne viral risks.

Clinical outcome after biliary drainage for metastatic colorectal cancer: Survival analysis and prognostic factors

INTRODUCTION Biliary obstruction secondary to colorectal cancer liver metastases is associated with a poor prognosis especially when chemotherapy cannot be re-started. The aim of this study was to determine the survival after biliary drainage and the associated prognostic factors. METHODS Patients from two French centers were included retrospectively after first biliary endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography drainage for biliary obstruction secondary to liver metastases of colorectal cancer, occurring during chemotherapy. RESULTS The final analysis included 69 patients. Overall median survival was 115 days. In univariate analysis, a previous liver surgery, technical and functional success of drainage and restarted chemotherapy were significantly associated with an improved survival. Chemotherapy was restarted after a median of 27 days. When drainage was efficient, survival improved from 33 to 262days (p<0.001). In multivariate analysis, significant protective factors for survival included previous a hepatectomy (HR 0.41) and functional success of the drainage (HR 0.29). Predictive factors for death included increased lines of chemotherapy (HR 1.68) and fever before drainage (HR 2.97). CONCLUSIONS This is the first study concerning the benefits of biliary drainage for malignant biliary obstruction during the course of chemotherapy for colorectal cancer. A successful biliary drainage leads to improved survival and allows achievement of chemotherapy for 70% of patients.

Targeting hotspots to reduce transmission of malaria in Senegal: modeling of the effects of human mobility

Background In central Senegal malaria incidences have declined in recent years in response to scaling-up of control measures, but now remains stable, making elimination improbable. Additional control measures are needed to reduce transmission. Methods By using a meta-population mathematical model, we evaluated chemotherapy interventions targeting stable malaria hotspots, using a differential equation framework and incorporating human mobility, and fitted to weekly malaria incidences from 45 villages, over 5 years. Three simulated approaches for selecting intervention targets were compared: a) villages with at least one malaria case during the low transmission season of the previous year; b) villages ranked highest in terms of incidence during the high transmission season of the previous year; c) villages ranked based on the degree of connectivity with adjacent populations. Results Our mathematical modeling, taking into account human mobility, showed that the intervention strategies targeting hotspots should be effective in reducing malaria incidence in both treated and untreated areas. Conclusions Mathematical simulations showed that targeted interventions allow increasing malaria elimination potential.

Identification and tracking of Addictovigilance signals in general practice: which interactions between the general practitioners and the French Addictovigilance Network?

Addictovigilance is a health vigilance dedicated to the survey of medicinal or illicit psychoactive substance use disorders (SUDs). France is the only European country to have a vigilance system specifically dedicated to substances with an abuse/addiction potential. The French Addictovigilance system is organized in a network of regional tertiary centres (called Abuse and Dependence Monitoring Centres, CEIP‐Addictovigilance) and works in close collaboration with Regional and National health authorities. Because of the essential and unavoidable nature of their practice in the French Healthcare system, general practitioners (GPs) are key actors to identify and track Addictovigilance signals. They have been involved in several of the pharmacoepidemiological surveys implemented by the French Addictovigilance Network (FAN). Now, they increasingly participate in clinical research projects and studies. In this article, interactions between GPs and the FAN are illustrated with two examples: patients on opioid substitution treatment and patients on opioid analgesics. Collaborations between GPs and the FAN could be further potentiated. In particular, more effective communication on psychoactive SUDs including abuse/addiction is necessary to optimize the implementation of preventive measures for patients on psychoactive substances medications, and to improve the attitudes of GPs and more widely health professionals in the management of any psychoactive user suffering from SUDs. In addition, both adapted training and improved collaborative research could contribute to the optimization (safety, quality) of professional practices.