Leslie Grammatico-Guillon

Paediatric bone and joint infections are more common in boys and toddlers: a national epidemiology study

Little is known about bone and joint infections (BJIs) in children, despite the risk of growth disturbance. This study examined BJIs epidemiology using the French National Hospital Discharge Database (HD).

Clinical and economic outcomes of infective endocarditis

Abstract Background: In France, the estimated annual incidence of infective endocarditis (IE) is 33.8 cases per million residents. Valvular surgery is frequently undergone. We report an epidemiological and economic study of IE for 2007–2009 in a French region, using the hospital discharge database (HDD). Methods: The population studied concerned all the patients living in Centre region, France, hospitalized for IE. We extracted hospital stay data for IE from the regional HDD, with a definition based on IE-related diagnosis codes. The predictive positive value (PPV) and sensitivity (Se) of the definition were 87.4% and 90%, respectively, according to the Duke criteria (definite IE frequency 74.4%). Hospitalization costs were estimated, taking into account the fixed hospital charges of the diagnosis-related group (DRG) and supplementary charges due to intensive care unit (ICU) stay. Results: The analysis included 578 patients. The annual average incidence was 45.4 cases per million residents. Valvular surgery was performed in 19.4% of cases. The hospital mortality was 17.6%. Multivariate analysis identified as risk factors for mortality an age ≥ 70 years (odds ratio (OR) = 3.03, 95% confidence interval (CI) = 1.78–5.18), staphylococcal IE (OR = 3.3, 95% CI = 1.9–5.7), chronic renal insufficiency (OR = 2.04, 95% CI = 1.00–4.15), ischemic stroke (OR = 2.55, 95% CI = 1.19–5.47), and hemorrhagic stroke (OR = 5.7, 95% CI = 1.9–17.3). The average cost per episode was

Surgical Site Infection After Primary Hip and Knee Arthroplasty: A Cohort Study Using a Hospital Database.

20 103 (€15 281). Conclusions: We report a higher incidence of IE than described by the French national study of 2008. Valvular surgery was considerably less frequent than in the published data, whereas mortality was similar. IE generates substantial costs.

Échec du traitement de plasmodium falciparum par atovaquone-proguanil

BACKGROUND Hip or knee arthroplasty infection (HKAI) leads to heavy medical consequences even if rare. OBJECTIVE To assess the routine use of a hospital discharge detection algorithm of prosthetic joint infection as a novel additional tool for surveillance. METHODS A historic 5-year cohort study was built using a hospital database of people undergoing a first hip or knee arthroplasty in 1 French region (2.5 million inhabitants, 39 private and public hospitals): 32,678 patients with arthroplasty code plus corresponding prosthetic material code were tagged. HKAI occurrence was then tracked in the follow-up on the basis of a previously validated algorithm using International Statistical Classification of Disease, Tenth Revision, codes as well as the surgical procedures coded. HKAI density incidence was estimated during the follow-up (up to 4 years after surgery); risk factors were analyzed using Cox regression. RESULTS A total of 604 HKAI patients were identified: 1-year HKAI incidence was1.31%, and density incidence was 2.2/100 person-years in hip and 2.5/100 person-years in knee. HKAI occurred within the first 30 days after surgery for 30% but more than 1 year after replacement for 29%. Patients aged 75 years or older, male, or having liver diseases, alcohol abuse, or ulcer sore had higher risk of infection. The inpatient case fatality in HKAI patients was 11.4%. CONCLUSIONS The hospital database method used to measure occurrence and risk factors of prosthetic joint infection helped to survey HKAI and could optimize healthcare delivery.

Rapid HIV test in family practice.

Le paludisme est une parasitose érythrocytaire de distribution (sub-) tropicale. Cette protozoose, à l’origine d’environ 250 millions d’accès annuels dans le monde, est due à des protozoaires du genre Plasmodium. Le moustique anophèle joue le rôle de vecteur dans la transmission de la maladie. Nous rapportons le cas d’une récidive d’accès palustre à Plasmodium falciparum après traitement bien conduit par atovaquone-proguanil (AP).

Hospital and ambulatory management, and compliance to treatment in HIV infection: Regional health insurance agency analysis

BACKGROUND The 2010-2014 HIV/AIDS French program recommends using HIV rapid diagnostic tests in family practice. Our aim was to assess the acceptability and feasibility of the RDT in family practice in France. METHODS The first part of this study was to determine the opinions of family practitioners (FPs) concerning the news guidelines for screening and the possible use of rapid HIV tests in their practice. The second part was a feasibility study of the actual use of rapid HIV tests given to FPs during six months. The third part was a qualitative analysis of experience feedback to determine the impediments to using rapid HIV tests. RESULTS Seventy-seven percent of the 352 FPs interviewed were favorable to rapid HIV tests use. The three main impediments were: misinterpretation of test result, complexity of quality control, and lack of training: 23 of the 112 FPs having volunteered to evaluate the rapid HIV tests followed the required training session. Sixty-nine tests were handed out, and three rapid HIV tests were used; the qualitative study involved 12 FPs. The participants all agreed on the difficult use of rapid HIV tests in daily practice. The main reasons were: too few opportunities or requests for use, complex handling, difficulties in proposing the test, fear of having to announce seropositivity, significantly longer consultation. CONCLUSION Although FPs are generally favorable to rapid HIV tests use in daily practice, the feasibility and contribution of rapid HIV tests are limited in family practice.

Therapeutic decision-making process in the intensive care unit: role of biological point-of-care testing.

OBJECTIVE We had for objective to study HIV management (hospital, ambulatory, and mixed) and assess compliance with health insurance database. METHOD We conducted a retrospective study using the French Social Security (CPAM) database. The inclusion criteria were: age>18years of age, at least 2 prescriptions of antiretroviral therapy. RESULTS Five hundred and seventy-five patients were included: extra-hospital (12), hospital (162), mixed (401). The prescriptions were exclusively hospital issued for 76.2% of the patients. Among the mixed group patients, 91% of treatments were delivered at least once in the community, and 45.6% of biological tests were performed in private laboratories at least once. The sex ratio (2.1 vs. 1.3), the number of patients having switched antiretroviral therapy (36.7% vs. 27.8%), and the frequency of biological tests (3.1 vs. 2.6) were significantly higher in the mixed group compared to the hospital group. The mean compliance was 90% in the hospital group and 91.8% in the mixed group. The compliance was<80% for 104 patients (21.8%). Patients with≥80% compliance were older (46.1years of age vs. 42.7years of age), with more frequent biological tests (3 per year vs. 2.5 per year), and more frequent switches in treatment (35.4% vs. 26.0%). CONCLUSION Prescriptions of ARV were almost exclusively hospital issued. Their dispensation and biological tests were split between hospital and extra-hospital settings. Most patients demonstrated an optimal compliance. The CPAM database allows describing HIV management and assessing compliance.

Comment on: Persistence and adherence to single-tablet regimens in HIV treatment: a cohort study from the French National Healthcare Insurance Database.

*Corresponding author: Dr. Antoine Guillon, CHRU Tours, Service de Réanimation Polyvalente, CHRU Bretonneau, 2 Bd Tonnellé, 37044 Tours Cedex 9, France, Phone: +0033247471322, Fax: +0033247396536, E-mail: antoine.guillon@univ-tours.fr; and Université François Rabelais, Faculté de Médecine, Tours, France Adrien Auvet and Mai-Anh Nay: CHRU Tours, Service de Réanimation Polyvalente, Tours, France; CHRU Tours, Département d’Anesthésie et Réanimation, Tours, France; and Université François Rabelais, Faculté de Médecine, Tours, France Leslie Grammatico-Guillon: Université François Rabelais, Faculté de Médecine, Tours, France; and CHRU Tours, Service d’information médicale d’épidémiologie et d’économie de la santé, UREH, Tours, France Fabien Espitalier: CHRU Tours, Département d’Anesthésie et Réanimation, Tours, France Pierre-François Dequin: CHRU Tours, Service de Réanimation Polyvalente, Tours, France; and Université François Rabelais, Faculté de Médecine, Tours, France Letter to the Editor

Voluminous pseudotumor due to Mycobacterium malmoense.

Sir, We read with interest the article by Raffi et al. entitled Persistence and adherence to single-tablet regimens in HIV treatment: a cohort study from the French National Healthcare Insurance Database. We are also interested in studying HIV management in France with adherence estimation and assessment using a health insurance database. In fact, we conducted an observational study using the French National Healthcare Insurance Database (CPAM), based on the complete local CPAM database of HIV-infected patients having at least two prescriptions of specific ART from March 2009 to December 2010. This exhaustive database allowed collection of the following for each patient: hospital or extra-hospital practice for prescribers; hospital or extra-hospital dispensation of treatments; hospital or extra-hospital biological tests; and antiretroviral agents prescribed. Our database, more specifically than the General Sample of Social Security Beneficiaries (French acronym EGB) used by Raffi et al., allows study of the care consumption of HIV-infected patients in the community and hospital. One of the strengths of our study is that our database includes both biological analyses and prescription. Our study represented 575 patients; the prescriptions were exclusively hospital issued for 76.2% of the patients. Compared with EGB, mean adherence was higher in our study (.90%, only one patient out of five had adherence ,80% whatever the ART used). The patients with adherence ≥80% were significantly older (46.1 versus 42.7 years, P1⁄40.03), with a greater yearly frequency of biological tests (3 versus 2.5, P1⁄40.004). They switched their ART more frequently, but this difference was not significant (35.4% versus 26.0%, P1⁄40.07). In our study, we were able to analyse the trajectory of care with hospital or extra-hospital management. There was a trend for HIV infection to shift to extra-hospital management, but the prescriber remains almost exclusively hospital based (76%). Raffi et al. concluded, in their study supported by Gilead, based on a healthcare insurance database, that persistence is higher in HIV-infected patients treated with a single-tablet regimen (STR) compared with other administration schedules. Lack of clinical or biological data necessitates careful interpretation about antiretroviral persistence. These study limitations were not considered. Combination ART (cART) persistence is an interesting composite marker of toxicity and efficacy if reasons to switch are recorded. For example, many hospital centres in France still recommend a PI/ritonavir induction NNRTI maintenance strategy for treatment-naive patients in their local guidelines. In these centres, PI/ritonavir persistence is low, but not associated with toxicities or lack of efficacy and could not be compared with firstline NNRTI persistence. The strategy in the study of Raffi et al. underestimates persistence with PI/ritonavir. Moreover, many clinical situations require physicians to stop a non-STR strategy (AIDS events like TB, pregnancy, chemotherapy). These clinical events were not recorded and could also underestimate persistence if a non-STR strategy is used. Raffi et al. found a significant benefit in terms of adherence with the STR in comparison with regimens with more than one daily intake, but no difference when compared with regimens involving more than one pill once daily. A recent meta-analysis of randomized studies evaluated the impact of regimen type on adherence. Adherence was better with onceversus twice-daily regimens, but the difference was modest, without virological suppression difference. Viral load is probably a stronger endpoint than adherence for a cART strategy. Furthermore, lack of clinical details could also result in misinterpretation of adherence data. All patients were considered antiretroviral naive because of an absence of cART in the 3 years before inclusion. However, treatment-experienced patients lost to follow-up for .3 years could be considered treatment naive. In the study of Raffi et al., more than a third (15/41) of raltegravirbased regimens were NRTI sparing with PI/ritonavir and/or NNRTI, suggesting a high proportion of treatment-experienced patients with risk factors of moderate adherence. Clinical trials are not representative of real life. A healthcare insurance database allows adherence analysis in real life. However, the tenofovir disoproxil fumarate/emtricitabine/efavirenz STR, the only STR analysed in the study of Raffi et al., has been available in France since 5 May 2009. Almost one-third of STR patients (23/76) started cART before 2009 and French availability. These patients were probably included in clinical trials with a heavy follow-up programme and better adherence than in real life. Finally, results must be viewed with caution according to the database and its exhaustivity. Our study used a complete regional database as compared with real life. Mean adherence was higher whatever the ART regimen and the previous treatment experience than in the study of Raffi et al. and no significant differences were found between administration schedules. The study by Raffi et al., together with our exhaustive results, demonstrates the potential use of a healthcare insurance database to analyse adherence to ART. The current information systems covering the entire population health services allow data analysis and production of indicators, and really could allow a large-scale and exhaustive assessment of management modalities and mean adherence for HIV-infected patients. However, lack of interface with clinical and biological characteristics requires careful Letters to the Editor

Key features of bone and joint infections following the implementation of reference centers in France

Nontuberculous mycobacteria (NTM) are non-communicable opportunistic organisms that typically infect immunocompromised hosts such as in malignancy or HIV/AIDS [1]. However, NTM infections are more frequently being reported in imunocompetent individuals with underlying chronic respiratory diseases, previous tuberculosis or conditions including alcoholism, smoking and long term use of steroids [2,3]. Mycobacterium malmoense is one of the NTM species most frequently isolated in Europe [4], and has been reported in nonspecific pulmonary infections in adults and sub acute/chronic cervical lymphadenitis in children [5]. Cutaneous infections are rare and clinical presentations are nodula [6,7]. Other uncommon presentations include, soft tissue, joint infections [8], urinary tract infection, tenosynovitis, and disseminated infection in patients with HIV [1,9]. The environment, especially water and soil are thought to be the principal source of M. malmoense. Recovery and identification of M. malmoense is challenging, as the mycobacteria are nonpigmented and slow growing, often taking several weeks to culture. Furthermore, there is no global consensus for treatment of M. malmoense infection. It is thought that a long term combination of rifampicin and ethambutol produce better results than other regimens [10,11]; quinolones and macrolides are not as effective [10,11]. Susceptibility testing of M. malmoense remains variable. We report the case of an old woman with unusual M. malmoense infection of the soft tissue presenting as a pseudotumor.