Nicole Desplaces

Mycobacterium xenopi spinal infections after discovertebral surgery: investigation and screening of a large outbreak

BACKGROUNDnMycobacterium xenopi spinal infections were diagnosed in 1993 in patients who had undergone surgical microdiscectomy for disc hernia, by nucleotomy or microsurgery, in a private hospital. Contaminated tap water, used for rinsing surgical devices after disinfection, was identified as the source of the outbreak. Several cases were recorded in the 4 years after implementation of effective control measures because of the long time between discectomy and case detection. The national health authorities decided to launch a retrospective investigation in patients who were exposed to M xenopi contamination in that hospital.nnnMETHODSnMailing and media campaigns were undertaken concurrently to trace exposed patients for spinal infections. Patients were screened by magnetic resonance imaging (MRI), and the scans were reviewed by a radiologist who was unaware of the diagnosis. Suspected cases had discovertebral biopsy for histopathological and bacteriological examination.nnnFINDINGSnOf 3244 exposed patients, 2971 (92%) were informed about the risk of infection and 2454 (76%) had MRI. Overall, 58 cases of M xenopi spinal infection were identified (overall cumulative frequency 1.8%), including 26 by the campaign (mean delay in detection 5.2 years, SD 2.4, range 1-10 years). Multivariate analysis showed that the risk of M xenopi spinal infection was related to nucleotomy and high number of patients per operating session.nnnINTERPRETATIONnFailures in hygiene practices could result in an uncontrolled outbreak of nosocomial infection. Patients who have been exposed to an iatrogenic infectious hazard should be screened promptly and receive effective information.

Outcome of patients over 80 years of age on prolonged suppressive antibiotic therapy for at least 6 months for prosthetic joint infection

OBJECTIVESnTo describe elderly patients treated with prolonged suppressive antibiotic therapy for a prosthetic joint infection (PJI) in cases where the infected prosthesis could not be removed.nnnMETHODSnAll patients aged ≥80 years with a documented PJI and treated with prolonged suppressive antibiotic therapy for more than 6 months were included retrospectively in this study. The following events were noted: failure including persisting infection, relapse, new infection, treatment discontinuation due to severe adverse events, and related death, and also unrelated death.nnnRESULTSnThirty-eight patients with a median age of 84 years (80-95 years) were included; there were 24 hip infections, 13 knee infections, and one shoulder infection. The main causative organisms were Staphylococcus aureus (39%) and Streptococcus agalactiae (16%). The most commonly prescribed antibiotics as prolonged suppressive therapy were penicillins. The median follow-up duration was 24 months; 60% of the patients were event-free at 24 months and were still on prolonged suppressive antibiotic therapy. Fifteen events (six failures and nine unrelated deaths) were observed. Hypoalbuminaemia, the presence of a sinus tract, and a staphylococcal PJI were associated with an increased risk of an event.nnnCONCLUSIONSnProlonged suppressive antibiotic therapy is an alternative therapy in elderly patients with PJI when surgery is contraindicated and when the bacteria are susceptible to well-tolerated oral antimicrobial therapy such as beta-lactams.

L’antibiothérapie suppressive, une réalité thérapeutique : à propos de 73 cas d’infection de prothèses articulaires

Introduction L’antibiotherapie suppressive (ABS) prolongee par voie orale est une alternative a un traitement curateur medicochirurgical des infections de prothese articulaire en cas de contre-indication medicale ou refus par le patient du traitement chirurgical en vue de controler l’infection. L’objectif de cette etude est de decrire les patients eligibles a ce traitement, les modalites therapeutiques et l’evolution sous traitement. Patients et methodes Etude retrospective incluant les patients ayant une infection de prothese articulaire documentee traitee par antibiotherapie suppressive. Resultats Entre 2004xa0et 2014, 73xa0patients ont ete inclus, d’âge median de 82xa0ans [46–94] pour une infection de prothese articulaire (43xa0hanches, 27xa0genoux, 2xa0epaules et 1xa0infection hanche–genou) fistulisee dans 38xa0% des cas. Vingt-neuf (42xa0%) patients avaientxa0≥xa01xa0facteur de risque d’infection. Le score ASA etaitxa0≥xa03xa0pour 73xa0% d’entre eux. Les bacteries en cause etaientxa0: 24xa0% de streptocoques (nxa0=xa017), 21xa0% de Staphylococcus aureus (nxa0=xa015xa0dont 5xa0SAMR), S.xa0epidermidis (nxa0=xa07xa0dont 5xa0SEMR), enterobacteries (nxa0=xa012), Propionibacterium acnes (nxa0=xa05), Enterococcus faecalis (nxa0=xa04), autres (nxa0=xa013). L’indication de l’ABS etait pour 48xa0patients (66xa0%), une contre-indication medicale a la chirurgie ou a l’anesthesie generale, pour 18 (25xa0%) un refus de la chirurgie et pour 7xa0un etat osseux non favorable a un traitement chirurgical optimal. Douze patients ont ete exclus de l’analyse car le suivi a etexa0≤xa03xa0mois. Parmi les 61xa0patients analyses, 55 (90xa0%) ont recu un traitement intensif initial, par voie intraveineuse puis par voie orale a posologie elevee, d’une duree mediane de 8xa0semaines, IQR [4–12]. Les antibiotiques utilises etaientxa0: betalactamine (cloxacilline, cefalexine ou amoxicilline) (nxa0=xa038, 62xa0%), clindamycine (nxa0=xa08), cotrimoxazole (nxa0=xa07), fluoroquinolone ou cycline. Trois patients ont eu initialement un drainage chirurgical non curatif. A la derniere consultation de suivi, (duree mediane de traitementxa0=xa021,5xa0mois), l’infection etait controlee chez 44 (72xa0%) patients ainsi que la douleur articulaire chez 42xa0patients, dont 39xa0patients sous antibiotherapie en cours et 5xa0patients suivis apres arret de l’antibiotherapie au bout de 1xa0a 4xa0ans de traitement. Chez les 17xa0patients restants, le traitement a ete arrete pour effets secondaires de stade 1xa0ou 2 (nxa0=xa06), reouverture de fistule (nxa0=xa05), nouvelle infection (nxa0=xa03), douleur non controlee (nxa0=xa01). Deux patients ont finalement accepte un traitement chirurgical curateur. Chez les 24xa0patients ayantxa0≥xa01xa0fistule a l’initiation du traitement, 12xa0ont vu leur(s) fistule(s) se refermer dans un delai maximal de 6xa0mois. Conclusion L’ABS est une realite therapeutique en alternative au traitement chirurgical curateur notamment chez le patient tres âge. Elle permet un controle de l’infection et de la douleur dans plus de deux tiers des patients. Elle merite d’etre comparee a une simple abstention therapeutique et mieux evaluee au niveau de son impact sur la qualite de vie des patients.