Introduction La résistance du Pseudomonas aeruginosa (PA) en soins intensifs est fréquente. Les molécules les plus inductrices de résistances, notamment croisés. telles que les carbapenemes et les fluoroquinolones sont les moins utilisés.Peu de données in vivo « en vie réelle » aident à caractériser la chronologie de l'acquisition de la résistance en fonction des antibiotiques utilisés, et la plupart de ces données ne sont évalués qu'a un an. Objectifs Décrire le délai d'acquisition de la résistance aux antibiotiques chez PA après un premier isolat sensible/intermédiaire in vivo en fonction des antibiotiques au sein d'un protocole d'antibiostewardship. Matériels et méthodes Nous avons mené une étude observationnelle rétrospective sur des isolats de PA prélevés au cours des soins diagnostiques courants, en excluant les cultures urinaires et les prélèvements cutanés ou de mattériels invasifs, par patients, collectés entre 2004 et 2024 en soins intensifs, en France.Les antibiotiques probabilistes utilisés sont une bithérapie par Tazocilline et Amikacine, le relais de première intention proposé est la piperacilline.Le relais par ciprofloxacine, carbapenems, et ceftazidime étant évités tant que possible.Le T0 a été défini comme la date du premier isolat sensible/intermédiaire (S/I), et l'acquisition de la résistance a été définie comme le premier isolat résistant (R). Une analyse par Kaplan-Meier et des modèles de risques proportionnels de Cox a été réalisé. Le temps médian avant l'apparition de la résistance et la probabilité de résistance à 180 jours ont été estimés. Résultats Le délai médian avant l'apparition de la résistance était le plus court pour la pipéracilline (16 jours), la pipéracilline-tazobactam (25 jours) et la ceftazidime (28 jours), avec plus de 60 % des isolats devenant résistants au bout de 180 jours.À 180 jours, la probabilité de résistance était la plus élevée pour la pipéracilline (79 %).A 180 jours la probabilité de résistance était la plus faible pour l'amikacine (25 %), ce taux persistent a 1 ans et 5 ans de suivis.Dans les modèles de Cox, l'amikacine (HR 0,12, p < 0,001), la ciprofloxacine (HR 0,33, p < 0,001) et l'imipénème (HR 0,28, p < 0,001) ont été associés à une acquisition de résistance significativement plus lente par rapport à la piperacilline et piperacilline tazobactam.L'analyse de Kaplan-Meier a démontré des différences significatives dans l'acquisition de la résistance entre les antibiotiques (log-rank p < 0,0001). Conclusion Les protocoles antibiotiques de service en soins intensifs d'antibiothérapie probabiliste à base de de piperacilline tazobactam et d'amikacine avec de la piperacilline en relais sont parfois associés à l'apparition microbiologique d'une résistance, qui survient dans plus de la moitié des cas au cours du premier mois de suivis.Toutefois ce protocole montre une faible acquisition de résistance croisé aux autres classes, avec une sensibilité importante, maintenue et prolongé de l'amikacine et dans une moindre mesure des fluoroquinolones et de l'imipénème.D'autres études, qualitatives, prospectives, cliniques et multicentrique, sont nécessaire sur le sujet.
OBJECTIVES:We aimed to assess the extent of integration of non-communicable disease (NCD) assessment and management in HIV clinics across Europe. METHODS:A structured electronic questionnaire with 41 multiple-choice and rating-scale questions assessing NCD assessment and management was sent to 88 HIV clinics across the WHO European Region during March-May 2023. One response per clinic was collected. RESULTS:In all, 51 clinics from 34 countries with >100 000 people with HIV under regular follow-up responded. Thirty-seven clinics (72.6%) reported shared NCD care responsibility with the general practitioner. Systematic assessment for NCDs and integration of NCD management were common overall [median agreement 80%, interquartile range (IQR): 55-95%; and 70%, IQR: 50-88%, respectively] but were lowest in central eastern and eastern Europe. Chronic kidney disease (median agreement 96%, IQR: 85-100%) and metabolic disorders (90%, IQR: 75-100%) were regularly assessed, while mental health (72%, IQR: 63-85%) and pulmonary diseases (52%, IQR: 40-75%) were less systematically assessed. Some essential diagnostic tests such as glycated haemoglobin (HbA1c) for diabetes (n = 38/51, 74.5%), proteinuria for kidney disease (n = 30/51, 58.8%) and spirometry for lung disease (n = 11/51, 21.6%) were only employed by a proportion of clinics. The most frequent barriers for integrating NCD care were the lack of healthcare workers (n = 17/51, 33.3%) and lack of time during outpatient visits (n = 12/51, 23.5%). CONCLUSION:Most HIV clinics in Europe systematically assess and manage NCDs. People with HIV appear to be screened more frequently than the general population at the same age. There are, however, larger gaps among eastern European clinics in general and for clinics in all regions related to mental health, pulmonary diseases and the employment of some essential diagnostic tests.
Background: Eastern Europe has a high burden of tuberculosis (TB)/HIV coinfection with high mortality shortly after TB diagnosis. This study assesses TB recurrence, mortality rates and causes of death among TB/HIV patients from Eastern Europe up to 11 years after TB diagnosis. Methods: A longitudinal cohort study of TB/HIV patients enrolled between 2011 and 2013 (at TB diagnosis) and followed-up until end of 2021. A competing risk regression was employed to assess rates of TB recurrence, with death as competing event. Kaplan–Meier estimates and a multivariable Cox-regression were used to assess long-term mortality and corresponding risk factors. The Coding Causes of Death in HIV (CoDe) methodology was used for adjudication of causes of death. Results: Three hundred and seventy-five TB/HIV patients were included. Fifty-three (14.1%) were later diagnosed with recurrent TB [incidence rate 3.1/100 person-years of follow-up (PYFU), 95% confidence interval (CI) 2.4–4.0] during a total follow-up time of 1713 PYFU. Twenty-three of 33 patients with data on drug-resistance (69.7%) had multidrug-resistant (MDR)-TB. More than half with recurrent TB ( n = 30/53, 56.6%) died. Overall, 215 (57.3%) died during the follow-up period, corresponding to a mortality rate of 11.4/100 PYFU (95% CI 10.0–13.1). Almost half of those (48.8%) died of TB. The proportion of all TB-related deaths was highest in the first 6 ( n = 49/71; 69%; P < 0.0001) and 6–24 ( n = 33/58; 56.9%; P < 0.0001) months of follow-up, compared deaths beyond 24 months ( n = 23/85; 26.7%). Conclusion: TB recurrence and TB-related mortality rates in PWH in Eastern Europe are still concerningly high and continue to be a clinical and public health challenge.
The HIV epidemic in Eastern Europe and Russia is large and not well-controlled. To describe the more recent molecular epidemiology of HIV-1, transmitted drug resistance, and the relationship between the epidemics in this region, we sequenced the protease and reverse transcriptase genes of HIV-1 from 812 people living with HIV from Ukraine (n = 191), Georgia (n = 201), and Russia (n = 420) before the initiation of antiretroviral therapy. In 190 Ukrainian patients, the integrase gene sequence was also determined. The most reported route of transmission was heterosexual contact, followed by intravenous drug use, and men having sex with men (MSM). Several pre-existing drug resistance mutations were found against non-nucleoside reverse transcriptase inhibitors (RTIs) (n = 103), protease inhibitors (n = 11), and nucleoside analogue RTIs (n = 12), mostly polymorphic mutations or revertants. In the integrase gene, four strains with accessory integrase strand transfer inhibitor mutations were identified. Sub-subtype A6 caused most of the infections (713/812; 87.8%) in all three countries, including in MSM. In contrast to earlier studies, no clear clusters related to the route of transmission were identified, indicating that, within the region, the exchange of viruses among the different risk groups may occur more often than earlier reported.
