Introduction L'endocardite infectieuse (EI) est une pathologie grave dont l'incidence augmente avec l'âge. Chez les patients âgés, sa prise en charge est complexe en raison de la nécessité d'une antibiothérapie intraveineuse prolongée à fortes posologies, exposant à un risque élevé d'événements indésirables, notamment confusion et insuffisance rénale aiguë, dans un contexte de comorbidités multiples et de polymédication. Peu d'études ont évalué la tolérance de ces traitements dans cette population. L'objectif principal de cette étude était de déterminer la fréquence et les causes des interruptions non programmées de l'antibiothérapie chez les patients âgés de plus de 75 ans atteints d'EI. Matériels et méthodes Il s'agit d'une étude ancillaire de ENDOLA, étude rétrospective, observationnelle et multicentrique Française ayant inclus 1 079 patients âgés de ≥75 ans hospitalisés entre 2016 et 2022 pour une EI certaine ou probable selon les critères de Duke-Li modifiés. Les données cliniques, biologiques et thérapeutiques ont été recueillies de manière standardisée. Le critère de jugement principal était l'interruption non programmée de l'antibiothérapie. Les critères secondaires incluaient les causes de ces interruptions et le profil des patients concernés. Résultats Parmi les 877 patients inclus (âge moyen 83 ± 5 ans, 41% âgés de ≥85 ans) atteints d'EI confirmée, une interruption non programmée de l'antibiothérapie est survenue chez 469 patients (53,5 %). Les principales causes étaient le décès (n=164), la survenue d'un événement indésirable (n=201) et des difficultés d'administration du traitement (n=52). Les événements indésirables les plus fréquemment responsables d'une interruption étaient l'insuffisance rénale (24%; n=114), les troubles neurologiques (4%; n=19) et les troubles digestifs (2,4%; n=11). Une insuffisance rénale à l'admission, une autonomie réduite, ainsi que l'utilisation de vancomycine et d'aminosides étaient associées à un risque accru d'interruption prématurée. Conclusion Chez les patients âgés atteints d'EI, l'antibiothérapie prolongée est fréquemment interrompue de manière non programmée. Ces résultats soulignent la nécessité d'adapter les stratégies thérapeutiques à la fragilité et au profil de tolérance de cette population.
PURPOSE:To set national dose interventional reference levels (IRLs) for adults undergoing the most common cardiac electrophysiology and pacing procedures. MATERIALS AND METHODS:A national multicentre survey was performed in 33 French cardiac electrophysiology and pacing departments. Eleven standard image-guided interventional procedures in cardiac electrophysiology and pacing were analysed. Air Kerma (AK), kerma-area product (PKA) and fluoroscopy time (T) were recorded for 10 to 30 patients per procedure and per centre. IRLs were calculated as the 3rd quartiles and medians of distributions. RESULTS:A total of 4219 patients (70.4 ± 14.4 years old, 32% women) were included. IRLs were suggested for three dosimetric indicators in the eleven procedures. For endovascular implantation (pacemaker and defibrillator), IRLs increased with the complexity of procedures. In terms of PKA and T, IRLs were 4.10 Gy.cm2 and 5.5 min for single-chamber pacemakers, 11.50 Gy.cm2 and 16.5 min for bi-ventricular pacemakers, 2.25 Gy.cm2 and 4.0 min for single-chamber defibrillators and 12.90 Gy.cm2 and 18.0 min for bi-ventricular defibrillators. For all pacemaker procedures, left bundle branch area pacing significantly increased PKA, AK, and T values (p < 0.05). For ablations, the lowest IRLs were found for accessory pathway ablation (4.10 Gy.cm2 and 10.5 min) and the highest for ablation of persistent atrial fibrillation (12.65 Gy.cm2 and 15.5 min). For all ablations, the main energy source used was radiofrequency (>75% of procedures). For most procedures, the IRLs proposed were close to most of those already published, or lower. CONCLUSION:This national multicentre study reports IRLs for the most common image-guided interventional cardiac electrophysiology and pacing procedures.
Background:Community-acquired bacterial meningitis remains associated with high mortality and neurological disability in critically ill adults. Contemporary data on outcomes in mechanically ventilated patients and on the role of invasive intracranial pressure monitoring are limited. We aimed to describe 90-day outcomes, identify predictors of unfavorable neurological outcome, and evaluate the association between invasive intracranial pressure monitoring and prognosis in mechanically ventilated adults with community-acquired bacterial meningitis. Methods:Retrospective multicenter cohort study (2012-2023) across 26 French ICUs. The primary endpoint was unfavorable functional outcome at day 90 (modified Rankin Scale score 3-6), assessed using multivariable mixed-effects regression and propensity score-based overlap weighting. Findings:Among 704 included patients (median age, 66 years [IQR, 48-70 years]; 421 men [59.8%]), 354 (50.3%) had an unfavorable outcome at day 90, including 220 (31.3%) who died. Independent predictors of unfavorable outcome included older age, septic shock, acute kidney injury, coagulation disorders, lower motor score on the Glasgow Coma Scale, pupillary abnormalities, and abnormal brain imaging findings at presentation. Appropriate initial antimicrobial therapy, along with adjunctive dexamethasone, was associated with improved outcomes. Invasive intracranial pressure monitoring was performed in 84/704 patients (11.9%) and was not associated with improved functional outcome in the overall cohort (odds ratio, 0.97; 95% CI, 0.48-1.96) or in prespecified subgroups. Interpretation:In this large real-world cohort, 90-day mortality and disability remain high and are largely driven by initial neurological and systemic severity. Invasive intracranial pressure monitoring was not associated with improved outcomes, and no clear benefit was identified in this observational analysis. Funding:None.
Following a first male urinary tract infection (mUTI), systematic investigation for predisposing factors is called for, as mUTIs frequently arise secondarily to anatomical or functional urinary tract abnormalities. Although no international consensus defines a minimal etiological work-up, guidelines from the French (AFU) and European (EAU) Associations of Urology provide a clinical framework. First-line assessment comprises a targeted history (laying emphasis on macroscopic hematuria and lower urinary tract symptoms, LUTS), digital rectal examination (DRE), the International Prostate Symptom Score (IPSS), and urinary tract ultrasonography with post-void residual (PVR) measurement. LUTS, classified as storage (urgency, frequency), voiding (weak stream, straining), or post-micturition (incomplete emptying) may indicate benign prostatic hyperplasia (BPH), the leading aetiology in men over 50. Ultrasound evaluates prostate volume, bladder morphology, and PVR; voiding diaries complement assessment when storage LUTS predominate. Alpha-blockers represent first-line therapy for BPH-related LUTS. Routine PSA testing following mUTI is not recommended, as elevations are non-specific: prostatitis may raise PSA independently of malignancy, and levels can remain elevated up to three months post-infection. No association exists between a first mUTI and prostate cancer, nor between PSA and UTI recurrence. Second-line referral is indicated for pyelonephritis, urinary retention, macroscopic hematuria, IPSS >7, PVR >100 mL, recurrent UTI, age under 40, or imaging abnormalities. Cross-sectional imaging (CT or MRI) is reserved for suspected obstruction, severe presentations, or treatment failure. This stratified approach optimizes cost-effectiveness, ensuring identification of underlying pathology (BPH, urolithiasis, or malignancy) while avoiding unnecessary investigations.
