Limits...
Treatment and Prophylactic Strategy for Coxiella burnetii Infection of Aneurysms and Vascular Grafts

View Article: PubMed Central - PubMed

ABSTRACT

Coxiella burnetii vascular infections continue to be very severe diseases and no guidelines exist about their prevention. In terms of treatment, the benefit of the surgical removal of infected tissues has been suggested by 1 retrospective study.

We present a case of a C burnetii abdominal aortic graft infection for which we observed a dramatic clinical and biological recovery after surgery. We thus performed a retrospective cohort study to evaluate the impact of surgery on survival and serological outcome for patients with Q fever vascular infections diagnosed in our center.

Between 1986 and February 2015, 100 patients were diagnosed with Q fever vascular infections. The incidence of these infections has significantly increased over the past 5 years, in comparison with the mean annual incidence over the preceding 22 years (8.83 cases per year versus 3.14 cases per year, P = 0.001). A two-and-a-half-year follow-up was available for 66 patients, of whom 18.2% died. We observed 6.5% of deaths in the group of patients who were operated upon at 2 and a half years, in comparison with 28.6% in the group which were not operated upon (P = 0.02). Surgery was the only factor that had a positive impact on survival at 2 and a half years using univariate analysis [hazard ratio: 0.17 [95% CI]: [0.039–0.79]; P = 0.024]. Surgery was also associated with a good serological outcome (74.1% vs 57.1% of patients, P = 0.03). In the group of patients with vascular graft infections (n = 47), surgery had a positive impact on serological outcome at 2 and a half years (85.7% vs 42.9%, P < 0.001) [hazard ratio: 0.40 [95% CI]: [0.17–098]; P = 0.046] and tended to be associated with lower although not statistically significant mortality (11.1% vs 27.6% of deaths, P = 0.19).

Surgical treatment confers a benefit in terms of survival following C burnetii vascular infections. However, given the high mortality of these infections and their rising incidence, we propose a strategy that consists of screening for vascular graft and aneurysms in the context of primary Q fever, to decide when to start prophylactic treatment, similar to the strategy recommended for the prophylaxis of Q fever endocarditis.

No MeSH data available.


Related in: MedlinePlus

Screening strategy for vascular Q fever infection.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC4998359&req=5

Figure 4: Screening strategy for vascular Q fever infection.

Mentions: Our results confirm that C burnetii vascular infections are very severe with an overall mortality rate of 18.2% at 2 and a half years of follow-up. These results contrast with what we observed for Q fever endocarditis (Figure 2). Thanks to well-established management strategies, Q fever endocarditis is now a much less severe infection, with reported overall mortality rates of 7% at 3 years of follow-up.35 Over the same period, as the result of adopting a strategy to detect and systematically administer prophylaxis to patients with risk factors for endocarditis, we have observed a dramatic reduction in C burnetii endocarditis incidence.30 This is illustrated by the ratio of endocarditis to acute Q fever, which has decreased over time (Figure 2). Currently, no systematic strategy exists for detecting predisposing vascular aneurysm or vascular prosthesis in the context of primary Q fever, so no prophylaxis can be initiated to decrease the incidence of vascular infections. However, given their severity, it would seem urgent to elaborate a screening strategy for early diagnosis and prophylaxis. We therefore propose such a strategy (Figure 4). The presence of a vascular graft should be systematically looked for in the medical history of patients diagnosed with a Q fever primo infection. If a vascular graft is present and no other criteria for vascular infection are found (Figure 4), prophylaxis consisting of a 12-month treatment of hydroxychloroquine and doxycycline should be administered. Major risk factors for aortic aneurysms are: men over the age of 65 who smoke or have smoked, and a family history of aneurysms.36 We suggest that patients over the age of 65 who are diagnosed with a Q fever primo infection undergo a CT scan or abdominal ultrasound (if renal contraindication) to screen for the presence of an aortic abdominal aneurysm. If an aneurysm is detected, prophylaxis should also be given. Eighteen FDG PET/CT could be helpful in the presence of an aneurysm or vascular graft, to detect precocious signs of infection, particularly in the event of persistent fever or poor serologic evolution (Figure 4).


Treatment and Prophylactic Strategy for Coxiella burnetii Infection of Aneurysms and Vascular Grafts
Screening strategy for vascular Q fever infection.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4998359&req=5

Figure 4: Screening strategy for vascular Q fever infection.
Mentions: Our results confirm that C burnetii vascular infections are very severe with an overall mortality rate of 18.2% at 2 and a half years of follow-up. These results contrast with what we observed for Q fever endocarditis (Figure 2). Thanks to well-established management strategies, Q fever endocarditis is now a much less severe infection, with reported overall mortality rates of 7% at 3 years of follow-up.35 Over the same period, as the result of adopting a strategy to detect and systematically administer prophylaxis to patients with risk factors for endocarditis, we have observed a dramatic reduction in C burnetii endocarditis incidence.30 This is illustrated by the ratio of endocarditis to acute Q fever, which has decreased over time (Figure 2). Currently, no systematic strategy exists for detecting predisposing vascular aneurysm or vascular prosthesis in the context of primary Q fever, so no prophylaxis can be initiated to decrease the incidence of vascular infections. However, given their severity, it would seem urgent to elaborate a screening strategy for early diagnosis and prophylaxis. We therefore propose such a strategy (Figure 4). The presence of a vascular graft should be systematically looked for in the medical history of patients diagnosed with a Q fever primo infection. If a vascular graft is present and no other criteria for vascular infection are found (Figure 4), prophylaxis consisting of a 12-month treatment of hydroxychloroquine and doxycycline should be administered. Major risk factors for aortic aneurysms are: men over the age of 65 who smoke or have smoked, and a family history of aneurysms.36 We suggest that patients over the age of 65 who are diagnosed with a Q fever primo infection undergo a CT scan or abdominal ultrasound (if renal contraindication) to screen for the presence of an aortic abdominal aneurysm. If an aneurysm is detected, prophylaxis should also be given. Eighteen FDG PET/CT could be helpful in the presence of an aneurysm or vascular graft, to detect precocious signs of infection, particularly in the event of persistent fever or poor serologic evolution (Figure 4).

View Article: PubMed Central - PubMed

ABSTRACT

Coxiella burnetii vascular infections continue to be very severe diseases and no guidelines exist about their prevention. In terms of treatment, the benefit of the surgical removal of infected tissues has been suggested by 1 retrospective study.

We present a case of a C burnetii abdominal aortic graft infection for which we observed a dramatic clinical and biological recovery after surgery. We thus performed a retrospective cohort study to evaluate the impact of surgery on survival and serological outcome for patients with Q fever vascular infections diagnosed in our center.

Between 1986 and February 2015, 100 patients were diagnosed with Q fever vascular infections. The incidence of these infections has significantly increased over the past 5 years, in comparison with the mean annual incidence over the preceding 22 years (8.83 cases per year versus 3.14 cases per year, P = 0.001). A two-and-a-half-year follow-up was available for 66 patients, of whom 18.2% died. We observed 6.5% of deaths in the group of patients who were operated upon at 2 and a half years, in comparison with 28.6% in the group which were not operated upon (P = 0.02). Surgery was the only factor that had a positive impact on survival at 2 and a half years using univariate analysis [hazard ratio: 0.17 [95% CI]: [0.039–0.79]; P = 0.024]. Surgery was also associated with a good serological outcome (74.1% vs 57.1% of patients, P = 0.03). In the group of patients with vascular graft infections (n = 47), surgery had a positive impact on serological outcome at 2 and a half years (85.7% vs 42.9%, P < 0.001) [hazard ratio: 0.40 [95% CI]: [0.17–098]; P = 0.046] and tended to be associated with lower although not statistically significant mortality (11.1% vs 27.6% of deaths, P = 0.19).

Surgical treatment confers a benefit in terms of survival following C burnetii vascular infections. However, given the high mortality of these infections and their rising incidence, we propose a strategy that consists of screening for vascular graft and aneurysms in the context of primary Q fever, to decide when to start prophylactic treatment, similar to the strategy recommended for the prophylaxis of Q fever endocarditis.

No MeSH data available.


Related in: MedlinePlus