Background We investigated whether dolutegravir (DTG) monotherapy could be used to maintain virological suppression in people living with human immunodeficiency virus (HIV) on a successful dolutegravir-based triple therapy. Methods MONCAY (MONotherapy of TiviCAY) was a 48-week, multicentric, randomized, open-label, 12% noninferiority margin trial. Patients with CD4 nadir >100/μL, plasma HIV-1 RNA <50 copies/mL for ≥12 months, and stable regimen with DTG/abacavir (ABC)/lamivudine (3TC) were 1:1 randomized to continue their regimen or to DTG monotherapy. The primary endpoint was the proportion of patients with HIV RNA <50 copies/mL at week 24 in intention-to-treat snapshot analysis. Virologic failure (VF) was defined as 2 consecutive HIV RNA >50 copies/mL within 2 weeks apart. Results Seventy-eight patients were assigned to DTG monotherapy and 80 to continue DTG/ABC/3TC. By week 24, 2 patients in the DTG group experienced VF without resistance to the integrase strand transfer inhibitor (INSTI) class; 1 patient discontinued DTG/ABC/3TC due to an adverse event. The success rate at week 24 was 73/78 (93.6%) in the DTG arm and 77/80 (96.3%) in the DTG/ABC/3TC arm (difference, 2.7%; 95% confidence interval [CI], –5.0 to 10.8). During subsequent follow-up, 5 additional VFs occurred in the DTG arm (2 of which harbored emerging resistance mutation to INSTI). The cumulative incidence of VF at week 48 was 9.7% (95% CI, 2.8 to 16.6) in the DTG arm compared with 0% in the DTG/ABC/3TC arm (P = .005 by the log-rank test). The Data Safety Monitoring Board recommended to reintensify the DTG arm with standardized triple therapy. Conclusions Because the risk of VF with resistance increases over time, we recommend avoiding DTG monotherapy as a maintenance strategy among people living with chronic HIV infection. Clinical Trials Registration NCT02596334 and EudraCT 2015-002853-36.

S. Tubiana). y Bruno Hoen and Xavier Duval contributed equally. z The members of COMBAT study group are listed at the Acknowledgments section. Contents lists available at ScienceDirect Clinical Microbiology and Infectionj o u r n a l h o m e p a g e : w w w . c l i n i c a l m i c r o b i o l o g y a n d i n f e c t i o n . c o m

ObjectivesWe assessed the determinants of mortality in infective endocarditis (IE), using the national hospital discharge databases (HDD) in 2011.MethodsIE stays were extracted from the national HDD, with a definition based on IE-related diagnosis codes. This definition has been assessed according to Duke criteria by checking a sample of medical charts of IE giving a predictive positive value of 86.1% (95% confidence interval (CI): 82.7% - 89.5%). The impact of heart valve surgery on survival has been studied if performed during the initial stay, and over the year of follow-up. Risk factors of in-hospital mortality were identified using logistic regression model for the initial stay and Cox Time-dependent model for the 1-year mortality.ResultsThe analysis included 6,235 patients. The annual incidence of definite IEs was 63 cases/million residents. Staphylococci and Streptococci were the most common bacteria (44% and 45%, respectively). A valvular surgery was performed in 20% of cases, but substantial variations existed between hospitals. The in-hospital mortality was 21% (ranging 12% to 27% according to the region of patients), associated with age>70, chronic liver disease, renal failure, S. aureus, P. aeruginosa or candida infection and strokes whereas valvular surgery, a native valve IE or intraveinous drug use (right heart IE) were significantly protective for an initial death. The same factors were associated with the one-year mortality, except for valvular surgery which was associated with a 1.4-fold higher risk of death during the year post IE.ConclusionWe reported a high IE incidence rate. Valvular surgery was considerably less frequent in this study than in the previous published data (near 50%) whereas mortality was similar. Surgery was associated with higher survival if undergone within the initial stay. There were significant regional differences in frequency of surgery but it did not impact mortality.

We describe the third case of prosthetic infection due to Erysipelothrix rhusiopathiae. The patient, a 68-yearold woman, had had total knee arthroplasty 12 months before diagnosis. She had been in contact with swine at home. We review the seven previous reports of septic arthritis due to E. rhusiopathiae. CASE REPORTA 68-year-old woman was referred to the orthopedic ward for total replacement of the right knee due to severe internal condyle osteonecrosis. She had a medical history of gout, chronic eczema of the lower limbs, and alcoholism with consequent cognitive disorders. A tricompartmental posterior stabilized cemented knee artroplasty, containing gentamicin, was performed. The patient did not experience any problems during the first 6 months of follow-up. The international knee scoring (IKS) system score was 80/200 before surgery and increased to 163/200 6 months after surgery. Soon after, the patient complained of eczema-like skin lesions on the lower limb, involving the site of surgical incision. During this period, neighbors reported seeing the patient feeding her neighbor's swine through the wire enclosure. The patient's general practitioner prescribed an intramuscular corticosteroid because of intense itching. Within weeks of receiving this treatment, she complained of swelling and pain in the right knee and received amoxicillinclavulanate. A radiography of the knee was normal. One month later, seropurulent fistulization of the right knee was observed at the distal end of the surgical incision site, and the patient was referred to the hospital. On admission, flexion of the right knee was reduced to 90°. The patient was not febrile. No cardiac murmurs, skin rash, or lymph node enlargement was found. The peripheral white blood cell count was 6,100 cells/mm 3 , and the C-reactive protein concentration was 74 mg/liter. Radiography revealed advanced osteolysis of the tibia, femur, and patella. Blood cultures remained sterile. Twelve months after right knee arthroplasty, surgical arthrotomy was carried out, yielding a sanguinepurulent "chocolate-like" fluid. Synovial resection was performed, revealing large geodes resulting from osteolysis in the femur, tibia, and patella. The prosthesis was removed and replaced by a vancomycin-and gentamicin-impregnated spacer. Intravenous rifampin and vancomycin treatment was started. Eleven peroperative samples were sent to the laboratory. All Gram staining tests were negative. Cultures were grown on blood agar plates under aerobic and anaerobic conditions and on chocolate agar plates incubated under 5% CO 2 . Cultures were negative on day 2. On day 4, four samples yielded pinpoint colonies. Microscopic observations of these first cultures revealed thin, short, cylindrical Gram-positive rods. Subcultures were set up for potential confirmation of Lactobacillus or Corynebacterium. These subcultures yielded enterococcus-shaped colonies on day 2. Bacteria were confirmed to be rod shaped but were longer and thinner than those observed in the initial cultures. On the basis of t...

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.