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Clinical features and prognostic factors of listeriosis: the
MONALISA national prospective cohort study
Caroline Charlier, Alexandre Leclercq, Benoît Cazenave, Benoît Pilmis,
Benoît Henry, Amanda Lopes, Mylène M Maury, Alexandra Moura, François
Gonet, Hélène Bracq Dieye, et al.
To cite this version:
Caroline Charlier, Alexandre Leclercq, Benoît Cazenave, Benoît Pilmis, Benoît Henry, et al.. Clinical
features and prognostic factors of listeriosis: the MONALISA national prospective cohort study. The
Lancet Infectious Diseases, New York, NY : Elsevier Science ; The Lancet Pub. Group, 2001-, 2017,
17 (5), �10.1016/S1473-3099(16)30521-7�. �pasteur-01475849�
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Clinical features and prognostic factors of listeriosis:
the MONALISA national prospective cohort study
Caroline Charlier MD
1,2,3,4
, Élodie Perrodeau MSc
5
, Alexandre Leclercq MSc
1,2,3
, Benoît Cazenave MD
1
,
Benoît Pilmis MD
1,4
, Benoît Henry MD
4,6
, Amanda Lopes MD
7
, Mylène M. Maury PhD
1,2,3
,
Alexandra Moura PhD
2,3
, François Goffinet MD
8
, Hélène Bracq Dieye
1,2,3
, Pierre Thouvenot
1,2,3
,
Marie-Noëlle Ungeheuer MD
9
, Mathieu Tourdjman MD
10
, Véronique Goulet MD
10
, Henriette de Valk MD
10
,
Prof. Olivier Lortholary MD
4
, Prof. Philippe Ravaud MD
5,11
and Prof. Marc Lecuit MD
1,2,3,4
on behalf of the MONALISA study group
1
Institut Pasteur, French National Reference Center and WHO Collaborating Center for Listeria, Paris, France
2
Institut Pasteur, Biology of Infection Unit, Paris, France
3
Inserm U1117, Paris, France
4
Paris Descartes University, Sorbonne Paris Cité, Necker-Pasteur Infectiology Centre, Necker-Enfants Malades
University Hospital, Institut Imagine, Assistance Publique-Hôpitaux de Paris, Paris, France
5
Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité, METHODS Team, UMR 1153,
INSERM, Paris Descartes University, Sorbonne Paris Cité, Paris, France
6
Pierre et Marie Curie University, Pitié Salpétrière University Hospital, Assistance Publique-Hôpitaux de Paris,
Paris, France
7
Denis Diderot University, Department of Internal Medicine, Lariboisière Hospital, Assistance Publique-
Hôpitaux de Paris, Paris, France
8
Paris Descartes University, Sorbonne Paris Cité, Port Royal Maternity, Department of Obstetrics, Cochin Port
Royal Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
9
Institut Pasteur, Center for Translational Science, ICAReB Biobanking Platform, Paris, France
10
Infectious Disease Department, The French Public Health Agency, Saint Maurice, France
11
Columbia University, Mailman School of Public Health, New York, NY, USA
Correspondence to Caroline Charlier and Marc Lecuit
caroline.charlier@pasteur.fr and marc.lecuit@pasteur.fr
Institut Pasteur
Biology of Infection Unit
French National Reference Center and WHO collaborating Center Listeria
28 rue du Dr. Roux, 75015 Paris, France
Phone: +33 1 40 61 34 20
Fax: +33 1 40 61 34 21
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RESEARCH IN CONTEXT
Evidence before this study
We searched PubMed on June 30, 2016, for English-language cohort studies published since Jan 1, 1980, of
patients with invasive listeriosis worldwide with the keywords “listeria”, “listeriosis”, “maternal”, and
“neurolisteriosis”. Studies had to include epidemiological or clinical data on listeriosis. All clinical forms of
infection were included (bacteraemia, neurolisteriosis, and maternal–neonatal infection). Host risk factors for
listeriosis have been well identified, but the clinical features and prognostic factors of the disease are based on
retrospective studies compiling heterogeneous data or random collected cases. Furthermore, no clinical trial has
ever been done and medical management is not evidence based.
Added value of the study
Our study is the first prospective clinical study focusing on all forms of invasive listeriosis. The study is based
on a national mandatory system that allowed the nearly complete capture of microbiologically proven cases. The
study shows a higher burden of listeriosis than reported before: more than 80% of infected mothers experienced
major fetal or neonatal
complications (fetal loss, very high prematurity, early or late onset disease); only 39% of patients with
neurolisteriosis survived and fully recovered. The study provides important new data to improve management
and predict outcome in listeriosis, such as determination of the time window for fetal losses (<29 weeks of
gestation and <3 days of adequate management) and new factors independently associated with mortality. Our
data show the deleterious effect of adjunctive dexamethasone in neurolisteriosis, and argue for the use of beta-
lactam and gentamicin or co-trimoxazole over other antimicrobials for bacteraemia and neurolisteriosis.
Implications of all the available evidence
Given the practical difficulties in completing clinical trials in listeriosis, these results could guide clinical
practice and suggest that combined amoxicillin and gentamicin should be considered the first-line combination
in invasive listeriosis, and that adjunctive dexamethasone should be avoided in cases of confirmed listeriosis.
ABSTRACT
Background: Listeriosis is a severe foodborne infection and a notifiable disease in France. We did a nationwide
prospective study to characterise its clinical features and prognostic factors.
Methods: MONALISA was a national prospective observational cohort study. We enrolled eligible cases
declared to the National Reference Center for Listeria (all microbiologically proven) between Nov 3, 2009, and
July 31, 2013, in the context of mandatory reporting. The outcomes were analysis of clinical features,
characterisation of Listeria isolates, and determination of predictors of 3-month mortality or persisting
impairment using logistic regression. A hierarchical clustering on principal components was also done for
neurological and bacteraemic cases. The study is registered at ClinicalTrials.gov, number NCT01520597.
Findings: We enrolled 818 cases from 372 centres, including 107 maternal–neonatal infections, 427 cases of
bacteraemia, and 252 cases of neurolisteriosis. Only five (5%) of 107 pregnant women had an uneventful
outcome. 26 (24%) of 107 mothers experienced fetal loss, but never after 29 weeks of gestation or beyond 2 days
of admission to hospital. Neurolisteriosis presented as meningoencephalitis in 212 (84%) of 252 patients;
brainstem involvement was only reported in 42 (17%) of 252 patients. 3-month mortality was higher for
bacteraemia than neurolisteriosis (hazard ratio [HR] 0·54 [95% CI 0·41–0·69], p<0·0001). For both bacteraemia
and neurolisteriosis, the strongest mortality predictors were ongoing cancer (odds ratio [OR] 5·19 [95% CI 3·01–
8·95], p<0·0001), multi-organ failure (OR 7·98 [4·32–14·72], p<0·0001), aggravation of any pre-existing organ
dysfunction (OR 4·35 [2·79–6·81], p<0·0001), and monocytopenia (OR 3·70 [1·82–7·49], p=0·0003).
Neurolisteriosis mortality was higher in blood-culture positive patients (OR 3·67 [1·60–8·40], p=0·002) or those
receiving adjunctive dexamethasone (OR 4·58 [1·50–13·98], p=0·008).
Interpretation: The severity of listeriosis is higher than reported elsewhere. We found evidence of a
significantly reduced survival in patients with neurolisteriosis treated with adjunctive dexamethasone, and also
determined the time window for fetal losses. MONALISA provides important new data to improve management
and predict outcome in listeriosis.
Funding: Programme Hospitalier Recherche Clinique, Institut Pasteur, Inserm, French Public Health Agency.
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INTRODUCTION
Listeria monocytogenes causes listeriosis, a severe foodborne bacterial infection. L monocytogenes is the
foodborne pathogen associated with the highest case-fatality rate in the western hemisphere, where its incidence
is estimated at around three to six cases per 1 million population per year.
1,2
Invasive listeriosis is classified in
three forms: bacteraemia, neurolisteriosis, and maternal–neonatal infection; localised forms are also reported.3–5
Epidemiological studies have identified host risk factors for bacteraemia and neurolisteriosis, including older
age, innate and cellular immune defects, malignancies, HIV infection, cirrhosis, diabetes mellitus, alcoholism,
and immunosuppressive therapies.6 However, all clinical and most epidemiological studies have been
retrospective and have compiled data from heterogeneous timeframes and geographical areas.
3–10
Thus, a precise
analysis of disease presentation based on homogeneous and prospectively acquired data is lacking. Furthermore,
because listeriosis cases are relatively rare and scattered, no clinical trial has been done, and therapeutic
guidelines are not evidence-based. The prognosis for listeriosis has not improved over the past decades.
3,7
Listeriosis has been a notifiable disease in France since 1999, with mandatory notification of culture-confirmed
cases and submission of isolates to the National Reference Center for Listeria (NRCL). A recent capture–
recapture study estimated at 85–87% the exhaustiveness of the national surveillance system for the 2008–13
period, and since 2000, an average 98% of nationally reported cases have isolates submitted to the NRCL.11
Taking advantage of the quasi-exhaustiveness of this surveillance system, we implemented the prospective
Multicentric Observational NAtional Study on LISteriosis and ListeriA (MONALISA), a nationwide cohort, to
precisely characterise the clinical patterns and identify prognostic factors for invasive listeriosis.
METHODS
Study design and patients
MONALISA is a national prospective observational cohort study. We enrolled eligible cases declared to the
NRCL (all microbiologically proven), in the context of mandatory reporting. We report the study in accordance
with the STROBE reporting guidelines for observational studies.
12
A case was defined as a patient in whom L
monocytogenes was isolated from a normally sterile site. We included all cases from Nov 3, 2009, to July 31,
2013, and classified these as maternal–neonatal infection, bacteraemia, neuro- listeriosis, or other form. Patients
originated from 372 centres within France. Maternal–neonatal infection was defined when L monocytogenes was
isolated in pregnant women, fetuses, or infants 1 month old or younger. When L monocytogenes was isolated
from samples of both mother and her infant, the event was counted as a single case. Bacteraemia was defined
when L monocytogenes was isolated from blood culture, without neurolisteriosis or maternal– neonatal infection.
Neurolisteriosis was defined when L monocytogenes was isolated from the cerebrospinal fluid (CSF) or a brain
abscess, when L monocytogenes was isolated from blood cultures in a patient with otherwise unexplained
neurological symptoms (altered consciousness, seizures, nuchal rigidity, or focal neurological symptoms), when
L monocytogenes was isolated from blood cultures and identified in CSF by PCR, and finally, in a single patient
with meningitis, when L monocytogenes was identified in CSF by PCR and all other microbiological analyses
were negative. Patients with neurolisteriosis and positive blood cultures were classified as neurolisteriosis cases.
Other forms were defined by the isolation of L monocytogenes from other normally sterile sites. Data on past
history, features at admission, and treatments were collected. All patients (or their legal representatives when
they were unable to consent) provided written informed consent. In accordance with French legislation,
MONALISA received institutional review board approval by the local ethics committee (Comité de Protection
des Personnes Ile-de-France 3, Nov 6, 2009). Biospecimen collection was declared to the Ministry of Research
(DC 2012-1698 coll 16). In accordance with French legislation, data from patients who died before contact were
included, provided that their next of kin agreed.
Procedures
L monocytogenes isolates were identified with API Listeria (BioMérieux, Marcy l’Etoile, France) and sequenced
using Illumina technology (appendix). Multilocus sequence types and inlA gene variants were extracted from
genome assemblies using Lm-BIGSdb.13 DNA extraction was done using the DNeasy blood and tissue
extraction kit (Qiagen, Aarhus, Denmark), from 5 mL of liquid cultures grown overnight at 35°C in brain–heart
infusion medium under aerobic conditions, following the manufacturer’s protocol. Library preparation was
carried out using the Nextera XT DNA sample kit and whole genome sequencing was done on the NextSeq 500
platform using 2×150 bp runs (Illumina, San Diego, CA, USA) at a minimum coverage of 40×. Paired-end reads
were trimmed with fqCleaner v05 to eliminate adapter sequences and discard reads with Phred scores of 20 or
less. Assemblies were obtained using CLC Assembly Cell 430 (Qiagen, Aarhus, Denmark).
Outcomes
We analysed clinical features, characterised L monocytogenes isolates, and determined predictors of 3-month
mortality or persisting impairment using logistic regression.
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Statistics
The sample size was a convenience sample, determined by the number of eligible cases during the study period.
We investigated the relation between unfavourable outcome and potential predictors by doing a multivariable
logistic analysis. Unfavourable outcome was defined as fetal loss for maternal–neonatal infections, 3-month
mortality for bacteraemia and neurolisteriosis, and also persisting neurological impairment for neurolisteriosis.
Variables showing associations at a significance level of α=0·20 in a univariable analysis were selected for
inclusion in the multivariable model and a stepwise selection was done. Missing values were imputed using a
multivariate imputation by a chained equations procedure. To further characterise cases associated with
bacteraemia and neurolisteriosis, we did a hierarchical clustering on principal components. Statistical analysis
was done with R software (version 3.2.2). All tests were two-tailed and p values less than 0·05 (calculated by χ2
test, Student’s t test, or Mann-Whitney test) were considered significant (appendix pp 8, 9). The study is
registered at ClinicalTrials. gov, number NCT01520597.
Role of the funding sources
The funder had no role in study design, data collection, analysis and interpretation, or writing of the report. The
corresponding authors had full access to the data and final responsibility for the decision to submit for
publication.
