Antibiotic susceptibility of cultivable microbiota from the oral cavity of captive Bothrops atrox and Bothrops lanceolatus: Implications for the treatment of snakebite-associated infections in the French departments of America.

INTRODUCTION: Secondary infection is a frequent complication after bites by Bothrops atroxin French Guiana or B. lanceolatus in Martinique. Knowledge of the bacteria present in snake mouths is a valuable aid for determining probabilistic antibiotherapy after Bothrops bite. The objectives of this study were to describe the cultivable bacteria of the oral microbiota of the specimens of B. atrox and B. lanceolatus kept in captivity, and to study their susceptibility to antibiotics. METHODS: Fifteen B. atrox and 15 B. lanceolatus were sampled. Bacterial cultures were performed and each morphotype on plates was identified using MALDI-TOF mass spectrometry. Antibiotic susceptibility was studied using the agar disk diffusion method, with possible determination of the MICs. RESULTS: One hundred and twenty-two isolates were identified: 52 isolates and 13 species in B. atrox, 70 isolates and 23 species in B. lanceolatus. The main species were Providencia rettgeri, Morganella morganii, Pseudomonas aeruginosa, Staphylococcus xylosus, and Paeniclostridium sordellii (only in B. lanceolatus mouths). For B. atrox, 96% of isolates were susceptible to piperacillin/tazobactam, cefepime, imipenem and meropenem, 94% to ciprofloxacin and 76% to cefotaxime and ceftriaxone. For B. lanceolatus, 97% of isolates were susceptible to meropenem, 96% to cefepime, 93% to imipenem and piperacillin/tazobactam, 80% to ciprofloxacin, and 75% to cefotaxime and ceftriaxone. Many isolates were resistant towards amoxicillin/clavulanate. CONCLUSION: Among currently recommended antibiotics, cefepime and piperacillin/tazobactam seem more suitable than cefotaxime or ceftriaxone in the event of a Bothrops bite. Ciprofloxacin may also be considered for B. atrox.

Outbreak of Salmonella Newport associated with internationally distributed raw goats' milk cheese, France, 2018.

Raw milk cheeses are commonly consumed in France and are also a common source of foodborne outbreaks (FBOs). Both an FBO surveillance system and a laboratory-based surveillance system aim to detect Salmonella outbreaks. In early August 2018, five familial FBOs due to Salmonella spp. were reported to a regional health authority. Investigation identified common exposure to a raw goats' milk cheese, from which Salmonella spp. were also isolated, leading to an international product recall. Three weeks later, on 22 August, a national increase in Salmonella Newport ST118 was detected through laboratory surveillance. Concomitantly isolates from the earlier familial clusters were confirmed as S. Newport ST118. Interviews with a selection of the laboratory-identified cases revealed exposure to the same cheese, including exposure to batches not included in the previous recall, leading to an expansion of the recall. The outbreak affected 153 cases, including six cases in Scotland. S. Newport was detected in the cheese and in the milk of one of the producer's goats. The difference in the two alerts generated by this outbreak highlight the timeliness of the FBO system and the precision of the laboratory-based surveillance system. It is also a reminder of the risks associated with raw milk cheeses.

Antifungal susceptibility testing practices in mycology laboratories in France, 2018.

A survey of mycology laboratories for antifungal susceptibility testing (AFST) was undertaken in France in 2018, to better understand the difference in practices between the participating centers and to identify the difficulties they may encounter as well as eventual gaps with published standards and guidelines. The survey captured information from 45 mycology laboratories in France on how they perform AFST (number of strains tested, preferred method, technical and quality aspects, interpretation of the MIC values, reading and interpretation difficulties). Results indicated that 86% of respondents used Etest as AFST method, with a combination of one to seven antifungal agents tested. Most of the participating laboratories used similar technical parameters to perform their AFST method and a large majority used, as recommended, internal and external quality assessments. Almost all the participating mycology laboratories (98%) reported difficulties to interpret the MIC values, especially when no clinical breakpoints are available. The survey highlighted that the current AFST practices in France need homogenization, particularly for MIC reading and interpretation.

Microbiology of French military casualties repatriated from overseas for an open traumatic injury.

BACKGROUND: This study aimed to describe the microbiological epidemiology of repatriated French soldiers with an open traumatic injury, and to measure the proportion of multidrug-resistant bacteria (MDRB). METHODS: Retrospective study including all French soldiers repatriated in 2011 and 2012 in Parisian military hospitals for open traumatic injury. Results of clinical samples and MDRB screening were collected. The antibiotic susceptibility was assessed using the agar disk diffusion method. Characterization of resistance mechanisms was performed using PCR. Genotyping of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) isolates was performed using rep-PCR. RESULTS: A total of 139 patients were included; 70% of them were repatriated from Afghanistan. At admission, 24/88 were positive for MDRB (28%), mainly ESBL-E but no carbapenemase-producing Enterobacteriaceae and vancomycin-resistant Enterococcus faecium were identified. Forty-five patients had lesion sample collection, and 28/45 had a positive culture. The most frequently isolated pathogens were Enterobacter cloacae, Pseudomonas aeruginosa, and Escherichia coli. For eight patients, a MDRB was isolated from the wound, mainly ESBL-E (7/8) but also one methicillin-resistant Staphylococcus aureus and one imipenem-resistant Acinetobacter baumannii. Among ESBL-E, the PCR evidenced the high prevalence of CTX-M15 enzymes. Rep-PCR performed on the 23 ESBL-producing E. coli isolates highlighted numerous profiles. CONCLUSIONS: Controlling the spread of ESBL-E is currently challenging for French Armed Forces. Despite any evidence of an epidemic clone, a high-level compliance with hygiene precautions is required throughout the chain of care to avoid cross contamination.

Envenomation by Micrurus psyches in French Guiana.

We report here the first known envenomation by Micrurus psyches, the so-called Carib coral snake, which occurred on April 2016 in the surroundings of Saint-Laurent-du-Maroni, Western French Guiana. Besides local neurological symptoms, it featured unexpected electrocardiogram changes, which were emergence of a first-degree atrioventricular block and biphasic T waves, both transient. NewWorld elapid venoms were not known for being cardiotoxic so far. The possible reasons of this cardiac injury are discussed.

Challenging Investigation of a Norovirus Foodborne Disease Outbreak During a Military Deployment in Central African Republic.

In January 2016, a large-scale outbreak of acute gastroenteritis was reported among French armed forces deployed in the Central African Republic. Challenging investigations, conducted from France, made it possible to identify a norovirus genogroup II in both stool and food samples, confirming a norovirus foodborne disease outbreak. Infected food handler management is discussed.

Outbreak of CTX-M-15-producing Enterobacter cloacae associated with therapeutic beds and syphons in an intensive care unit.

An outbreak of extended-spectrum ß-lactamase-producing Enterobacter cloacae (ESBL-ECL) occurred in our intensive care unit (ICU) and involved 18 patients (8 infected and 10 colonized). The mean age of patients was 69 years, and all infected patients had underlying medical conditions. Within hours' recognition of the spread of ESBL-ECL, the infection control team requested for staff education, reinforcement of infection control measures, and environmental screening. New transmissions were observed in the institution after weeks of enhanced infection control measures. Microbial swabbing revealed bacterial contamination of some mattresses and syphons with epidemiologic links between environmental, screening, and clinical isolates. This outbreak resulted in the temporary closure of the ICU for complete biocleaning.

[What is your diagnosis? A "fat arm". Onchocerciasis]. / Une histoire de "gros bras".

We report a case of edema of the right forearm with pruriginous papules and eosinophilia in the blood. The patient had lived in a forested area of Cameroon. The clinical, laboratory, and geographical findings led to a diagnosis of onchocerciasis, despite the absence of microfilaments on skin biopsy samples. The patient was successfully treated with ivermectin and doxycycline.

Faecal carriage of extended-spectrum ß-lactamase-producing enterobacteria among soldiers at admission in a French military hospital after aeromedical evacuation from overseas.

The aim of this study was to assess the faecal carriage of carbapenemase-producing enterobacteria (CPE) and extended-spectrum ß-lactamase (ESBL)-producing enterobacteria among soldiers at admission in a French military hospital after aeromedical evacuation from overseas. During a period of 1 year, 83 rectal swabs collected in French soldiers at admission were screened for multidrug-resistant enterobacteria with a chromogenic medium. ESBL detection was performed with the double-disc synergy test in the absence or presence of cloxacillin. The genotypic characterisation of resistance mechanisms, sequence typing and phylotyping was performed by polymerase chain reaction (PCR) and sequencing with bacterial DNA extracted from isolates. No CPE was detected. Eleven ESBL Escherichia coli isolates belonging to four phylogenetic groups were detected, including ten CTX-M-15 and one CTX-M-14. The overall gut colonisation with ESBL-producing bacteria (13.25 %) was 6-fold higher than that reported in soldiers in the suburbs of Paris in 2009. ESBL faecal carriage was particularly high (34.48 %) in soldiers repatriated from Afghanistan (risk ratio = 18.62; p = 0.0001). This study highlights the importance of systematic additional contact precautions and CPE/ESBL screening in soldiers repatriated from overseas in French hospitals.

[Which antivenom for Cerastes envenoming?]. / Quel antivenin pour les envenimations par les vipères du genre Cerastes ?

During Echis viper envenoming, the administration of a single FAV-Afrique(®) antivenin vial generally corrects hemostasis disorders in less than twelve hours. The correction of hemostasis after 36 hours by 4 vials of FAV-Afrique(®) is thus not in favor of the usefulness of this antivenin for Cerastes envenoming . Mortality due to viper envenoming in Africa is high, but more than 90 % of poisoned patients survive despite the absence of appropriate antivenom. The severity of poisoning depends on several factors: age and condition of the patient, location of the bite, composition and amount of injected venom, management delay, and therefore, survival is not necessarily synonymous of effectiveness of antivenom treatment. Cerastes venoms contain many enzymes that disrupt various stages of hemostasis. It remains to prove that FAV-Afrique(®), a polyvalent antivenom adapted to venom of the main species responsible for envenoming in sub-Saharan Africa, (Bitis, Echis, Naja and Dendroaspis), is able to neutralize these specific proteins. The most logical approach of Cerastes envenoming is the administration of an antivenin adapted to species found in North Africa: Favirept(®) (Sanofi Pasteur) is a polyvalent antivenom adapted to the venoms of C. cerastes, Bitis arietans, Echis leucogaster, Macrovipera deserti, Naja haje and Naja nigricollis.

Abdominal wall and intra-peritoneal abscess by Propionibacterium avidum as a complication of abdominal parietoplasty.

Propionibacteria are organisms of low pathogenicity and only a minority of clinical Propionibacterium isolates is clinically significant. Herein, we report a rare case of Propionibacterium avidum abdominal wall and intra-peritoneal abscess that developed in 46-year-old woman after abdominal parietoplasty.

[Pulmonary embolism in the context of severe envenomation by a Moroccan viper]. / Embolie pulmonaire dans les suites d'une envenimation grave par une vipère marocaine.

Heparin, which was widely used thirty years ago for the treatment of viper envenomations, is now contra-indicated during the acute phase, which is at risk for hemorrhage and death. We report a case of pulmonary embolism, a rare situation in the context of viper envenomation. By means of this case report, we want to discuss the pathophysiological links between envenomation and thromboembolic disease, and on the other hand, the potential heparin usefulness, not during the acute, hemorrhagic phase, but as a prophylactic treatment when hemorrhagic risk has been replaced by an inflammatory syndrome, with increased fibrinogen and platelets which are then prothrombotic factors.

[Adder bites in France]. / Envenimations par les vipères en France.

Snake bites are a major public health problem in the tropics but they have a low incidence in Europe and are responsible for few deaths each year. The incidence is higher in children than in adults but no difference in severity seems to be observed between children and adults. In France, snake envenomations are due mainly to Vipera aspis and Vipera berus. The clinical presentation is usually limited to a local syndrome with pain and local inflammatory edema, but systemic signs occur in 17% of cases. Clinical grading published by the Institut Pasteur in Paris helps to assess the severity of envenomation and to decide the use of antivenom. Every bitten patient must be transferred in a hospital for medical assessment. Specific treatment is based on antivenom immunotherapy. However, other medical and surgical treatments have limited value.

[Haemostasis disorders caused by snake venoms]. / Troubles de l'hémostase induits par les venins de serpents.

Various haemostasis disorders can occur following snakebite. Almost all ophidian species that are responsible for serious, even lethal, human envenomations are concerned. Venoms of these snakes are rich in proteins interfering with haemostasis, including many enzymes. These proteins can be classified in four groups according to their action. The haemorrhagins induce capillary permeability disorders. The proteins disturbing the primary haemostasis can activate as well as inhibit platelets: phospholipases A2, serine proteases and metalloproteinases, L-amino-acido-oxydases, phosphoesterases, disintegrins, C-type lectins, dendropeptin, agregoserpentin, thrombolectin. The proteins interfering with coagulation are separated into procoagulant proteases (prothrombin activator, thrombin-like enzymes, factor X and factor V activators) and anticoagulant proteases (factor IX and X inhibitors, protein C activator, anticoagulant phospholipases A2). The venom components acting on fibrinolysis are the fibrinolytic enzymes and the plasminogene activators. The clinical consequence of these mechanisms is a local as well as diffuse haemorrhagic syndrome. A hypofibrinogenemy, even an afibrinogenemy is frequently noted. Other haemostasis parameters are disturbed: PT collapse, a patient's ACT several times higher than the control and non-systematic thrombopenia. Ophidian venoms take part in many medical, diagnostic or therapeutic, applications in medicine. Currently, the antivenomous immunotherapy is the only efficient treatment in these haemorrhagic disorders.

[Neurotoxins from snake venom]. / Neurotoxines ophidiennes.

Many snakes are able to quickly immobilize prey, thanks to their venom neurotoxins. Most of these snakes belong to families Elapidae or Hydrophidae but neurotoxins were also isolated from families Viperidae and Colubridae. Ophidian neurotoxins can be classified into several categories: neurotoxins which inhibit synaptic transmission (postsynaptic and presynaptic neurotoxins) and neurotoxins which facilitate it excessively (dendrotoxin and fasciculin). Their toxicity is dose-dependent, and venom effects are extremely fast. The clinical feature is a potentially fatal neurological syndrome, the so called cobraic syndrome. Because death by respiratory arrest may occur quickly with cobraic syndrome, immunotherapy is a true emergency, because toxins irreversible fixing makes immunotherapy effect uncertain after a few hours passed.