Cessation of screening for intestinal carriage of extended-spectrum ß-lactamase-producing Enterobacteriaceae in a low-endemicity intensive care unit with universal contact precautions.

OBJECTIVES: The usefulness of screening for carriage of extended-spectrum ß-lactamase-producing Enterobacteriaceae (ESBL-E) with active surveillance cultures (ASC) remains equivocal in low-endemicity intensive care units (ICUs). Our primary objective was to appraise the impact of ceasing ASC on the incidence of ICU-acquired ESBL-E infections in an ICU with universal contact precautions (CP). Patient outcomes and carbapenem consumption were also investigated. METHODS: A single-ICU, retrospective, uncontrolled before-and-after study including all patients admitted for ≥3 days during two consecutive 1-year periods with and without ASC. RESULTS: A total of 524 and 545 patients were included during the ASC and the no-ASC periods, respectively. Twenty-eight patients (5.3%) from the ASC period were ESBL-E carriers. An ICU-acquired ESBL-E infection (median duration of risk exposure, 4 (range 2-9) days for both periods) occurred in 1.1% and 1.5% of patients admitted during the ASC and the no-ASC periods (p = 0.64), with no inter-period variation in incidence after adjustment on competing risks of death and ICU discharge (standardized hazard ratio (SHR) 2.32, 95% CI 0.80-6.73, p = 0.12). An admission during the no-ASC period exerted no independent impact on the hazards of ESBL-E infections (adjusted OR 1.16, 95% CI 0.38-3.50, p = 0.79), in-ICU death (SHR 1.22, 95% CI 0.93-1.59, p = 0.15) and extended length of stay (SHR for discharge 0.89, 95% CI 0.79-1.01, p = 0.08). Carbapenem exposure in patients without ESBL-E infection decreased between the ASC and no-ASC periods (75 versus 61 carbapenem-days per 1000 patient-days, p = 0.01). CONCLUSIONS: In a low-endemicity ICU with universal CP, the withdrawal of routine screening for ESBL-E carriage had no significant effect on the incidence of ICU-acquired ESBL-E infections and patient outcomes. Carbapenem consumption decreased in patients without ESBL-E infection.

The incidence of Staphylococcus aureus ST8-USA300 among French pediatric inpatients is rising.

Methicillin-resistant Staphylococcus aureus (MRSA) formerly colonized and infected only inpatients in hospitals, but have been reported in community settings worldwide over the last 20 years. In France, the prevalence of such MRSA remains low and outbreaks have, until now, been mainly due to the ST80 clone. However, there were two outbreaks of MRSA clone ST-USA300 recently in France, including one involving children. To investigate epidemiological developments, we studied the 77 MRSA isolated from pediatric patients hospitalized between 2008 and 2013 in three French hospitals. The median incidence of MRSA was stable and low (0.137 per 100 admissions). The prevalence of Panton-Valentine leukocidin (PVL)-positive MRSA was high (33.8 %). The 26 PVL-positive MRSA were genetically diverse, with two clones being predominant: ST80 (12 isolates, 46.1 %) and ST8-USA300 (8 isolates, 30.8 %). The incidence of ST8-USA300 increased over the 6-year period. We believe that screening for ST8-USA300 should be improved: medical biologists should be encouraged to search for PVL genes in all MRSA isolates recovered from abscesses, whatever the susceptibility pattern of the isolate, and not only when suggestive of ST80.

[Outbreak of dermatophytosis in a high-level French judo team: prospective study 2006/2011. Efficacy of a therapeutic protocol introduced in 2004/2005]. / Épidémie de dermatophytoses chez les judokas du pôle France d'Orléans : étude prospective 2006/2011 et évaluation de l'efficacité des mesures instaurées en 2004/2005.

BACKGROUND: Outbreaks of dermatophytosis have been reported more and more frequently in combat sports such as wrestling and judo. Such outbreaks are difficult to treat due to the involvement of numerous actors and structures. The main aim of our study was to determine whether the use of a standardized treatment in a high-level judo team could successfully reduce the outbreak. Our secondary objectives were to study the topography of lesions and ascertain whether consultations for suspected dermatophytosis were significantly more frequent during the 4 weeks following a judo training course. MATERIALS AND METHODS: We conducted a prospective follow-up study from October 2004 to the end of June 2005 (series 1) and then from September 2006 to June 2011 (series 2) during which all new suspected cases of dermatophytosis in a judoka from Pôle France Orléans were examined at the Orléans Dermatology Department. For each consultation, we prepared a map of lesions and mycological samples, and patients received standardized treatment. RESULTS: We compared the two series and a considerable decrease was noted in dermatophytosis outbreaks after the introduction of these measures. The mean number of visits per training season was 97 for series 1 and 21.6 per training season for series 2. The mean numbers of episodes of cutaneous lesions clinically active per training season were 74 for series 1 and 16.8 for series 2. Lesions were localized mainly on the forearms, face and neck (40% for series 1 and 73% for series 2). "Waves" of visits (at least two visits per week) occurred significantly more frequently (68%) during the 4 weeks following a training period than during the rest of the year. CONCLUSION: Standardized management of this outbreak reduced the number of infectious episodes.

[Outbreak of cutaneous dermatophytosis in the Judo French Programme in Orleans: September 2004-June 2005]. / Epidémie de trichophyties cutanées chez les judokas du pôle France d'Orléans: septembre 2004-juin 2005.

BACKGROUND: High contact sports regularly allow transmission of infectious agents, including fungi such as dermatophytes. The occurrence of dermatophytosis outbreaks among wrestlers has been extensively described since the 90s. The emergence of such outbreaks among judokas was described for the first time in December 2004. We report here an outbreak which occurred in a high level judo team and is, to our knowledge, the largest ever published. PATIENTS AND METHODS: From October 2004 to June 2005, every judokas of the Pôle France Orléans who were suspect of dermatophytosis were addressed to one single dermatologist. Lesions were sampled for fungal culture and their anatomical cartography was extensively raised. Two protocols of treatment were defined. RESULTS: 97 medical appointments occurred over the period, leading to 74 clinically-defined episodes of dermatophytosis, distributed as 51 primo-contaminations and 23 re-contaminations (new episode in an individual who was considered cured). The distribution of the lesions on the body was: forearms > anterior trunk > neck and face > scalp. Among the 74 episodes, 53 could grow Trichophyton tonsurans. Infected athletes received oral and topical antifungal treatments. No adverse effects were noticed. DISCUSSION: This series among judokas is the largest ever published. It allowed the description of the specific clinical and anatomical presentation of tinea corporis gladiatorum, emphasising that contamination takes place through direct skin to skin contacts during practice. T. tonsurans is regularly the responsible fungus in recently published series. Caring for such an outbreak raises specific problems because of the numerous structures involved and of the nature of these structures and of the sportive goals they aim at. CONCLUSION: This outbreak is probably part of a wider one diffusing among high level judo teams. Stopping it requires the cooperation of several distinct actors, among which sports federations as well as sports-related physicians and dermatologists should play a major role.

Outbreak of tinea corporis gladiatorum, a fungal skin infection due to Trichophyton tonsurans, in a French high level judo team.

An outbreak of 49 cases of tinea corporis gladiatorum due to Trichophyton tonsurans infection occurred in a high level judo team of 131 members in Orleans, central France, between October 2004 and April 2005. The team was divided into 5 groups: cadet-junior boys (n=44), cadet-junior girls (n=33), male university students (n= 15), female university students (n=21), and a group called 'pole technique' made up of high level judokas who have finished academic study (n=18). The outbreak involved 86% of the cadet-junior boys, but only 6 men in the 'pole technique' (33%) and only 5 of the 69 other team members (7%) (cadet-junior girls and university students). We describe the outbreak and the results of a survey that found a known risk factor for the 'pole technique': sharing an electric hair shaver. Personal hygiene practices were found to be very good among the cadet-junior boys. The high attack rate in this group may be linked to the poor shower facilities in the gymnasium where they practiced that led them to have their showers several hours after the end of daily practice.

[Digital purpura revealing septicaemical rat-bite fever]. / Purpura digital isolé révélant une streptobacillose septicémique après morsure de rat.

INTRODUCTION: Infection with Streptobacillus moniliformis is an uncommon illness which can lead to death if untreated. We report the case in which initially cutaneous signs permitted diagnosis and further identification of the organism. CASE REPORT: A 42 year-old woman presented with a three-day history of acrally distributed purpuric macules on her fingers. Two days later, she was admitted for arthritis of the knees and wrists. There were two large pustules on the left elbow and the right knee. Laboratory studies showed inflammatory changes. The diagnosis of streptobacillary rat-bite fever was made after isolation of Gram-negative bacilli from a blood-culture and from cutaneous lesions. Finally identification of the organism was made by molecular biology analysis. The patient received intravenous ofloxacin and imipenem with complete resolution of arthritis and the cutaneous lesions. DISCUSSION: Streptobacillary rat-bite fever is a systemic infectious disease. It is caused by Streptobacillus moniliformis, organism found in the oropharyngeal flora of small rodents, especially rats. The illness is uncommon in urban settings. It starts by fever, followed by arthritis and rash. Septicaemical rat-bite fever may start only with cutaneous involvement such as acral purpura, like in our case. This clinical manifestation must be recognized by the dermatologist, because the illness can lead to death if untreated.

Storage of stools specimens and of Mueller-Kauffmann enrichment broths during week-ends does not hinder the isolation of Salmonella strains.

Technicians are fewer in the laboratory during week-ends. Therefore, following the day of arrival, stools submitted for isolation of Salmonella are either processed immediately or stored at +4 degrees C. The same difference exists for Mueller-Kauffmann enrichment broths (MK): either immediately plated, or stored at room temperature at the end of their overnight incubation when it occurs on saturday morning. Prevalences of Salmonella in 5548 stools of human origin were compared following their day of arrival in the week. Results showed that the storage of stools at +4 degrees C during the week-ends yields a higher rate of isolation of Salmonella though the difference is not significant (prevalence 2.6% for stored stools, versus 2.1%), but significantly improves the isolation of Salmonella from their MK enrichment (4.3% vs 2.6%, p < 0.01), and that storage of overnight incubated MK at room temperature for the week-end also improves significantly the isolation of Salmonella (5.0% vs 2.6%, p < 0.001).

Electron microscopic description of accretions occurring in endotracheal tubes used in adults.

The purpose of the study was to describe the architecture of accretions occurring in endotracheal tubes used in adults by using a conservative procedure and transmission electron microscopy. The study included 12 tubes for which microbiological data of the tracheobronchial secretions were available. Observations were performed on inducted areas of the lumen. All tubes were covered with a several micrometers-to several millimeters-thick layer of mucus. The layers displayed stratified structures and showed granulations, neutrophils or cellular elements. When bacteria were seen, they made no contact with the polymer. This data suggest that adherence properties of bacteria towards the polymer were not involved at these stages of colonization and that a bacterial biofilms is a rare opportunity.

Study of Rambach and NBGL agar on 4037 stools of human origin and 584 veterinary samples submitted for isolation of Salmonellae.

Rambach agar and novobiocin-brilliant green-glycerol-lactose (NBGL) agar are two recently described media designed for Salmonella isolation. Rambach and NBGL agars were compared to usual media in human and veterinary routines, by evaluation of sensitivities and predictive values of suspect colonies. In the human routine, 4037 stools, sensitivities were 79% for Hektoen agar, 51% for Rambach agar and 96% for NBGL agar at the direct plating for a total of 94 strains; and 89%, 87% and 94% respectively at the plating of Mueller-Kauffmann enrichment broth for a total of 143 strains. Predictive values of suspect colonies were respectively 58%, 93%, 91% at the direct plating; and 25%, 74%, 80% at the plating of Mueller-Kauffmann enrichment broth. In the veterinary routine, 584 samples, sensitivity was 65% on the association of Salmonella-Shigella and Hektoen agars, 70% on Rambach agar and 85% on NBGL agar, for a total of 40 strains. Predictive values of suspect colonies were 7.4%, 82.3% and 83% respectively. These results showed that Rambach and NBGL agars have distinct properties, and are both highly predictive. The highest sensitivities were achieved by the NBGL agar.

Novobiocin-brilliant green-glycerol-lactose-agar: further routine evaluation on 5554 human stools and 982 veterinary samples.

In order to provide a wider evaluation of "Novobiocin-brilliant green-glycerol-lactose" (NBGL) agar, dishes of this medium were added to standard media: Hektoen (H), Salmonella-Shigella agar (SS), at all plating steps for 5554 stool cultures of human medical routine (280 isolates) and 982 samples of veterinary routine (133 isolates). NBGL expectedly missed lactose-glycerol positive strains of the serotype Senftenberg (n = 4), H2S negative strains (n = 1), and strains of the Typhi serotype (n = 7). Otherwise, three strains, of serotype Virchow, were unable to grow on NBGL (0.7% of positive samples). Nevertheless overall sensitivities were increased by approximately 10% in the human routine (H: 70%; SS: 63%; NBGL: 94%; at the direct plating step) (H: 83%; SS: 84%; NBGL: 92%; at the enrichment plating step) and by 48% in the veterinary one (NBGL: 97%; versus usual media: 68%). Positive predictive values of black centred colonies were significantly higher on NBGL in human routine (H: 38%; SS: 40%; NBGL: 89%; at the direct plating step) (H: 20%; SS: 21%; NBGL: 82%; at the enrichment plating step); and in the veterinary one as well (NBGL: 90%; versus usual media: 17%). These data suggest that NBGL agar does improve Salmonella isolation in these kinds of routines, and that growth should be made sure before experiments using given strains.

Novobiocin, brilliant green, glycerol, lactose agar: a new medium for the isolation of Salmonella strains.

We describe a medium, novobiocin, brilliant green, glycerol, lactose (NBGL) agar, for the routine isolation of Salmonella strains from stool samples. The NBGL agar principle involved the use of the antisaprophytic effect of brilliant green and novobiocin. Glycerol and lactose were added in order to distinguish between Citrobacter and Salmonella. NBGL was used in parallel with salmonella-shigella (SS) and Hektoen (H) agar for culturing 2,853 stool samples, of which 184 were confirmed to be salmonellae. NBGL showed a high sensitivity: 94% in direct plating compared to 74% (p < 10(-3)) and 65% (p < 10(-5)) for H and SS, respectively, and 96% in enrichment broth plating vs. 83% (p < 10(-4)) and 86% (p < 10(-3)), respectively, for H and SS. In direct plating using NBGL, 95% of black-centred colonies were confirmed to be salmonellae (vs. 31% and 36%, H and SS). In enrichment plating using NBGL, this figure was 82% (vs. 26% and 28%). The results suggest that NBGL agar is advantageous for the isolation of non-Typhi H2S+ salmonellae.

Electron-microscopic description of accretions occurring on tips of infected and non-infected central venous catheters.

OBJECTIVE: The purpose of the study was do describe the architecture of accretions occurring on the tips of central venous catheters (CVC). DESIGN: A conservative procedure was used followed by two different techniques of electron microscopy. SETTING AND PATIENTS: the study included 19 catheters which have been used on intensive cared adults, and which were chosen among those of parallel 300 CVC study. MEASUREMENTS AND RESULTS: CVC were considered sterile, contaminated, colonized or infected according to microbiological and clinical criteria. CVC were found to remain much cleaner than in past descriptions. When present, accretions were located on the olive-shaped end, and displayed stratified structures with three types of material: amorphous material, thrombus components and inflammatory cells. Bacteria were not seen, even on culture positive CVC. Candida albicans was found on one CVC in the cytoplasm of granulocytes, and made no direct contact with the plastic surface. CONCLUSION: This technique should contribute to the understanding of the pathobiology of CVC infection and provide information proving or precluding the involvement of microbial adherence to polymers in vivo.

Comparison of Hektoen and Salmonella-Shigella agar on 6033 stools of human origin submitted for routine isolation of Salmonella sp. and Shigella sp.

From 1989 through 1991, 6033 stool specimens from patients at Orleans Hospital (France), were cultured for enteric pathogens. Hektoen agar (HE) was compared with Salmonella-Shigella agar (SS) after direct streaking and after overnight enrichment in Mueller-Kauffmann broth. Yersinia strains were not computed. Seven strains of Salmonella serotype Typhi were isolated, on both media, and excluded from computations for discussed reasons. Out of a total of 9 Shigella strains, HE isolated 9 and SS isolated 7. No statistically significant difference appeared about isolation of non-Typhi Salmonella strains (127 vs 114 from direct streaking, 237 vs 243 after enrichment). Predictive values of suspicious colonies were not statistically different. Numbers of false positives were not different, except for black centred colonies of the direct streaking (231 on HE vs 186 on SS, p less than 0.05). The skill of technologists was not taken into account but was found likely to be more accurate on SS agar. This data suggest that, since the frequency of Shigella sp became much lower, the differential of efficiency of HE vs SS agar is no longer obvious in human medical routine.

[Comparison of polyurethane and polyethylene for central venous catheter in intensive care units]. / Comparaison polyuréthane-polyéthylène pour le cathétérisme veineux central en réanimation.

Polyurethane (PU) and polyethylene (PE) central venous catheters were compared for their respective responsabilities in catheter related sepsis (CRS). From may 1988 to may 1989, 300 central venous catheters were inserted. Insertion sites were freely chosen by physicians. The polymer type was randomized. Catheters were removed after 10 days in place. Microbial loads were assessed on insertion sites, catheter hubs and tips, and blood drawn through the catheters lumen. One hundred eighty three catheters were available for complete evaluation (101 PE, 82 PE). Eleven were responsible for CRS, 4 were colonized (BB3 according to Brun-Buisson's classification), 19 were contaminated (BB2), and 149 were sterile (BB1). When comparing the "infected" group (CRS+BB3) and the "noninfected" (BB2 + BB1), no difference appeared between the tested polymers. CRS were significantly associated with insertion into the internal jugular vein. It seems useless to exclude from clinical practice any of the biomaterials tested.

Electron microscopic studies of endotracheal tubes used in neonates: do microbes adhere to the polymer?

Fourteen neonates intubated at birth for 1-16 days had a microbiological follow up. After removal, tubes were examined using electron microscopy. Tubes became covered with a slimy accretion from the third day in place, independently of bacterial colonization, which was, in all but one cases, restricted to the rough areas of the tubes. Only Candida albicans and the corresponding slimy coat were found on smooth areas of tube. Cocci were noticed on 3 tubes. They were associated with the slimy accretion. Transmission micrographs elicited a thick material that was lying between cocci and polymer. These results showed that, on neonates' endotracheal tubes, accretion occurred independently of microbial colonization and that when colonization occurred, cocci adhered preferentially to a biological coat of human origin rather than the medical devices.

[Polyurethane versus polyethylene: in vivo randomized study of infectious complications of central catheterization]. / Polyuréthanne versus polyéthylène: étude randomisée in vivo des complications infectieuses du cathétérisme central.

Polyurethane (PU) and polyethylene (PE) catheters were distributed by randomization among adult ICU patients to evaluate the impact of the catheter polymer on the rate of catheter-related sepsis (CRS). The two catheters were otherwise strictly identical. Three hundred central venous catheters were randomized and inserted in the subclavian or internal jugular vein, at the discretion of the clinician. Mean duration of insertion was 9.2 (+/- 3) days for both catheter types and mean number of line openings was 159 (+/- 60). A bacteriologic culture using a variant of Maki's technique was performed on the 205 catheters removed before patient discharge. No significant differences were found between the two catheters. Total number of tip infections was 33 and polyurethane and polyethylene prevalence ratio was 0.7. A clinical evaluation was performed for the 183 catheters inserted for a least 48 hours (in 142 patients). Patients were divided into four clinical categories according to previously reported definitions (Brun-Buisson et al., 1987). Clinical tip-infection rate was 4.4% and polyurethane and polyethylene ratio was 0.7. For three additional catheters (1.6%), only the Luer-lock was infected. These three catheters were made of polyethylene and were inserted into the internal jugular vein. The Luer-lock was made of polypropylene.

[Pharyngeal and tracheal flora in intubated neonates: interrelations and role of streptococci]. / Flores pharyngée et trachéale du nouveau-né intubé: inter-relations et rôle des streptocoques.

Fourteen neonates intubated within 48 hours of birth were studied for a mean period of two weeks. None were candidates for antimicrobial therapy. Microorganism loads were evaluated twice a week, quantitatively in the pharynx and semiquantitatively in the trachea. Most microorganisms recovered were Gram-positive cocci. All species acquired reached 10(7) CFU/g by the time of the second sampling. All species recovered from the pharynx were recovered from the trachea within 0.25 weeks. The presence of alpha-hemolytic streptococci did not modify the other populations. A colonization pattern similar to that seen in the digestive tract but with specific features due to countercurrent colonization is suggested.

[Modification of aerobic digestive flora in patients in intensive care during and after treatment with cefmenoxime]. / Modifications des flores digestives aérobies de malades de réanimation pendant et après un traitment par cefménoxime.

To evaluate the resistant strains selection during treatment with cefmenoxime, a 3rd generation cephalosporin, 10 adult inpatients of an intensive-care unit had quantitative stool cultures, before the treatment, on the 7-10th day of therapy, and 7-10 days after the end of the antibiotic course. The results show that the selecting effect of cefmenoxime is not different from the effect previously observed for cefotaxime.

Evolution of the barrier effects against an exogenous drug-sensitive Escherichia coli strain after single or repeated oral administration to newborns and infants aged up to three months admitted to an intensive-care unit.

60 neonates--42 newborns 0-30 days old and 18 infants 31-90 days old--without previous antibiotic treatment were chosen and randomized into three groups (A, B, C). The strain of Escherichia coli administered was antibiotic-sensitive and azide-resistant (E. coli AZ). The digestive implantation was quantified by an index. We studied the variations of this index between the single administration group (A) and the 5 administrations group (B) and with age in both groups. Drug-resistant enterobacteria were also numbered in each stool, and their variations were studied by comparing groups A and B to a control group (C) receiving no administration. Multiple administrations did not lead to different results from the single ones. Age played a negative role in the colonizations after single administration, but a positive one after multiple administrations. Drug-resistant enterobacteria were not affected by any procedure. The drug susceptibility of E. coli AZ was lost in only 1 infant.