Vancomycin treatment is a risk factor for vancomycin-nonsusceptible Staphylococcus capitis sepsis in preterm neonates.

OBJECTIVES: Multidrug-resistant, vancomycin-nonsusceptible Staphylococcus capitis is an emerging cause worldwide of late-onset sepsis (LOS) in preterm neonates. The pathophysiology and risk factors for S. capitis-related LOS are poorly understood, but we hypothesized that S. capitis LOS follows translocation from the gut microbiota rather than catheter invasion. The objective of this study was to investigate the risk factors of S. capitis LOS and gut colonization. METHODS: We conducted a prospective single-centre cohort study of patients hospitalized in a tertiary-care unit (Lyon, France) from June 2011 to January 2012. S. capitis gut colonization was determined weekly from stool cultures. The determinants of gut colonization and LOS were established by multivariate Cox proportional hazards models. RESULTS: Eighty-three (36.2%) of 229 patients had S. capitis-positive stool culture, and 28 (12.2%) developed S. capitis LOS during hospitalization. Independent risk factors for S. capitis LOS included prior administration of vancomycin independent of a previous LOS episode (hazard ratio 6.44, 95% confidence interval 2.15-19.3, p 0.001) and low birth weight (hazard ratio 0.72 per 100 g increase, 95% confidence interval 0.55-0.95, p 0.02). The prior administration of vancomycin was also an independent risk factor for S. capitis colonization (hazard ratio 3.45, 95% confidence interval 2.07-5.76, p <0.001), particularly in the first week of life and in noncolonized neonates. CONCLUSIONS: Neonates treated with vancomycin are at a higher risk of LOS caused by vancomycin-nonsusceptible S. capitis. The use of vancomycin in neonates must urgently be optimized to limit the selection of vancomycin-nonsusceptible strains, for which alternative antibiotics are lacking.

Evaluation of the new Vitek 2 GN card for the identification of gram-negative bacilli frequently encountered in clinical laboratories.

The new Vitek 2 GN card (bioMérieux, Marcy-l'Etoile, France) was developed for better identification of fermenting and nonfermenting bacilli. This new card allows the identification of 159 taxa. A total of 426 isolates (331 fermenting and 95 nonfermenting gram-negative bacilli) belonging to 70 taxa covered by the database were evaluated. All isolates were identified in parallel with the ID 32 GN, the API 20E, and the API 20NE methods. The system correctly identified 97.4% (n=415) of the strains. Only 2.1% (n=9) needed additional testing. One strain (0.25%) was misidentified (Klebsiella pneumoniae subsp. pneumoniae), and another one (0.25%) was not identified (Morganella morganii subsp. morganii). The new GN card gives more accurate identifications overall for gram-negative bacilli when compared to the systems described in other similar studies.

Outbreaks of contaminated broncho-alveolar lavage related to intrinsically defective bronchoscopes.

From 5 March 2001 to 19 October 2001, outbreaks of broncho-alveolar lavage (BAL) contamination with Enterobacteraceae were detected in our 700-bed institution. We report the investigation of these outbreaks. A case was defined as the occurrence of pairs of specific Enterobacteraceae in BAL specimens among any patients who underwent bronchoscopy in the respiratory unit during the period of the outbreak. Contamination was identified in 117 BAL samples during three outbreaks among 418 patients, and was associated with bronchoscopes 11 and 12 (P<0.001). The other five devices in use were not linked with the outbreaks. During the first outbreak, particular pairs of micro-organisms were associated with a specific bronchoscope (Klebsiella pneumoniae/Proteus vulgaris with bronchoscope 11, and Morganella morganii/Proteus mirabilis with bronchoscope 12). Cultures of sputa from two patients also yielded M. morganii some days after bronchoscopic examination. Isolates from contaminated BAL samples and bronchoscope 11 had similar patterns by pulsed-field gel electrophoresis. No further cases occurred after removal of the implicated bronchoscopes. No deficiencies in disinfection procedures were detected and the source of contamination was found to be a loose port of the biopsy channel of the bronchoscope. Our findings underscore the urgent need to test bronchoscopic samples regularly and to improve the design and structure of bronchoscopes.

[Pubic osteomyelitis in athletes]. / Les ostéomyélites du pubis de l'athlète.

INTRODUCTION: Pubic osteomyelitis has been described in three situations: children in whom Staphylococcus aureus is the preeminent pathogen; elderly patients who have undergone genitourinary procedures, and parenteral drug abusers. In contrast, pubic osteomyelitis in athletes has been described less often. We report three cases of acute staphylococcal pubic osteomyelitis in young athletic men and present a review of the literature. EXEGESIS: The clinical presentation in each case was acute groin, hip, or perineal pain; fever; inability to bear weight; and pubic symphysis tenderness. The diagnosis was established by blood culture and radiologic changes. CONCLUSIONS: Staphylococcus aureus pubic osteomyelitis should be suspected in athletes who have febrile hip or groin pain. The pathogenesis of this disease is thought to involve preexisting trauma or athletic injury and subsequent seeding of this area during transient bacteremia. Prolonged antimicrobial therapy is required for the cure, and debridement with curettage may be necessary if patients have persistent infection or sequestra.

Non-tuberculous mycobacterial tenosynovitis: a review.

The clinical characteristics, outcome and treatment of non-tuberculous mycobacterial tenosynovitis are reviewed. From lesions localized in the hand, 10 different species of non-tuberculous mycobacteria have been reported. The most common are Mycobacterium marinum and Mycobacterium kansasii. Other less frequent organisms are Mycobacterium avium complex, Mycobacterium szulgai, Mycobacterium terrae, Mycobacterium fortuitum, Mycobacterium chelonae, Mycobacterium abscessus, Mycobacterium malmoense and Mycobacterium xenopi. The infections appear to be the result of previous trauma, surgical procedure, corticosteroid injection or non-apparent inoculation (water contamination). Immunosuppression is sometimes associated with the infections and can be considered as a risk factor. Surgical debridement and appropriate mycobacterial cultures are critical to enable diagnosis and appropriate management. Specimens should be inoculated on a range of media and incubated at a range of temperatures in order to isolate mycobacteria with different growth characteristics (with prolonged incubation). The optimal treatment of these infections is discussed.

Prevalence and pathogenicity of Clostridium difficile in hospitalized patients. A French multicenter study.

BACKGROUND: Although Clostridium difficile is the main agent responsible for nosocomial diarrhea in adults, its prevalence in stool cultures sent to hospital microbiology laboratories is not clearly established. OBJECTIVES: To determine the prevalence of C difficile in inpatient stools sent to hospital microbiology laboratories and to assess the relationship between serotypes and toxigenicity of the strains isolated and the clinical data. METHODS: From January 18, 1993, to July 31, 1993, the presence of C difficile was systematically investigated in a case-control study on 3921 stool samples sent for stool culture to 11 French hospital microbiology laboratories. The prevalence of C difficile in this population (cases) was compared with that of a group of 229 random hospital controls matched for age, department, and length of stay (controls). Stool culture from controls was requested by the laboratory although not prescribed by the clinical staff. Serotype and toxigenesis of the strains isolated were compared. RESULTS: The overall prevalence of C difficile in the cases was twice the prevalence in the controls (9.7% vs 4.8%; P < .001) and was approximately 4 times as high in diarrheal stools (ie, soft or liquid) as in normally formed stools from controls (11.5% vs 3.3%; P < .001). The strains isolated from diarrheal stools were more frequently toxigenic than those isolated from normally formed stools. Serogroup D was never toxigenic, and its proportion was statistically greater in the controls than in the cases (45% vs 18%; chi 2 = 5.2; P < .05). Conversely, serogroup C was isolated only from the cases. Clostridium difficile was mainly found in older patients ( > 65 years), suffering from a severe disabling disease, who had been treated with antibiotics and hospitalized for more than 1 week in long-stay wards or in intensive care. CONCLUSIONS: This multicenter period prevalence study clearly supports the hypothesis of a common role of C difficile in infectious diarrhea in hospitalized patients. Disease associated with C difficile should therefore be systematically evaluated in diarrheal stools from inpatients.

[Adequate intrathecal diffusion of teicoplanin after failure of vancomycin, administered in continuous infusion in three cases of shunt associated meningitis]. / Diffusion intrathécale efficace de la teicoplanine aprés échec de la vancomycine, administrées en perfusion continue, dans trois cas de méningite sur shunt.

Glycopeptides which have excellent in vitro activity against the Gram-positive causal agents of meningitis unfortunately have a poor CSF penetration. Vancomycin distribution into CSF is improved when administered by a continuous intravenous route and staphylococcal shunt related infection have been reported to be cured. Teicoplanin has good in vitro activity against a lot of staphylococci, and activity superior to vancomycin, against streptococci and is less toxic. In three children with shunt ventriculitis (S epidermidis 2, S. faecalis 1) despite a continuous infusion, vancomycin 15 mg/kg over 60 minutes onset, then 50 mg/kg/day was clinically and bacteriologically ineffective with very poor CSF levels even if high blood levels. After failure of vancomycin we used teicoplanin as a continuous i.v. infusion 6 mg/kg over 60 mn onset, then 12 mg/kg/day. This treatment was quickly effective and well tolerated.

[Susceptibility of strict anaerobic bacteria to antibiotics in France: a multicenter study]. / Sensibilité aux antibiotiques des anaérobies stricts en France: étude multicentrique.

During 1992, the in vitro antibiotic susceptibility of 462 anaerobic bacteria was performed in 7 hospitals, by the reference agar dilution method. Among the 222 Bacteroides fragilis group strains, only one Bacteroides fragilis strain was resistant to imipenem and all bêtalactams, even combined with bêtalactamase-inhibitors while metronidazole resistance could not be detected. One major outer membrane protein (probably a porin) was lacking in some of the six amoxicillin-clavulanic acid resistant Bacteroides fragilis group strains. Evolution in antibiotic resistance rates could be assessed only for clindamycin and piperacillin whose resistance rates increased to 14 and 15.8 p. cent, respectively. On the whole anaerobic strains resistance rates were: imipenem 0.2, ticarcillin-clavulanic acid 0.5, amoxicillin-clavulanic acid or metronidazole 1.5, piperacillin 9.1, cefotaxime-sulbactam 9.7, cefoxitin 12.8, clindamycin 13.7, cefotaxime 27.2, amoxicillin 45 and ciprofloxacin 70, respectively.

Evaluation of two new chromogenic media for detection of Salmonella in stools.

A clinical collaborative study was conducted to compare two new chromogenic agar media, Rambach agar and the Salmonella Detection and Identification Medium (SMID) (bioMérieux, France), with two conventional media, Salmonella-Shigella agar and Hektoen agar. Thirty-nine Salmonella strains involving 14 serotypes were isolated from 1,454 stool specimens. After enrichment in a selective broth, 100% sensitivity was obtained with each medium. The SMID and Rambach agars are considerably more specific than the conventional media. Although SMID agar detects all Salmonella serotypes, it is not as specific as Rambach agar, which requires a complementary test (C8 esterase test) to detect all serotypes.

[Treatment of salmonellosis and shigellosis with the new quinolones]. / Traitement des salmonelloses et shigelloses par les nouvelles quinolones.

Sixty patients with enterocolitis (36 men, 24 females), mean age thirty seven (12 to 84) have been treated with new quinolones. Two groups have been constituted. First group included patients without bacteremia despite enterocolitis. Among them, 9 patients suffered from shigellosis (8 S. flexneri, 1 S. sonnei). Twenty-two patients had a minor salmonellosis (13 S. typhimurium, 4 S. enteritidis, 1 S. blockley, 1 S. Virchow, 1 S. london, 1 S. baildon, 1 S. C2 group). Patients in the second group underwent a septicemic salmonellosis (18 S. typhi, 3 S. paratyphi, 8 other Salmonella serotypes). All patients but one received an oral treatment. Forty-seven patients received 400 mg/day ofloxacin, 8 patients 1.500 mg/day ciprofloxacin, 5 patients 800 mg/day pefloxacin. Treatment lasted an average of 10 days (5 to 31 days). Apyrexia was observed within an average of 3 days (1 to 8 days). Blood culture have always been sterile after a two days treatment duration. No more shigella or salmonella was found in feces, five days after beginning of treatment. No relapse has been observed within a 30 days mean background (1 to 180 days). Not any intolerance needed to stop treatment. Patients have been hospitalized on an average of 11 days. Therefore, new quinolones will represent an effective, well tolerated treatment for salmonellosis or shigellosis.

Chronokinetic study of netilmicin in man.

Netilmicin 1.5 mg/kg body weight was administered intravenously every 8 h for 2 days to 8 patients with normal renal function. Significant elevation of mean and trough plasma concentrations was found at 05.00 h and 09.00 h. This was considered to be due to circadian variation, with possible accumulation during the night. The clinical importance of this phenomenon in relation to the development of aminoglycoside toxicity awaits further investigation.

[Management of a pregnant woman with Streptococcus group B]. / Conduite à tenir chez une femme enceinte portant un streptocoque du groupe B.

The relative rarity (1 to 5 cases for 1,000 births) of neonatal infections secondary to B Streptococcus, the epidemiological characteristics of this germ, especially the unstable vaginal carriage, make it difficult to select a therapeutic approach. Systematic screening of B Streptococcus and the treatment of all carriers or only of high-risk patients, present several practical problems, are complex to implement but the cost/benefit ratio seems however acceptable. Prophylactic intrapartum antibiotic treatment of known carriers of B Streptococcus does not seem debatable any longer, at least the treatment of those presenting other risk factors: premature delivery, premature rupture of the membranes, fever occurring during delivery. Today, the best prophylaxis of neonatal infections seems to be the intrapartum antibiotic treatment (ampicillin) resulting in a spectacular decrease of the frequency of neonatal contamination.

[Mediastinitis caused by anaerobic bacteria. 4 cases]. / Médiastinites à germes anaérobies. Quatre observations.

In 4 cases of mediastinitis caused by anaerobes and consecutive to dental abscess (2 cases), perforation of the oesophagus and tonsillar abscess, the diagnosis was based on widening of the mediastinum associated, in 2 cases, with pneumomediastinum. II all 4 cases, Bacteroides fragilis was present among other germs. Treatment consisted of surgical drainage by thoracotomy (2 cases), or cervicotomy and antibiotic therapy. Two of the patients, who were old and had underlying diseases, died.

[Intracranial hypertension in comatose bacterial meningitis]. / Hypertension intracrânienne des méningites bactériennes comateuses.

The intracranial pressure of 31 patients with bacterial meningitis, in a comatose state and with a score lower than 6 on Glasgow's scale, was monitored by means of an extradural captor in order to detect intracranial hypertension and optimize its treatment. All patients had intracranial hypertension during the first 48 hours. Brain perfusion pressure was inferior to 50 mmHg in 5 cases. Computed tomography of the brain showed cerebral oedema in 16 cases. Twenty (64%) of the patient survived, 15 of them without sequelae. Monitoring intracranial pressure in patients with bacterial meningitis and coma makes it possible to optimize treatment and shows that a less than 50 mmHg brain perfusion pressure is associated with a 100% death rate.