Risk factors for Pseudomonas aeruginosa acquisition in intensive care units: a prospective multicentre study.

BACKGROUND: Pseudomonas aeruginosa is a major nosocomial pathogen in intensive care units (ICUs); however, endogenous versus exogenous origin of contamination remains unclear. AIM: To identify individual and environmental ICU risk factors for P. aeruginosa acquisition. METHODS: A five-month prospective multicentric study was performed in ten French ICUs. Adult patients hospitalized in ICU for ≥ 24 h were included and screened for P. aeruginosa colonization on admission, weekly and before discharge. P. aeruginosa acquisition was defined by a subsequent colonization or infection if screening swabs on admission were negative. Water samples were obtained weekly on water taps of the ICUs. Data on patient characteristics, invasive devices exposure, antimicrobial therapy, P. aeruginosa water and patient colonization pressures, and ICU characteristics were collected. Hazard ratios (HRs) were estimated using multivariate Cox model. FINDINGS: Among the 1314 patients without P. aeruginosa on admission, 201 (15%) acquired P. aeruginosa during their ICU stay. Individual characteristics significantly associated with P. aeruginosa acquisition were history of previous P. aeruginosa infection or colonization, cumulative duration of mechanical ventilation and cumulative days of antibiotics not active against P. aeruginosa. Environmental risk factors for P. aeruginosa acquisition were cumulative daily ward 'nine equivalents of nursing manpower use score' (NEMS) [hazard ratio (HR): 1.47 for ≥ 30 points; 95% confidence interval (CI): 1.06-2.03] and contaminated tap water in patient's room (HR: 1.76; CI: 1.09-2.84). CONCLUSION: Individual risk factors and environmental factors for which intervention is possible were identified for P. aeruginosa acquisition.

[Fatal lactic acidosis in a patient infected by HIV and treated with stavudine and didanosine]. / Acidose lactique fatale chez une patiente infectée par le VIH et traitée par stavudine et didanosine.

We report a case of severe lactic acidosis in an human immunodeficiency virus (HIV)-infected patient treated with combination regimen of stavudine, didanosine and nevirapine. Antiretroviral nucleoside analogs are inhibitors of mitochondrial DNA polymerase gamma, resulting in the dysfunction of the mitochondrial respiratory chain. Despite symptomatic treatments and intravenous L-carnitine supplementation, lactic acidosis persisted, leading to multiorgan failure. The patient died 7 days after admission to the intensive care unit. Retrospective analysis of published cases showed neither specific nor predictive signs of outcome that is usually fatal, with no effective therapy to date. We therefore recommend determining blood lactate in patients with onset of unexplained general fatigue or digestive signs and to stop all antiretroviral treatments in the case of lactate increase.

Pneumococcal cellulitis in an HIV-infected adult.

Streptococcus pneumoniae is an uncommon cause of cellulitis. In almost all of the reported cases, the infection occurred in immunosuppressed patients, especially in those with connective tissue diseases. We report a case of cervical cellulitis associated with septicemia which occurred in an HIV-infected adult.

Polymicrobial meningitis revealing an anterior sacral meningocele in a 23-year-old woman.

Polymicrobial meningitis has become increasingly rare during recent decades. Historically, it has mainly been reported as being associated with disorders of the ENT-sphere. The treatment of these infections being optimized, polymicrobial meningitis nowadays is essentially a complication of gastrointestinal or gynaecological disorders and trauma. We present a case of polymicrobial meningitis following puncture of a unrecognized pre-sacral meningocele in a patient with Currarino syndrome and review of the relevant literature.

Group B streptococcus meningitis in an HIV-positive adult: case report and review.

We report a new case of meningitis due to group B streptococci (S. agalactiae) in an HIV-positive patient. Only three other cases have been reported so far, and common features are discussed.

Spontaneous Escherichia coli meningitis in an adult.

Spontaneous meningitis due to gram-negative bacilli (excluding Hemophilus influenzae) is an infrequent infection in adult patients. It usually occurs in patients with underlying immunosuppressive conditions. Most of the cases are due to Escherichia coli and represent a complication of bacteraemia. The infection has a high mortality rate which may be as high as 90%, especially if associated with septicaemia. We report the case of a 53-y-old man with spontaneous, community-acquired Escherichia coli meningitis who was admitted with an unusual presentation. Blood and urine cultures were negative.

Primary sternal osteomyelitis and septicaemia due to Staphylococcus aureus.

Primary sternal osteomyelitis is rare in these recent decades. Only scattered cases have been reported, most of them in intravenous drug users. We report the case of an 88-y-old woman who presented a primary sternal infection due to Staphylococcus aureus associated with secondary septicaemia. The only predisposing factor was radiotherapy for a malignant tumour of the right mammary gland 20 y ago. Diagnostic evaluation and therapeutic management are briefly discussed.

[Optimizing antibiotic therapy in a hospital setting]. / Optimisation de l'antibiothérapie curative à l'hôpital.

Optimal use of antibiotics in hospitalized patients raises several problems. i) Does the patient really have an infection treatable with antibiotics? Currently, there are no clinical or biological data which can resolve this question with sufficient sensitivity and specificity. ii) Are microbial samples warranted before starting treatment? All bacteria isolated from cerebrospinal, ascitis, pleural or articular fluids are pathogens whereas a quantitative assessment is required for bacteria isolated from the upper or lower respiratory tract. iii) If an antibiotic is needed should a single drug or a multiple drug regimen be prescribed? Twenty years ago two-drug regimens were necessary. Synergism and better spectrum were the keystones of two-drug therapy. Today, single-drug regimens are sufficient except in case of Staphylococcus, Pseudomonas or some Enterobacteriacae infections. iv) Which administration route is best? In hospitalized patients, the parenteral route is generally used with a rapid switch to oral administration, usually within 48 hours. v) How long should the antibiotics be given? Treatment duration depends on the bacteria, the patient and the organ involved. vi) How can resistance be avoided? Rotating between antibiotics has been proposed to reduce the emergence of multidrug resistant bacteria, although this concept remains to be validated by controlled studies.

[Lactic acidosis and multi-organ failure secondary to anti-retroviral therapy in HIV-infected patients]. / Acidose lactique et défaillance multiviscérale secondaire aux thérapeutiques antirétrovirales chez les patients infectés par le VIH.

A SERIOUS COMPLICATION: Antiretroviral therapy may induce severe lactic acidosis with multiorgan failure in HIV-infected patients. CLINICAL DESCRIPTION: Patients are admitted for onset of dyspnea, abdominal pain, nausea, vomiting or diarrhea, with weight loss and general fatigue over the past few days. Physical findings are usually not contributive except for constant presence of hepatomegaly. Laboratory examinations reveal severe metabolic acidosis with increased anion gap and serum lactate elevation. Perturbations of hepatic and pancreatic enzyme values may exist. Echotomography and CT scan demonstrate fatty liver, confirmed by histological examination of the biopsy. Outcome in the intensive care unit is generally multiorgan failure and death. Symptomatic treatments, mechanical ventilation, bicarbonate infusion or hemodialysis appear to be ineffective in most severe cases. PATHOPHYSIOLOGY: Antiretroviral nuceloside analogs are inhibitors of mitochondrial DNA polymerase gamma. This explains the dysfunction of the mitochondrial respiratory chain, leading to inhibition of lactate metabolism in the liver and enhancement of serum lactate and acetone body levels. Elevation of lactate/pyruvate and beta-hydroxybutyrate/acetoacetate ratios suggest mitochondrial dysfunction. Many other co-factors may be associated. THERAPEUTIC APPROACH: Several therapeutic strategies (thiamine, coenzyme Q, carnitine and riboflavin) have been tried. They rely on the pathophysiological hypothesis that sustained cellular dysfunctions cause this clinical syndrome.

[Neurologic toxicity of methotrexate in a patient with cerebral arteritis. Report of a case]. / Toxicité neurologique du méthotrexate avec artérite cérébrale. Un cas.

We report the case of an 18 year-old woman treated for femoral osteogenic sarcoma who presented generalized seizures requiring sedation, tracheal intubation and artificial ventilation. CT brain scan showed diffuse hypodensities. Doppler studies showed an increased cerebral arterial resistance. Regional cerebral blood flow was decreased. A right carotid angiogram showed abnormalities consistent with diffuse cerebral arteritis. The patient slowly recovered and 6 weeks later, magnetic resonance imaging showed disseminated areas of hyposignal on T1 and hypersignal on T2 weighted images. We reviewed the different published cases of acute high dose methotrexate neurotoxicity and the different underlying mechanisms.

Clinical biological features of Ballantyne syndrome and the role of placental hydrops.

Ballantyne syndrome was first described in association with severe hydrops fetalis caused by rhesus isoimmunization, and lately, in association with diverse etiologies of nonimmunological severe fetal hydrops. This report is a case of typical Ballantyne syndrome in association with lethal hydrops fetalis caused by Ebstein's anomaly. It is likely that any severe fetal hydrops with massive placental hydrops may produce Ballantyne syndrome. Hemodilution could be the main biological feature, differentiating Ballantyne syndrome from usual preeclamptic syndromes. Pathophysiological hypotheses are discussed.

Streptococcus B meningitis in post-partum.

We report a case of post-partum meningitis due to group B-streptococcus developing 24 h after vaginal delivery. Diagnosis was established by latex agglutination of streptococcus B-antigenes and confirmed by cerebrospinal fluid-culture later on. Clinical and haematological signs of meningitis disappeared after treatment with ampicillin. In a review of the literature we found eight other cases of streptococcal post-partum meningitis. In all of these cases, delivery was vaginal and no antibioprophylaxis was given.

[Thrombosis of the basilar trunk in a young woman previously treated by radiotherapy for malignant lymphoma]. / Thrombose du tronc basilaire chez une jeune femme précédemment traitée par radiothérapie pour lymphome malin.

We report the case of a 23-year-old-woman, who had received mediastinal radiotherapy for non-Hodgkin lymphoma. Five years later, she presented a basal artery thrombosis. Arteriography showed an ectopic origin of the left vertebral artery on the aortic arch located within the irradiation field. This artery was irregular and narrowed up to 15 cm from its origin. All other cerebral arteries were normal. We reviewed the literature of other observations describing radiation-induced cervical arteritis.

Adult respiratory distress syndrome and pancytopenia associated with miliary tuberculosis in a HIV-infected patient.

Adult respiratory distress syndrome (ARDS) is a rare but severe complication of miliary tuberculosis, which may appear even after introduction of antituberculosis therapy. Mortality has been reported to be as high as 100% if there is associated pancytopenia. We report a case of a patient infected with the human immunodeficiency virus who presented with miliary tuberculosis associated with pancytopenia and adult respiratory distress syndrome.