Suction drainage fluid culture during septic orthopaedic surgery, a retrospective study.

We evaluated the usefulness of suction drainage fluid culture after septic orthopaedic surgery to predict early surgical reintervention. We conducted a retrospective observational study, at the Groupe Hospitalier Paris Saint-Joseph between 2014 and 2019. All the patients undergoing septic orthopaedic surgery, with perioperative samples and a postoperative suction drainage device, were enrolled. We compared the group with positive or negative postoperative drainage fluid cultures, respectively, on surgical outcome. We included 246 patients. The drainage fluid culture was positive in 42.3% of the cases. Early surgical reintervention concerned 14.6% of the cases (n = 36), including 61.1% of patients with positive drainage fluid culture (n = 22/36). The risk factors associated with positive drainage fluid cultures were the debridement of the infected site (without orthopaedic device removal), an infection located at the spine, perioperative positive cultures to Staphylococcus aureus. The complete change of the orthopaedic device, and coagulase-negative staphylococci on the preoperative samples, was associated with negative drainage fluid cultures. Positive drainage fluid culture was predictive of early surgical reintervention, and coagulase-negative staphylococci in the preoperative samples and knee infection were predictive of surgical success. Postoperative drainage fluid cultures were predictive of early surgical reintervention. Randomized multicentric studies should be further conducted.

Emergence of Ceftriaxone Resistance during a Case of Pneumococcal Meningitis with Fatal Evolution.

We report a case of a 62-year-old man treated for Streptococcus pneumoniae meningitis by ceftriaxone and dexamethasone. After neurological improvement, neurological degradation by vasculitis occurred, despite effective concentrations of ceftriaxone in the serum and cerebrospinal fluid (CSF). S. pneumoniae with increased MICs to third-generation-cephalosporins (3GC) was isolated from the ventricular fluid 10 days after the isolation of the first strain. Isolate analysis showed that a mutation in the penicillin-binding protein 2X (PBP2X) has occurred under treatment.

Clinical impact of rapid bacterial identification by MALDI-TOF MS combined with the bêta-LACTA™ test on early antibiotic adaptation by an antimicrobial stewardship team in bloodstream infections.

BACKGROUND: Bloodstream infections (BSI) can potentially be life-threatening infections and are associated with a high crude mortality, moreover with an inappropriate first-line antibiotic therapy. Bacterial resistance is more and more frequently observed. New strategies of BSI management are urgently needed. MATERIALS AND METHODS: During an 18-months period, we prospectively evaluated the clinical impact of rapid bacterial identification by MALDI-TOF MS technology combined with an antimicrobial stewardship team (AST) intervention. Furthermore, during an 8-months period, we combined this strategy with the rapid detection of third-generation cephalosporin (3GC) resistance by the Bêta-LACTA™ test (BLT) directly on blood cultures. We then evaluated the theoretical impact of BLT on antibiotic therapy adaptation and establishment of infection control measures. RESULTS: A total of 335 blood cultures were enrolled during the study. MALDI-TOF MS gave accurate identification for 301 blood cultures (89,8%) and led to early antibiotic therapy adaptation for 73 episodes (21.8%). BLT was performed on 141 blood cultures, revealing 28 3GC-resistant bacteria (19.9%). Twenty-one patients (75%) received a non-adapted first-line treatment. The antibiotic therapy adaptation was delayed by 28.1 hours and the establishment of infection control measures by 35 hours with antimicrobial susceptibility testing, compared to the theoretical adaptation with BLT result. CONCLUSIONS: These tools can be included in a strategy of bloodstream infections management for a better patient care, optimizing and saving the use of antibiotics, notably carbapenems as well as diminishing the spread of multi-drug resistant bacteria by applying rapidly infection control measures.

Implementation of Alere i Influenza A & B point of care test for the diagnosis of influenza in an ED.

STUDY OBJECTIVE: This study aimed to evaluate the impact of implementing rapid point-of-care testing (POCT) with the Alere i Influenza A & B in an emergency department (ED) during an influenza epidemic. METHODS: Direct nasal swabs were prospectively collected following the physical examination of patients aged >18years who presented to the ED of a tertiary hospital in France with influenza-like illness (ILI) symptoms (N=301) between February 1st and March 31st, 2016, which coincided with an influenza epidemic. Laboratory-based testing (standard of care) was used to obtain a diagnosis in February 2016 (pre-POCT cohort) and positive results were confirmed using polymerase chain reaction. The primary endpoint was patient time in the ED. RESULTS: A total of 169 and 132 patients participated in the pre-POCT phase and POCT phase respectively. A significantly higher proportion of patients received a positive diagnosis in the POCT cohort compared with the pre-POCT cohort (31% versus 5.3%, P<0.01). Mean time spent in the ED and hospitalization rate were significantly lower in the POCT cohort (6.06h versus 4.15h, P=0.03, and 44.4% versus 9.7%, P=0.02, respectively). Despite similar rates in the prescription of antibiotics and antiviral therapies, the proportion of patients who were referred for additional tests was significantly lower in the POCT cohort (78.1% versus 62.1%, P=0.003, and 80.5% versus 63.6%, P=0.01, respectively). CONCLUSIONS: The Alere i Influenza A & B POCT reduced the length of stay in ED, the hospitalization rates, and the number of additional diagnostic tests compared with standard of care testing.

Infective endocarditis: Clinical presentation, etiology, and early predictors of in-hospital case fatality.

OBJECTIVE: We aimed to assess the clinical presentation, microbial etiology and outcome of patients presenting with infective endocarditis (IE). PATIENTS AND METHODS: We conducted a four-year retrospective study including all patients presenting with IE. RESULTS: We included 121 patients in the study. The median age was 74.8years. Most patients had native valve IE (57%). Staphylococcus aureus accounted for 24.8% of all IE. Surgery was indicated for 70 patients (57.9%) but actually performed in only 55 (44.7%). Factors associated with surgery were younger age (P=0.002) and prosthetic valve IE (P=0.001). Risk factors associated with in-hospital mortality were diabetes mellitus (OR=3.17), chronic renal insufficiency (OR=6.62), and surgical indication (OR=3.49). Mortality of patients who underwent surgery was one sixth of that of patients with surgical indication who did not have the surgery (P<0.001).

[Vaccinations of HIV-infected travelers]. / Vaccinations du voyageur infecté par le VIH.

Human immunodeficiency virus (HIV) positive international travelers are at higher risk of infectious complications. The pretravel assessment often provides an opportunity to update routine vaccinations and HIV patient specific vaccinations including pneumococcus, hepatitis A, hepatitis B, and influenza. Other vaccinations may be required or recommended. Decision for vaccination require considering the risk and severity of the vaccine, preventable diseases in the destination area, the nature of the vaccine (live attenuated vaccines or not), the patient's immune status, and the risk of virological rebound as a consequence of vaccination. The immunogenicity of vaccines is decreased in HIV patient with low CD4 cell counts (above 500 cells per cubic millimetres and particularly above 200 cells per cubic millimetres) and in patients with a persistent HIV RNA viral load. Vaccines should be administered to patients whose HIV infections are in the early stage or in patients receiving HAART with a satisfactory immune status and reduced HIV RNA level. Testing of postvaccination antibodies is useful if serological protective levels are defined. In case of non-response after vaccination, few studies suggest that additional revaccination, increase of vaccine dose, intradermic vaccination, or use of prime-boost combination may be successful. Further research is needed to define vaccination strategies, adapted to the immune status of the HIV patient.

Differential improvement in survival among patients with AIDS after the introduction of HAART.

We explored changes in the survival of patients with AIDS (PWA) according to the availability of antiretroviral drugs (1994-2002). We tested whether changes in the hazard ratio of progression to death (HR) have been homogeneous among various groups of PWA. We included 4158 PWA diagnosed in Paris, notified to the French National Surveillance Institute by 2002. Four calendar periods were defined: monotherapy (1994-95), bitherapy-HAART transition (1996), early HAART (1997-99), late HAART (2000-October 2002). HR were calculated with Cox models, including the calendar period, modelled as a time dependent covariate. Models were stratified by age, transmission category, CD4 cell count, and AIDS-defining illnesses (ADI) group. Cumulative survival at 60 months increased from 44.0% (before July 1996) to 75.6% (after July 1996) and median survival increased from 31.9 months to >76 months. Adjusted HR reached a minimum in the late HAART period (HR 0.22, 95% CI: 0.19-0.26). No difference in the decrease of the HR has been found by age. HR decreased and was marked during the late HAART period across all HIV transmission categories, including intravenous drug use. HR decreased significantly for all ADIs groups, including tumours. Among PWA diagnosed with tuberculosis, the HR decreased significantly only in the late HAART period. HR decrease was stronger for PWA with a CD4 cell count < or =200/mm(3). Substantial improvements in survival after the introduction of HAART were found for all PWA but varied by specific ADIs and the degree of immunosuppression.

Investigation of a nosocomial outbreak of extended-spectrum beta-lactamase VEB-1-producing isolates of Acinetobacter baumannii in a hospital setting.

A nosocomial outbreak of epidemiologically related VEB-1 extended-spectrum beta-lactamase-producing isolates of Acinetobacter baumannii occurred in 33 patients in an intensive care unit. A case-control study identified previous treatment with third-generation cephalosporins as the only risk factor for A. baumannii acquisition. Rationale for antibiotic use should be strengthened.

Short peripheral venous catheters: effect of evidence-based guidelines on insertion, maintenance and outcomes in a university hospital.

This study was designed to evaluate the impact of hospital-wide guidelines for short peripheral venous catheters (SPVC) insertion on the frequency of local catheter-related complications. In a 1051-bed Parisian university hospital, two observational, point prevalence surveys were undertaken in 1996 and in 1998, separated by implementation of written guidelines for SPVC insertion. The outcomes of SPVC insertion were defined as the presence or absence of local catheter-related complications (erythema, purulence around the insertion point, tenderness or induration along the cannulated vein). The proportion of polyurethane catheter materials used (56% vs. 81%, P<0.001), correct and sterile fixation (80% vs. 92%, P<0.05), non-movable catheters (92% vs. 98%, P=0.03) and insertion record (58% vs. 76%, P<0.01) increased between 1996 and 1998. The frequency of local catheter-related complications decreased (15% vs. 4%, P<0.01). Age >73 years [odds ratio (OR) 6.0, 95% confidence interval (CI) 1.28-28.05] was positively associated with local catheter-related complications, whereas duration of insertion (until 72 h) (OR 0.29, 95% CI 0.09-0.89) and the implementation of guidelines (OR 0.26, 95% CI 0.09-0.67) were negatively associated with local catheter-related complications. The implementation of guidelines was independently negatively associated with local catheter-related complications (OR 0.31, 95% CI 0.09-0.97). The results suggest that hospital guidelines for SPVC insertion can improve catheter care and significantly reduce local catheter-related complications.

Dermatoses associated with travel to Burkina Faso and diagnosed by means of teledermatology.

BACKGROUND: The pattern of dermatoses occurring in travellers to tropical areas is poorly documented. OBJECTIVES: To diagnose skin diseases in travellers to Burkina Faso by means of teledermatology; to assess the educational value of teledermatology for the local general practitioner (GP). METHODS: Patients (Westerners and Burkinabese nationals) were included in the study if they presented with a cutaneous disease to the GP based in Ouagadougou, Burkina Faso. Images of the skin lesions were acquired with a point-and-shoot digital camera and sent via the Internet, together with the clinical history. Diagnostic concordance between dermatologists in France and the GP in Ouagadougou was analysed as a simple proportion of agreement and 95% confidence interval. RESULTS: One hundred and twenty-four patients (M/F ratio 1.17; 80.6% Westerners) were included in the study. One hundred and thirty dermatoses were identified: 73 (56%) were of infectious origin, and 19 (15%) were related to eczematous dermatitis. The skin infections were mainly due to bacteria (18%), fungi (14%) or arthropods (13%). Parasitic dermatoses were observed only in Burkinabese nationals. Among Westerners, fungal dermatoses were observed only in long-term residents. The diagnostic agreement between the local GP and the remote dermatologists was 49% overall (95% confidence interval 41-58). Agreement between the GP and the dermatologists on the dermatological category improved significantly over time (P<0.05). CONCLUSIONS: Telemedecine can improve the management of cutaneous diseases among Western travellers. Most dermatoses observed in Western travellers to Burkina Faso are of infectious origin. Teledermatology has educational value for local GPs.

Failure of an ointment based on IR3535 (ethyl butylacetylaminopropionate) to prevent an outbreak of cercarial dermatitis during swimming races across Lake Annecy, France.

Cercarial dermatitis, a re-emerging disease world-wide, may affect those engaged in water sports. Many of those who swim in the annual cross-lake races at Annecy in France, for example, develop such dermatitis. In an attempt to see whether ethyl butylacetylaminopropionate (IR3535) would protect swimmers from the dermatitis, the exposed skin on the right side of each of 78 participants in the cross-lake races of 2001 was treated with IR3535-based ointment. When contacted by telephone during the week following the races, 64 (82%) of the subjects reported that they had developed cercarial dermatitis. Subjects with a past history of cercarial dermatitis were more likely to report an attack in 2001 than those who said that they had never had such dermatitis prior to 2001 (P=0.001). The skin lesions were scattered all over the body in 89% of the cases and limited to the left side of the body in 11%. Of the 63 cases who reported time of onset, 32 (51%) had noticed lesions within an hour of the race. The mean duration of clinical manifestations was 4.8 days (range=30 min-18 days). The clinical manifestations were significantly more severe in the subjects aged >16 years than in the younger subjects, although these two age-groups swam in separate races. Thirty-one of the affected subjects attempted to cure their dermatitis, using any of five different treatments. Overall, the results were disappointing, with the IR3535-based ointment, which had initially been developed as an insect repellent, appearing to offer little, if any, protection against cercarial dermatitis.