Management of an Acinetobacter baumannii outbreak in an intensive care unit.

INTRODUCTION: Acinetobacter baumannii is a ubiquitous pathogen resistant to desiccation and responsible for healthcare-associated infections (HAI), especially in intensive care units (ICU) where it is responsible for 5-10% of HAIs. An A. baumannii outbreak occurred in the ICU of the University Hospital of Angers, France. OBJECTIVES: To describe the A. baumannii outbreak and to evaluate the control measures taken. The secondary objective was to evaluate the impact of the electronic alert system on the incidence of multidrug resistance to antibiotics. METHODS: We performed a descriptive study of A. baumannii carriers during the outbreak. Case contacts and carriers were described using the epidemic curve and a case synopsis table. RESULTS: From August 2011 to September 2013, 49 patients presenting with an extended-spectrum beta-lactamase-producing A. baumannii infection were identified: thirty-four were colonized and 15 were infected. No death was due to the outbreak. Measures taken were: geographical and technical isolation of patients, dedicated team implementation, contact precaution implementation including hand hygiene measures, appropriate use of gloves, and reinforcement of bio-cleaning procedures. CONCLUSION: Some patients were re-admitted to hospital while still being carriers; this could explain epidemic peaks. The immersion mission of the hygiene nurse contributed to answering healthcare workers' queries and led to a better cooperation between the ICU and the hygiene team.

Tetanus associated with road accidents in the infectious diseases department of Point G University Hospital, Bamako, Mali.

The aim of this study was to describe the epidemiological, clinical, and prognostic aspects of tetanus associated with road accidents and to make recommendations. This observational study collected retrospective clinical data over a 9-year period about adults admitted for trismus and/or generalized or localized paroxysm after a road accident. The study included 25 patients, accounting for 22.12 % of all tetanus cases. Men were massively overrepresented (sex-ratio M/F: 24/1). The median age was 34 ± 8 years. In all, vaccination status was unknown for 4 patients and known to be negative for 21. Immunoprophylaxis was nonexistent in all cases. The generalized clinical form was dominant (96 %). Severity reached level III for 12 % of patients. The points of entry included open leg fractures (4 cases), head wounds (2), mucocutaneous wounds (14), and muscle contusions (5). The mean time to referral for tetanus was 8 ± 7 days, and the median hospital stay 9.08 ± 11 days. Patients were mostly residents of urban (56 %) and suburban areas (28 %) [P = 0.04]. Two cases were complicated by severe malaria. The mortality rate was 60 %, and 52 % of the deaths occurred within the first 72 hours after hospitalization. It is essential to promote serum therapy and tetanus immunization for patients after road accidents. Increasing the awareness of traditional healers of these treatments deserves consideration.

Impact of serodiagnosis on the management of Lyme borreliosis at Angers University Hospital.

INTRODUCTION: Lyme borreliosis (LB) is an emerging arthropod-borne disease the diagnosis of which is made on clinical and biological data. We assessed the Angers University Hospital physicians' management of LB, in case of positive serology, and estimated their compliance to European recommendations (EUCALB). METHODS: We retrospectively included 75 cases with positive ELISA serologies confirmed by Western-Blot, performed at the Angers University Hospital between 2008 and 2012. RESULTS AND DISCUSSION: There were 4 cases of early localized phase, 26 of early-disseminated phase (including 17 cases of neuroborreliosis), and one case of late phase. The curative management complied with EUCALB guidelines in 28 cases out of 31. CONCLUSION: Serology remains a reference diagnostic tool for LB, as long as the practitioner is aware of the main clinical and biological criteria.

Post-international adoption medical follow-up at the Angers university hospital between 2009 and 2012.

OBJECTIVE: The authors had for aim to describe infectious diseases in internationally adopted child at arrival in France. PATIENTS AND METHODS: We made a retrospective descriptive study of the children's files having undergone medical check-ups between 2009 and 2012. RESULTS: One hundred and eighty-two files were included: 80% of the children came from Africa, 15% from South America and the Caribbean, 3% from Asia, and 2% from Europe. Forty-three percent were diagnosed with tinea. HIV, hepatitis C, and syphilis blood tests were all negative. Six children presented with acute or chronic hepatitis B, another 5 children with acute hepatitis A. One blood test for cysticercosis was positive. Two children presented with malaria. 58% of the children carried an intestinal parasite; the most prevalent was Giardia duodenalis. Bacteriological stool culture was positive for 17 children, for 9 with an antibiotic resistant bacterium. Twenty-seven children had a positive virological stool culture, 2 for a poliovirus. CONCLUSION: A systematic infectious check-up should be performed for a child adopted internationally when he/she arrives in France. This allows diagnosing diseases requiring an emergency treatment, or asymptomatic but severe diseases when chronic. Some blood tests must be double-checked when the child arrives, because of possible false negative initial tests results in the country of origin. Screening, early treatment, and implementing prophylaxis can decrease the risk of transmission to relatives. It also allows monitoring the antimicrobial resistance of some pathogens and the reintroduction of the poliovirus in France.

[Non-neuromeningeal cryptococcosis in patients with AIDS in Bamako, Mali: 2 case reports]. / Cryptococcose extra-neuroméningée au cours du sida à Bamako, Mali (à propos de 2 observations).

Non-neuromeningeal cryptococcosis forms resulting from disseminated infection are rarely reported in African literature and are non-documented in Malian medical ward. We report two clinical observations. Case 1: a 26-year-old patient, carrying the HIV-1 infection, in which the clinical examination revealed skin lesions simulating molluscum contagiosum and functional impairment of the lower limbs. Radiography of the lumbar spine showed vertebral osteolysis on L4-L5. Cryptococcal research remained negative in the CSF but positive at histological examination of the skin lesions and in pathological products of lumbosacral drainage. The treatment with fluconazole and ARV led to a favorable outcome. Case 2: a 42-year-old patient, admitted for fever cough, known for his non-compliance to ARVs and in which the examination found a syndrome of pleural condensation and a painful swelling of the outer third of the right clavicle (around the acromio-clavicular joint). Paraclinical investigations concluded in osteolysis of the acromial end of the right clavicle and an image of the right lung with abundant effusion. Cryptococcal research was positive in the pleural effusion and in the product of aspiration of acromio-clavicular tumefaction, negative in CSF. It seems important to think of a cryptococcal etiology even in the absence of clinical meningeal signs in front of any cutaneous sign and any fluctuating swelling in HIV+ patient.

[Malian first observation of disseminated African histoplasmosis with predominant bone localizations in an HIV-negative child in Bamako (Mali). Review of the literature]. / Première observation malienne d'histoplasmose africaine disséminée à prédominance osseuse chez un enfant VIH négatif. Revue de la littérature.

Endemic deep fungal infections are still under recognised diseases in daily medical practice because of their rarity in sub-Saharan area. The African histoplasmosis Histoplasma capsulatum var. duboisii (H. capsulatum duboisii) is the most frequent variety described in Mali through limited studies in adult patients, since the first case described by Catanei and Kervran (1945). Our case report is a disseminated histoplasmosis in a young 6-year-old african child. He was male and rural. The infectious localisations were mucosae, skin, lymphnodes, urinary tract and bones. Evolution has been marred by an episode of worsening of symptoms despite initial clinical improvement with ketoconazole. After healing of mucocutaneous lesions, we noticed a limitation of ampliation of both wrists. The radiographic bone lesions were lysis of the right lower end of the right radius and cubitus and fragmentation of cubital epiphysis of the same arm. Lacunes were present on the fifth right finger in metatarsus and phalanx; lacune and blowing aspect of the second phalanx of the left third finger was noted. The disseminated form of African histoplasmosis may occur in HIV-negative subject. The prognosis depends on early diagnosis and administration of appropriate and well-conducted therapy.

[Neuromeningeal cryptococcosis in Mali]. / La cryptococcose neuro-méningée au Mali.

Cryptococcal meningitis is the most common fatal central nervous system infection in AIDS patients in Sub-Saharan Africa. The purpose of this prospective study conducted from March 2003 to February 2004 in the internal medicine and infectious diseases departments of the Point G University Hospital Center was to investigate the clinical, prognostic and epidemiological profile of Cryptococcus neoformans infection in patients hospitalized for brain and meningeale infection (BMI). Diagnosis of neuromeningeal cryptococcosis (NMC) was based on positive identification of Cryptococcus by direct exam of the cebrospinal fluid (CSF) after India ink staining and/or culture on Sabouraud medium without actidione. During the study period, a total of 569 patients were hospitalized including 235 (41.3%) with HIV infection. Overall C. neoformans was identified in 14 patients. Median patient age was 39 +/- 8 years. There was a male preponderance with a sex ratio of 1.8 (9 men/5 women). Patients with BMI were HIV-positive in 85.7% of cases (n=12) and HIV-negative in 14.3% (n=2). The overall and HIV-specific prevalence of BMI was 2.5% and 5.1% respectively. The CD4 lymphocyte count was between I and 49 cells/mm3 in 64.3% of cases. The main clinical symptoms were cephalea in 85.7% of cases, altered consciousness in 50% and nausea/vomiting in 35.7%. Neurological manifestations (hemiparesis and cranial nerve deficit) were noted in 14.3%. HIV infection is the main purveyor of NMC in Mali. The actual incidence of cryptococcosis is unclear due to the poor sensitivity of diagnostic techniques. This study highlights diagnostic difficulties related to clinical polymorphism and poor technical facilities. Agglutination testing of blood and CSF is recommended, but mortality remains.

[Buruli ulcer or Mycobacterium ulcerans infection]. / L'ulcère de Buruli ou infection à Mycobacterium ulcerans.

Buruli ulcer is a severe necrotizing cutaneous infection due to Mycobacterium ulcerans. The disease is currently expanding, especially in West Africa, and the WHO is supporting a vast research program to better understand the modes of transmission, to develop diagnostic methods, and to define specific treatment protocols. The disease transmission could be linked to environment and especially water striders. After M. ulcerans inoculation, cutaneous lesions appear, as broad painless ulcers, and thus ignored by patients. The production of mycolactone, a toxin, only virulence factor known at this time, is responsible for the cytotoxic effect on skin tissues. Complications may occur, especially super infections and more rarely bone involvement responsible for osteomyelitis. The prognosis is usually functional with sometimes severe sequels, and skin and tendinous retraction as well as amputation are frequent. The diagnosis is usually made on PCR but this is difficult in developing countries, direct examination is not very reliable, and culture is long and difficult. The disease often remains ignored and undiagnosed, leading to evolved clinical presentations and sequels. The treatment is not defined yet. It is often surgical exeresis with skin graft, not always efficient. Antibiotic combination protocols are under evaluation.

Venous thrombosis in immunocompetent patients with acute cytomegalovirus infection: a complication that may be underestimated.

In the present study, we retrospectively studied clinical and laboratory findings associated with cytomegalovirus (CMV) infection in immunocompetent patients. We focused on severe CMV infection. Among 38 patients, five had a severe form of infection: one had meningitis, one had symptomatic thrombocytopenia and three had venous thromboses with pulmonary embolism, a rarely described complication. CMV-induced thrombosis has been reported in immunocompromised patients such as transplant recipients and patients with AIDS. Recent case reports have also described thrombotic phenomena in immunocompetent patients with CMV infection. Our study suggests that venous thrombosis during acute CMV infection is an underestimated complication.

[Travelers' knowledge of vaccines. A survey including 400 people having consulted an international vaccination center]. / Connaissances des voyageurs à propos des vaccins. Enquête auprès de 400 personnes consultantes d'un centre de vaccinations internationales.

UNLABELLED: The authors conducted a survey in an international vaccination centre. The aim of the study was to assess the travelers' knowledge of vaccines and to check their health record to determine the vaccination rate. We used a self-administered questionnaire and added vaccination certificates to the document. RESULTS: Most of the travelers knew about complications due to vaccinations, but ignored their contraindications. Knowledge decreased over the age of thirty. The travelers agreed with antihepatitis B vaccination and only 10% mentioned the risk of multiple sclerosis. The list of compulsory vaccinations and their schedule were well-known but some of the travelers ignored their vaccine status and said they trusted their general practitioner. Only 40% of people over 20years of age were able to present their national or international vaccination certificate, a reason for underestimating the vaccination rate. CONCLUSION: It would be necessary to have a "World Health Organization" type vaccination certificate available for all French people over 20years of age, while improving the smart health card and training practitioners to better inform their patients about vaccinations.

[Neuromeningeal cryptococcosis in non-HIV patients to CHU ward of Point G in Bamako (Mali): 3 case report]. / Cryptococcose neuroméningée chez des patients VIH négatif au CHU du Point G de Bamako (Mali): à propos de trois observations cliniques.

We report 3 clinical observations of neuromeningeal cryptococcosis which occurred without any immunodepression related to HIV infection. Our patients were male. They did not present any particular medical history indicating a diagnosis of cryptococcosis. Nevertheless we found a professional exposure to the risk of inhalation of C. neoformans capsules. The diagnosis was based on presence of encapsulated yeast of Cryptococcus in the direct exam by China ink and culture on Sabouraud medium. CD4 lymphocytic count was done in two patients (case 1:899 cells/mm3; case 2:347 cells/mm3). Idiopathic lymphocytopenia was noted in one case. Co-morbidity of 5. pneumoniae meningitis was reported in one patient (case 3). Treatment was based on injectable amphotericin B in monotherapy (case 1), followed by perfusion of fluconazole cure (case 2). Case 3 was treated by perfusion of amphotericin B associated with ceftriaxone (case 2). No secondary prophylactic treatment was administered. Evolution was favorable after follow-up of 5 years (case 1) and of 4 years (case 2). The third patient died during hospitalization.

[Breast abscess with Salmonella typhi and review of the literature]. / Un abcès du sein à Salmonella typhi et revue de la littérature.

We report the case of a 54-year-old woman who presented with breast abscess, which appeared through a common alimentary toxi-infection with Salmonella Typhi, infection, which implied twelve patients having attended the same restaurant. With around hundred native cases a year in France, typhoid fever is not a very frequent toxi-infection. Among the known extra-intestinal manifestations of Salmonella infections, the breast abscess remains rare and the literature revealed less than ten published cases, including some revealed the disease. In our observation, the imputability of S. Typhi was retained based on the chronology of the clinical signs, specific treatments, and the successful outcome under antibiotherapy, in spite of the negativity of the breast abscess bacteriological samples. We also analyze rare cases of breast abscess due to S. Typhi found in the literature.

Acute cytomegalovirus infection and venous thrombosis: role of antiphospholipid antibodies.

Cytomegalovirus (CMV)-induced thrombosis has been reported in immunocompromised patients, such as transplant recipients and patients with AIDS. Recent cases also describe thrombotic phenomena in immunocompetent patients with CMV infection. Various mechanisms may explain the role of CMV in thrombosis: this virus can damage endothelial cells, activate coagulation factors, and induce production of antiphospholipid (aPL) antibodies. We present a case report of a previously healthy white woman with a pulmonary embolism associated with CMV infection and the presence of aPL antibodies, and we discuss the role of the aPL antibodies associated with CMV infection in the pathogenesis of thrombosis.

[Association of urinary tract infections and HIV infection in an internal medicine ward of Hospital of Point G-Bamako-Mali]. / L'association infection urinairie st infection VIH a dans le service de medicine interne de l'Hopital du Point G-Bamako-Mali.

We gathered 14 clinical observations of urinary track infections in AIDS patients in Internal Medicine wards from August 1, 1998 to July 31, 1999. Urinary track infection and HIV were both present in 1.75% of 797 hospitalized patients. The specific prevalence was 14.43% among AIDS patients. The sex ratio (female/male) was 1.33. The mean age of patients was 37.2 years with ranges between 25 years and 59 years. Urinary symptoms were discret. Urinary tract infection was primarily evidenced by urine leucocytes > 10(4) organism/ml and a bacteriuria > 10(5) colony-forming units/ml. The main pathogenswere Escherichia coli (42.85%), Klebsiella pneumoniae (28.57%), Colibacilles app. (21.42%) and Enterobacter cloacae (7.14%). All isolated germs were sensible to the gentamicin, to the amikacin, to the nalidixic acid, to the cefoxitine, to the ceftazidime to the cefotaxime and the ciprofloxacin. Cephalosporin of 3rd generation, aminoglycosides, and fluoroquinolone can be used like treatment of first line in urinary tract infection suspicion case in Bamako. Our patients were highly immunosuppressed with the majority of them being in class IV C of CDC of Atlanta (90%) and CD4 count constantly bellow 200 cells/mm3. The main opportunistic affections were non bacilar bacterial pneumopathies (28.57%), oesophagal mycosis (71.42%), the association of cerebral toxoplasmosis and pulmonary tuberculosis (35.71%). All urinary infections were cured by mean of 5 days of treatment. Very few recidivism was found (1 case).