Epidemiology and clinical characteristics of Klebsiella spp. meningitis in France.

OBJECTIVES: To describe the epidemiology of Klebsiella spp. meningitis in France with respect to clinical and bacteriological data. METHODS: We performed a four-year multicenter, retrospective, observational study. The primary objective was to provide a clinical description of patients with Klebsiella spp. meningitis. Secondary objectives were to compare community-acquired meningitis and healthcare-associated meningitis and to analyze factors associated with mortality. RESULTS: We enrolled 131 patients with Klebsiella spp. meningitis. Eighty-two (62.6%) infections were reported following neurosurgery. Twenty-eight strains (21.4%) were resistant to third-generation cephalosporins (3GC). The median [IQR] cellularity was 980/mm3 [116-5550], the median protein level was 5.67 [1.62-9] g/L and the median CSF glucose level was 2.5 [0-3.4] mmol/L. The in-hospital mortality rate was 23.6%. Community-acquired meningitis isolates were more frequently susceptible to 3GC than isolates from healthcare-associated meningitis (89.2% versus 72%; P=0.04). Comorbidities reported for patients with community-acquired meningitis were mainly diabetes mellitus and liver cirrhosis. In multivariate analysis, focal neurological disorder at the time of diagnosis was the only factor associated with in-hospital mortality (P=0.01). CONCLUSIONS: Purulent meningitis caused by Klebsiella spp. needs to be considered in patients with community-acquired meningitis and preexisting conditions, as well as in case of meningitis following neurosurgical procedures.

Be careful about MICs to amoxicillin for patients with Streptococci-related infective endocarditis.

BACKGROUND: A variety of microorganisms can cause infective endocarditis (IE), with Staphylococci and Streptococci accounting for the majority of cases. Streptococci are a common cause of community-acquired IE but few studies have focused on this subgroup of endocarditis. METHODS: A retrospective multicentre study was conducted between 2012 and 2017 in 12 hospital centres in France. Data were extracted from the local diagnosis-related group database and matched with microbiological results. After identification, the records were retrospectively analysed. RESULTS: A total of 414 patients with streptococcal endocarditis were included. The patients were predominantly male (72.8%) and the median age was 73.2 years (interquartile range [IQR] 61.3-80.9). The majority of patients (70.6%) had native valve endocarditis. Embolic complications were seen in 38.8% of patients. Viridans group Streptococci (VGS) and bovis-equinus group Streptococci (BGS) accounted for 52.4% and 34.5% of isolated strains, respectively. Minimum inhibitory concentrations (MICs) of amoxicillin were <0.125, 0.125-2 and >2 mg/L for 59.6%, 27% and 1% of isolates, respectively. In-hospital mortality for patients with Streptococci-related IE was 17.8%. In multivariate analysis, the only factor associated with in-hospital mortality was MIC for amoxicillin between 0.25 and 2 mg/L (P = 0.04; OR = 2.23 [95% confidence interval (CI) 1.03-4.88]) whereas performance of cardiac surgery for IE was a protective factor (P = 0.001, OR = 0.23 [95% CI 0.1-0.56]). CONCLUSIONS: IE remains a serious and deadly disease despite recent advances in diagnosis and treatment. Adaptation of antibiotic doses to MICs for amoxicillin and surgery may improve patient outcome.

[Isolated hemorrhagic pleurisy due to Panton-Valentine leukocidin-positive Staphylococcus aureus]. / Pleurésie hémorragique isolée à Staphylococcus aureus à leucocidine de Panton-Valentine.

Panton-Valentine leucocidin is a major virulence factor produced by some strains of Staphylococcus aureus (SA-PVL). The best-described invasive infection is a necrotizing haemorrhagic pneumonia. Pleural effusion is not uncommon but is always associated with a parenchymal lesion. Here, we report a case of haemorrhagic pleurisy attributable to isolated SA-PVL.

Staphylococcus Aureus Carriage in French Athletes at Risk of CA-MRSA Infection: a Prospective, Cross-sectional Study.

BACKGROUND: Staphylococcus aureus (SA) is a leading cause of infectious diseases in sports teams. In recent decades, community-associated SA (CA-SA) strains have emerged worldwide and have been responsible for outbreaks in sports teams. There are very few data on the prevalence of these strains in France, and none on the carriage among athletes. METHODS: We conducted a cross-sectional study to determine the SA carriage proportion among athletes practicing sports at risk for CA-SA infection in a French county, and determined the methicillin-resistant and/or CA-SA proportion. We also analyzed SA carriage according to risks factors and studied the SA clonality in a sample of our population. RESULTS: We included 300 athletes; SA carriage proportion was 61% (n = 183) and one was MRSA carrier (0.33%). The MRSA strain belonged to the clonal complex ST5. None of the strain produced Panton Valentine Leucocidin, and we did not find clonal distribution within the teams. Interestingly, we found a high throat-only carriage (n = 57), 31.1% of the SA carriers. CONCLUSION: We found a high SA carriage with a local epidemiology quite different than that reported in a similar population in the USA. Further studies on SA carriage should include throat sampling. TRIAL REGISTRATION: The approved protocol was registered on ClinicalTrial.gov , NCT01148485.

Molecular quantification of bacteria from respiratory samples in patients with suspected ventilator-associated pneumonia.

Ventilator-associated pneumonia (VAP) is the most common infection in critically ill patients. Initial antibiotic therapy is often broad spectrum, which promotes antibiotic resistance so new techniques are under investigation to obtain early microbiological identification and quantification. This trial compares the performance of a new real-time quantitative molecular-based method with conventional culture in patients with suspected VAP. Patients with suspected VAP who were ventilated for at least 48 h were eligible. An endotracheal aspirate (ETA) and a bronchoalveolar lavage (BAL) were performed at each suspected VAP episode. Both samples were analysed by conventional culture and molecular analysis. For the latter, bacterial DNA was extracted from each sample and real-time PCR were run. In all, 120 patients were finally included; 76% (91) were men; median age was 65 years, and clinical pulmonary infection score was ≥6 for 73.5% (86) of patients. A total of 120 BAL and 103 ETA could be processed and culture results above the agreed threshold were obtained for 75.0% (90/120) of BAL and 60.2% (62/103) of ETA. The main isolated bacteria were Staphylococcus aureus, Pseudomonas aeruginosa and Haemophilus influenzae. Performance was 89.2% (83.2%-93.6%) sensitivity and 97.1% (96.1%-97.9%) specificity for BAL samples and 71.8% (61.0%-81.0%) sensitivity and 96.6% (95.4%-97.5%) specificity for ETA samples when the molecular biology method was compared with conventional culture method (chosen as reference standard). This new molecular method can provide reliable quantitative microbiological data and is highly specific with good sensitivity for common pathogens involved in VAP.

Fusobacterium nucleatum infections: clinical spectrum and bacteriological features of 78 cases.

PURPOSE: Few series describe the clinical spectrum of Fusobacterium spp. infections. Among them, fewer discuss F. nucleatum, even though there are many clinical cases. METHODS: We performed a retrospective study over 8 years (from 2007 to 2014) in Limoges University Hospital, France, to assess clinical and bacteriological aspects of infections due to F. nucleatum. RESULTS: Eighty-one patients with F. nucleatum positive cultures were included in this study, irrespective of sample origin. Abscesses (n = 43), bacteraemia (n = 18) and bone infections (n = 8) were the most common types of infections, Abscesses were found in various organs (mostly skin, brain, pleura, liver). Co-morbidities were found in 38 patients (47 %) with neoplasia, diabetes, and alcoholism and history of smoking. There were more neoplasms in patients with bacteraemia than in patients with abscesses (p = 0.007). In 51 cases (65.4 %), infection was polymicrobial, either during bacteraemia or abscesses. Main associations were with Streptococcus spp., Peptostreptococcus spp. and/or Prevotella spp. The sources of infection, when found, were either dental or gastrointestinal. All isolates were susceptible to penicillin, clindamycin and metronidazole. CONCLUSIONS: Infections involving F. nucleatum are uncommon and potentially severe, with many abscesses requiring surgery. Bacteraemia was mainly associated with co-morbidities such as cancer. Polymicrobial infections were very common and there is probably interaction and/or synergy between F. nucleatum and some other commensal bacteria to cause infections and abscesses.

Campylobacter fetus infections.

BACKGROUND: Campylobacter fetus infections usually occur in immunodepressed patients or patients presenting with diabetes mellitus or cancer. They rarely cause diarrhea but frequently cause bacteremia or vascular diseases. The therapeutic management is not well codified and fluoroquinolone resistance is continuously increasing. METHODS: We conducted a retrospective study of C. fetus infections from January 2007 to August 2013 at the Limoges teaching hospital. The infections were defined by at least 1 bacteriological sample positive for C. fetus. RESULTS: Twenty patients were included (15 men), with an average age of 73 years (43-91). Sixteen presented with cancer, 12 with solid cancer including 9 of the urinary tract, and 9 patients with hematologic diseases. Five patients presented with diabetes mellitus, 9 with isolated bacteremia, 3 with cellulitis, and 3 with septic arthritis. The diagnosis was made by blood cultures for 17 patients. Twenty percent of the isolates were resistant to amoxicillin and 30% to fluoroquinolones. The therapeutic regimens and the treatment duration were quite different. The outcome was unfavorable for 3 patients whose implanted port had not been removed and 1 with subdural hematoma infection. 1 patient died. CONCLUSIONS: C. fetus infection occurs in case of underlying diseases, most frequently promoting urinary tract cancer. Fluoroquinolones must not be used without susceptibility testing and catheters should be removed.

An antibiotic-resistant class 3 integron in an Enterobacter cloacae isolate from hospital effluent.

Hospital effluents are involved in dissemination of antibiotic-resistant integrons. We describe here a new class 3 integron, In3-5, detected in an Enterobacter cloacae isolate retrieved from a random French hospital effluent sample collected in 2009. In3-5 carries two gene cassettes: the new blaOXA -256 and an aac(6')-Ib variant, respectively conferring resistance to ß-lactams and aminoglycosides. In3-5 is located on an IncQ-like backbone plasmid. Class 3 integrons could thus be involved in the dissemination of antibiotic resistance in both clinical settings and the environment, and could participate in the exchange of antibiotic-resistance genes between these two ecosystems.

Lyme endocarditis.

Lyme borreliosis is a common tick-borne disease with a wide variety of clinical manifestations. Cardiac involvement has been reported during both the acute phase (atrioventricular block, pericarditis) and the chronic stage (dilated cardiomyopathy), but is rare (<5%). Here we describe the first case of Borrelia afzelii Lyme endocarditis, in a 61-year-old man living in an endemic area of France. The diagnosis was confirmed by detection of B. afzelii DNA in the mitral valve by specific real-time PCR. He was treated empirically with amoxicillin for 6 weeks and remains well 12 months later.

Bordetella holmesii bacteremia in a renal transplant recipient: emergence of a new pathogen.

Bordetella holmesii is a gram-negative rod that was initially identified in 1995. It causes bacteremia, pneumonia, and endocarditis mostly in patients with anatomical or functional asplenia. We report here, to the best of our knowledge, the first case of B. holmesii bacteremia in a renal transplant recipient following rituximab therapy for recurrence of membranoproliferative glomerulonephritis.

[Chronic subdural hematoma infected by Campylobacter fetus: case report]. / Infection d'hématome sous-dural chronique à Campylobacter fetus : à propos d'un cas.

We report here a rare case of chronic subdural hematoma infected by Campylobacter fetus in a 86-year-old woman. She was admitted for confusion and disorientation in a context of high fever and diarrhoea. After two surgeries, the evolution was finally good with a combination of antibiotics (amoxicillin and clindamycin). Chronic subdural hematoma is a potential site for bacterial infection. Our case suggests that C. fetus infection should be suspected in elderly patients presenting with fever and enteritis. The frequency of such cases may be underestimated, due to the difficult diagnosis of C. fetus. It is also suspected that C. fetus could play a role in the recurrence of hematoma, because of its vessel tropism.

Quantitative multiplex real-time PCR for detecting class 1, 2 and 3 integrons.

OBJECTIVES: Integrons are bacterial genetic elements that can capture and express genes contained in mobile cassettes. Integrons have been described worldwide in Gram-negative bacteria and are a marker of antibiotic resistance. We developed a specific and sensitive Taqman probe-based real-time PCR method with three different primer-probe pairs for simultaneous detection of the three main classes of integron. METHODS: Sensitivity was assessed by testing mixtures of the three targets (intI integrase genes of each integron class) ranging from 10 to 10(8) copies. Specificity was determined with a panel of integron-containing and integron-free control strains. The method was then applied to clinical samples. RESULTS: The PCR method was specific and had a sensitivity of 10(2) copies for all three genes, regardless of their respective quantities. The method was quantitative from 10(3) to 10(7) copies, and was able to detect integrons directly in biological samples. CONCLUSIONS: We have developed a rapid, quantitative, specific and sensitive method that could prove useful for initial screening of Gram-negative isolates, or clinical samples, for likely multidrug resistance.

[Perilunar dislocations of the carpus. Value of surgical treatment]. / Luxations périlunaires du carpe. Intérêt du traitement chirurgical.

Between 1980 and 1990, 60 patients presenting with 62 peri-lunar dislocations of the carpus have been surgically treated. One case was a subluxation of the scaphoid and 61 were posterior perilunar dislocations, among them were 32 grade I, 23 grade II, 4 grade III, 2 unknown grade according to the Witvoët and Allieu scale. In 36 cases the scaphoid was fractured in 5 were associated a fracture of the scaphoid and a scapho-lunar dislocation. 48 cases have been reviewed after a 31 month follow-up average. The result was satisfactory in 83 per cent of these cases, unsatisfactory results being observed in cases of delayed surgery or incomplete reduction. In 36 cases a dynamic radiological examination was available after a 36 month follow-up average. 27 wrists were stable, 9 were not (7 D.I.S.I., 2 V.I.S.I.) 8 of these were related to unsatisfactory reductions. Diagnosis was delayed in 10 cases which ended with less satisfactory results. The authors think that conservative treatment is not adequate, they propose different surgical procedures according to the possible association of a fracture of the scaphoid.

[Flap coverage of open fractures of the leg by high energy]. / Recouvrement par lambeau des fractures ouvertes du segment jambier par haute énergie.

This retrospective study has been made on 23 patients with open fractures of the tibia, type III or IV in Byrd's classification. Ten of these patients showed an aggravation of the soft tissue lesions after the initial treatment. At the beginning of our study, 22 patients had already achieved union and 1 had been amputated. All the patients have had a covering by one or several flaps. The analysis of the results concerns different types of fracture: the time interval between the accident and the first covering by flap, the type of the flap, the length of the hospitalization, the complications; the recovery of the function. First covering by flap has been made in the acute phase in 6 cases, in the sub-acute phase in 12 cases and in the chronic phase in 5 cases. The results of the patients covered in the acute phase were better, than those of the patients covered by flap in the sub-acute or the chronic phase. Early covering of the open fractures of the tibia is recommended. A classification of the open fractures, derived from the classification of Byrd is suggested. We included a type "O" for the fractures with potential aggravation. Different types of flap of the leg have been described. Our behaviour in high energy fractures of the tibia is determined by the necessity to look for a potential fracture aggravation and by the intention of an early covering of the open fracture.

[Cross-forearm replantation in bilateral amputation]. / Replantation croisée d'avant-bras dans une amputation bilatérale.

We report the case of a 27-year-old patient who sustained a traumatic amputation of his 4 limbs. For the right upper limb, the site of amputation was at the level of the upper third of the forearm. For the left upper limb, the site of amputation was at the level of the Cower third of the forearm. In both cases, the loss of soft tissue was so extensive that hand replantation was impossible in the initial position. In such an unusual case, replantation of the right hand to the left side was attempted in this young patient. Osteosynthesis of the radius to the ulna in supination was performed, and arteries, veins, nerves and tendons were repaired. The other segments of amputated limbs were debrided and cleaned. Within a year, protective sensibility was restored in the replanted hand, but intrinsic muscles were paralysed. Secondarily, transfer of thumb opposition and capsulorrhaphy at the level of the metacarpophalangeal joints of long fingers were performed in order to provide a useful key-grip between the three first fingers.