Outcome of patients with diabetes with negative percutaneous bone biopsy performed for suspicion of osteomyelitis of the foot.

AIMS: To assess the outcome of patients with diabetes with suspicion of osteomyelitis of the foot who had undergone a percutaneous bone biopsy that yielded negative microbiological results, with focus on the occurrence of osteomyelitis at the biopsied site. METHODS: Medical charts of adult patients with diabetes with a negative percutaneous bone biopsy were reviewed. Patients' outcome was evaluated at least 2 years after the initial bone biopsy according to wound healing, the results of a new bone biopsy and bone imaging evaluation when applicable. RESULTS: From January 2001 to January 2008, 41 patients with diabetes (30 men/11 women; mean age 58.1 ± 9.6 years; mean diabetes duration 15.8 ± 6.7 years) met study criteria. Osteomyelitis was suspected based on combined clinical and imaging diagnostic criteria. On follow-up at a mean duration of 41.2 ± 22.5 months post-bone biopsy, 16 patients had complete wound healing (39.0%). Of the 25 other patients, 15 had a new bone biopsy performed, six of which yielded positive microbiological results, and among the 10 patients who neither healed nor underwent bone biopsy, comparative radiography of the foot showed a stable aspect of the biopsied site in six of them, for whom the data were available. Finally, osteomyelitis of the foot at the site where the initial bone biopsy had been performed was confirmed during follow-up in six patients (14.6%) and was suspected in four additional patients (9.7%). CONCLUSIONS: The results of the present study suggest that, of patients with diabetes with the suspicion of osteomylelitis and a negative percutaneous bone biopsy, only one out of four will develop osteomyelitis within 2 years of the biopsy.

Safety of prolonged high-dose levofloxacin therapy for bone infections.

The records of 84 patients with bone infections treated with high-dose levofloxacin (i.e. 0.75-1g daily) for more than 4 weeks were reviewed. Patients were given either 500 mg b.i.d. throughout the treatment period [Group 1 (n=41)], 500 mg b.i.d. for 3 weeks and then 750 mg q.d. [Group 2 (n=21)] or 750 mg q.d. for the whole treatment period [Group 3 (n=22)]. All patients had combined therapy, including levofloxacin-rifampin in 62 cases (73.8%), for an average duration of 13.7 weeks. Muscular pain and/or tendonitis were reported in 19 patients (22.6%) which affected more patients in Groups 1 and 2 than in Group 3 (14/41 and 5/21 vs. 0/22; p=0.01 and 0.001, respectively). A dosage of 750 mg q.d. may be warranted for prolonged high-dose levofloxacin treatment in patients with bone infections rather than 500 mg b.i.d. for the entire duration of treatment, or for the first 3 weeks.

[Are the principles of treatment of chronic osteitis applicable to the diabetic foot?]. / Les principes du traitement de l'ostéite chronique sont-ils applicables au pied diabétique?

OBJECTIVE: The interest of the management of bone infections in the diabetic foot, inspired by the recommendations for the treatment of chronic osteitis, was assessed in this study. METHODS: Twenty bone infections in 17 diabetic patients with moderate to mild infections of the feet were confirmed by the results of X-ray and/or scintigraphic studies and bone surgery biopsy cultures revealing one or more bacteria sensitive to standard osteitis treatment (rifampicine + fluoroquinolone). The patients had received this treatment per os for a median duration of 6 months (3 to 10 months). Clinical follow-up was carried out during a consultation at 1, 3 and 6 months during treatment and then by telephone every six months after the end of treatment. Clinical success was defined as the disappearance of any local sign of infection and by the absence of relapse during the post-treatment follow-up period. The evolution of the bone infection was also assessed by the results of a control conducted 3 to 6 months after initiation of the antibiotic treatment. RESULTS: At the end of the treatment, all signs of infection had disappeared in 15/17 patients (88.2%) and no relapse had occurred in 14 (82.3%) patients at the end of a median post-treatment period of 22 months (12 to 41 months). Resection of necrotic bone was performed at the same time as the bone biopsy in 2 patients. The median duration of hospitalisation was of 14 days (3 to 53 days). During the study, a multi-resistant germ was isolated in 4 patients (1 Pseudomonas aeruginosa, 3 Staphylococcus aureus). During the post-treatment follow-up, 3 patients dies from causes unrelated to the infection treated. No serious adverse event was reported during the study. DISCUSSION: The results of this pilot study support the rationale of applying the treatment regimens of chronic osteitis to diabetic lesions of the feet, but are only applicable to comparable patients presenting with non-severe lesions of the feet. Moreover, the use of antibiotics with potent selection of resistance such as rifampicine and fluoroquinolone, requires that bone biopsies be taken, which is not easy in all the diabetic foot care centres. We are presently conducting a study to identify the sub-populations of diabetic patients who could benefit from such treatment.

Characteristics and prognosis in patients with prosthetic vascular graft infection: a prospective observational cohort study.

Prosthetic vascular graft infection (PVGI) is a devastating complication, with a mortality rate of up to 75%, which is especially caused by aortic graft infection. The purpose of this study was to evaluate factors associated with in-hospital mortality of patients with definite graft infection, and with long-term outcome. We reviewed medical records of 85 patients treated for PVGIs defined by positive bacterial culture of intraoperative specimens or blood samples, and/or clinical, biological and radiological signs of infection. In-hospital patient mortality was defined as any death occurring during the initial treatment of the graft infection. Cure was defined as the absence of evidence of relapsing infection during long-term follow-up (≥1 year). Eighty-five patients (54 aortic and 31 limb graft infections) treated by surgical debridement and removal of the infected prosthesis (n=41), surgical debridement without removal of prosthesis (n=34) or antimicrobial treatment without surgery (n=10) were studied. The only microbiological difference observed between patients with early (occurring within 4 months after surgery) vs. late PVGI and between those with aortic vs. limb PVGI was the incidence of PVGI caused by Staphylococcus aureus, which was greater in patients with limb PVGI. Overall cure was observed in 93.2% of 59 patients with a follow-up of a minimum of 1 year. Overall in-hospital mortality was 16.5% (n=14). Two variables were independently associated with mortality: age >70 years (OR 9.1, 95% CI 1.83-45.43, p 0.007) and aortic graft infection (OR 5.6, 95% CI 1.1-28.7, p 0.037).

[Cluster of indigenous typhoid fever cases in a French city]. / Cas groupés de fièvre typhoïde autochtone dans une agglomération française.

BACKGROUND: A cluster of indigenous typhoid fever cases in the greater Lille area, in January 2009, triggered investigations to identify the contamination source and to optimize care for infected individuals. METHODS: A case was defined as a person, living in the greater Lille area of, having presented with symptoms of typhoid fever, from January to March 2009. RESULTS: Sixteen cases of typhoid fever were identified between January 23 and March 22, 2009. Patients, none of whom had travelled, had all participated in a common meal on January 10, 2009. A woman, who helped prepare the meal and who had previously stayed in an endemic zone, was detected as the asymptomatic carrier of Salmonella Typhi. CONCLUSION: In France, although typhoid fever remains essentially an imported disease, there is a risk of indigenous epidemic and its diagnosis can be suggested for individuals who have not travelled. The features of this cluster illustrate the importance of respecting basic rules of hygiene in catering.

[Compliance to the antibiotic committee guidelines in Tourcoing Hospital]. / Evaluation du respect des choix de molécules recommandées par le guide d'antibiothérapie de l'adulte du centre hospitalier de Tourcoing.

AIMS OF THE STUDY: We evaluated the compliance to the antibiotic committee guidelines of Tourcoing Hospital. METHODS: A national nosocomial infections prevalence study was conducted in June 2006. We collected additional data on the name and indication of prescribed antibiotics compared to recommended drugs in our therapeutic guidelines. Endpoints were antibiotic indication, compliance to local guidelines, unjustified combination therapy and deescalation therapy if possible. Situations non included in the guidelines were evaluated on a case to case basis after discussion with the prescribing physician. Pediatric (N=5) or prophylaxis (N=4) prescriptions were not analysed. RESULTS: Antibiotics were used in 97/669 (14.5%) patients including 32% in acute care, 11% in rehab and 0,9% in long term care. Drugs recommended in the guidelines were used in 63 cases (60.5%) including 56.3% first line and 4.2% justified second line therapy. When including situations not included in the guidelines and judged as correct, compliance reached 64.9%. The 41 variations from guidelines observed in 34 patients concerned: molecule choice (N=12), lack of antibiotic indication (N=12), unjustified combination therapy (N=12), drug choice in combination therapy (N=5), lack of deescalation (N=1). Lower respiratory tract (N=12) and urinary tract (N=7) infections as well as fluoroquinolones (N=12) were the most frequent deviations from guidelines. CONCLUSION: Compliance rate is encouraging. This study pinpoints specific targets for future interventions.

[ParaSight F in the diagnosis of Plasmodium falciparum malaria]. / Apport du ParaSight F dans le diagnostic du paludisme à Plasmodium falciparum.

The ParaSight F is a new diagnostic test for Plasmodium falciparum infections and is based on the detection of a trophozoite-derived antigen, the histidine rich protein II (HRP-II). To assess the usefulness of this test, we conducted a prospective study and analyzed 62 blood specimens from 38 patients, using thin blood films, thick blood films and the ParaSight F test. Compared to thick blood film, on samples taken before and during treatment, the ParaSight F test had 86.4% sensitivity and 100% specificity. In 31.5% of P. falciparum infected patients, parasitemia was lower than 1 parasite/1000 red blood cells, with all specimens being positive by the ParaSight F test. In 15 cases, specimens were negative by thin blood film, but were positive by thick blood film and by the ParaSight F test. Two patients had, after their treatment was started, positive results by ParaSight F and negative results by thick blood film. Cross-reactivity occurred neither with other Plasmodium species, nor in cases of severe inflammatory syndrome. Persistence of antigenemia was monitored in 14 patients receiving quinine. At day five of treatment, antigenemia persisted in seven patients. In conclusion, the ParaSight F test does not allow following up the efficacy of treatment, identifying other Plasmodium species, or assessing parasitemia. However, because this test is easy to perform and has good sensitivity and specificity, it is a useful tool in emergent context, in cases of parasitemia lower than the thin blood film threshold, and in cases morphologically difficult to decipher.

[2d-generation cephalosporins in the treatment of gram-negative superinfections]. / Les céphalosporines de seconde génération dans le traitement des surinfections à bacilles gram négatif.

The second generation cephalosporins are those drugs that are totally or partially resistant to betalactamases (cefamandole, cefuroxime) or the cephamycins (cefoxitine). This property allows them to destroy the enterobacteria resistant to cefalotine and they may have a place in the treatment of certain post-operative infections (abdominal, gynaecological, urinary) on their own or in combination with an aminoglycoside. They also may be of use in combination with an aminoglycoside in the management of secondary septicaemia infections. Outside of these indications which are dependent on the bacteriological findings, their use should be limited even when there is an absence of organisms that are Cefalotine sensitive on the antibiogram. This careful approach (which applies particularly for cefotaxine) may be abandoned once a certain quantity of resistant strains have emerged. For the time being, the second generation cephalosporins ought to be used only for specific indications, and as a general rule should not be first line antibiotic treatment.

Clinical and bacteriological efficacy, and practical aspects of amikacin given once daily for severe infections.

In a multicentre non-randomized open prospective study, 124 patients hospitalized in medical infectious disease or intensive care units, with severe community and hospital-acquired bacterial infections were treated with 15 mg/kg body weight amikacin in a once-daily dose given as a 30 min iv infusion, combined with other antibiotics. Infections were bacteriologically proven in 101 patients. The clinical responses showed 83.1% primary success and 83.9% definitive cure predominantly in intensive care patients with hospital-acquired infections and pneumonia. Bacteriological eradication was achieved in 67.3%. Bacteria associated with true failures and colonizations were predominantly Pseudomonas, Acinetobacter and Staphylococcus spp. The risk of nephrotoxicity may be decreased with such a regimen of amikacin, but no conclusions could be drawn with regard to ototoxicity. In summary, a once-daily dosing regimen of amikacin 15 mg/kg is practical and probably efficacious and safe in severely infected patients.

[Use of moxalactam in intensive care units: clinical and bacteriological results related to serum and bronchial concentrations ]. / Emploi du moxalactam en réanimation. Résultats cliniques et bactériologiques rapportés aux concentrations sériques et bronchiques.

Twenty-patients (14 with mechanical ventilation) received moxalactam in an intensive care unit for pneumonia (3 cases), empyema (5 cases), bronchopneumonia (8 cases), bronchopneumonia with bacteremia (4 cases), 23 organism were isolated and 16 were hospital-acquired: Staphylococcus (3), Escherichia coli (1), Klebsiella-Enterobacter-Serratia (5), Proteus (3), Aeruginosa (2), Acinetobacter (2), These patients received moxalactam at the dosage of 500 mg/8H, 5 at 1 g/12H and 13 at 1 g/8H. Daily dosage ranged between 25 and 50 mg/kg; mode of administration was IM (16) or IV infusion pump (5) and mean duration of treatment was 12 days (range 6-21). Serum and bronchial secretion samples were assayed by the agar diffusion technique utilizing a susceptible strain of enterobacter cloacae (0.06 microgram/ml) as assay organism. At 1 h, mean serum concentrations were 31.5 micrograms/ml after 1 g IM every 12H, 54.9 micrograms/ml after 1 g IM every 8H and at 30 mn after the end of the infusion, serum concentrations were 54.2 micrograms/ml. At the same time, bronchial secretion concentrations were respectively 2.1 micrograms/ml, 5 micrograms/ml and 3.7 micrograms/ml. Clinical cures were obtained in 16 (80%) and bacteriological cures occurred in 14 (70%); of the 12 hospital - acquired infections patients, 8 experienced clinical cures (66%) and the emergence of the following organisms was observed during moxalactam treatment: Staphylococcus (1), Enterococcus (1), Pseudomonas aeruginosa (1), Acinetobacter (3), For the 20 patients, we noted 4 adverse effects: pruritic morbilliform eruption (1), thrombocytosis (1), eosinophilia (2), To avoid failures, the usefulness of routine combinations with amyglycosides is discussed for the cases of hospital - acquired infections.

[Corynebacterium endocarditis. Diagnostic difficulties (author's transl)]. / Endocardite aiguë á Corynebacterium diphteriae Difficultés diagnostiques.

The authors report a case of endocarditis due to Corynebacterium diphtheriae. THe bacteriological study is difficult since this micro-organism can be undistinguishable from a saprophytic diphtheroid. The observed case is compared to previously published observations. All have in common the great severity of the illness, and the high mortality rate. Despite the clinical symptoms and the cerebrospinal fluid (CSF) abnormalities, meningitic involvement could not be demonstrated.

[Bronchial diffusion of piperacillin in 18 intensive care patients]. / Etude de la diffusion bronchique de la pipéracilline chez dix-huit patients de réanimation.

Eighteen patients (13 under mechanical ventilation) in an intensive care unit received piperacillin for pneumonia (7 cases) or bronchial infection (11 cases), related to Haemophilus influenzae (7), Streptococcus pneumoniae (4) or miscellaneous pathogens (7) including Staphylococcus, E. coli, Klebsiella pneumoniae and Proteus mirabilis. Each patient was given 2g piperacillin intravenously every six hours. Concentrations in serum and bronchial secretion samples were assayed by the agar diffusion technique using a susceptible strain of Bacillus subtilis ATCC 6633. Maximum concentrations were 157 micrograms/ml in serum and 3.60 micrograms/ml in bronchial secretions. These results are similar to those obtained with the same dosage by 0. Cars in serum (150 micrograms/ml) and by G.E. Marlin in the bronchial secretions (3.78 micrograms/ml). They approximate those published for other penicillins with the same dosage.

[Kinetics of the local immune response in lobar pneumonia]. / Cinétique de la réponse immunitaire locale dans les pneumonies lobaires.

In 19 patients suffering from lobar pneumonia and treated with antibiotics, bronchoalveolar lavages were performed in attempt to follow the course of the biological disorders caused by the pulmonary bacterial infection. The cytologic study of the fluid harvested from 14 patients with normal immune reactivity showed, firstly, a polymorphonuclear leucocytosis and, after about ten days, a lymphocytosis, reaching 30 to 70% of the alveolar cell population. These cell disorders existed only in the lobe affected by the pneumonia process. In five alcoholics (one of them also splenectomized), the polymorphonuclear leucocytosis lasted 15 to 25 days and the lymphocytosis was delayed and moderate. We also searched for the pneumococcal antigen by counter-current immunoelectrophoresis using a polyvalent antiserum. We found it in 13 patients, 7 with a positive hemoculture for pneumococcus and 6 negatives. Clearance of this antigen was slow, non modified by alcoholism. We found this antigen in two patients later, between the 90th and 110th days, in the lavage fluid concentrated fifty times. The quantitative and qualitative study of the immunoglobulins revealed considerable individual variations, owing to the variable intensity of the local inflammation phenomenons and to the technical difficulties of their dosage in the lavage fluid.

[Pneumococcal septicemia: 145 cases (author's transl)]. / A propos de cent quarantecing cas de pneumococcémie.

Over a six year period, 145 pneumococcal septicemias were seen at the Tourcoing Hospital. This represents 0.39% of all hospitalized patients and 19.8% of all septicemias seen over the same period. A mortality rate of 38.6% was recorded. Prognostic factors were analyzed. The mortality rate was significantly higher in women (46.5%), in patients admitted for a reason unrelated to the septicemia (50.8%), and in patients with septic shock (81.5%) which was frequent (22.8%). An underlying poor general condition was present in 88.2% of the patients. This confirms the high risk of pneumococcal infections in some patients who should be protected by vaccination.

Granulocyte-macrophage colony-stimulating factor and tumor necrosis factor alpha in patients with human immunodeficiency virus (HIV) type 1 infection.

Variations in cytokine production in patients with human immunodeficiency virus (HIV) infection could be involved in the physiopathology and in the progression of the disease. Therefore we studied the level of granulocyte-macrophage colony-stimulating factor (GM-CSF) and tumor necrosis factor alpha (TNF alpha) produced in patients with HIV infection at stage II (asymptomatic seropositives) and stage IV (AIDS) of the CDC classification, by using an enzyme amplified sensitivity immunoassay. We measured the level of GM-CSF and TNF alpha in supernatant of phytohemagglutinin-activated peripheral blood mononuclear cells from patients and healthy individuals. In one out of 10 stage II patients and 4 out of 14 stage IV patients, we obtained higher levels of GM-CSF than the mean + 2 S.D. of controls, but in 3 stage IV patients with very low CD4+ T lymphocyte counts (< 50/mm-3) compared to other patients, the GM-CSF values were very low. High levels of TNF alpha were detected in 3 out of 10 stage II and 6 out of 11 stage IV patients. The high values of TNF alpha were associated with high values of GM-CSF in stage II and in most of AIDS patients except those with very low CD4+ T cell counts, who produced low levels of GM-CSF. Plasma levels of cytokines were evaluated in 10 stage II, 22 stage IV patients and 20 controls. Increased levels of GM-CSF (more than 9 pg/ml) were observed in the plasma from 8 out of 10 stage II patients and 17 out of 22 stage IV patients.(ABSTRACT TRUNCATED AT 250 WORDS)