[Cutaneous infection due to Mycobacterium chelonae during anti-TNF therapy]. / Infection cutanée a Mycobacterium chelonae au cours d'un traitement par anti-TNF.

BACKGROUND: Mycobacterium chelonae is a ubiquitous, rapidly growing, opportunistic, non-tuberculous mycobacterium that can cause skin and bone tissue infections. We report a case of cutaneous infection due to M. chelonae following anti-TNF therapy. CASE REPORT: A 70-year-old woman with a medical history of rheumatoid arthritis was admitted for several purple nodular cutaneous lesions on her right leg evolving for 2 months. At admission, she was on prednisone, methotrexate and adalimumab for her rheumatoid arthritis. Skin lesions appeared 5 days before etanercept, which was taken for 5 months before being discontinued for adalimumab. Both the histopathological examination and bacterial culture of involved skin showed the presence of M. chelonae. Adalimumab was immediately discontinued and a combination of amoxicillin-clavulanic acid and tigecyclin was started. DISCUSSION: TNF-alpha plays a pivotal role in immune reaction to intracellular pathogens. Very few cases of cutaneous infection involving M. chelonae in association with an anti-TNF-alpha therapy have been reported in the literature. To our knowledge, this is the first case occurring during treatment with etanercept and symptoms worsened with the introduction of adalimumab. In addition, this case underlines the difficulties of effectively treating this mycobacterium.

Tuberculosis and HIV infection: a cohort study of incidence and susceptibility to antituberculous drugs, Bordeaux, 1985-1993. Groupe d'Epidémiologie Clinique du SIDA en Aquitaine.

OBJECTIVES: To assess the temporal trends in incidence of tuberculosis (TB) in HIV-infected patients, to evaluate the impact of pulmonary TB on the Centers for Disease Control and Prevention (CDC) 1993 AIDS case definition and to assess the frequency of Mycobacterium tuberculosis strain resistance. DESIGN: A retrospective study within a cohort. SETTING: The Bordeaux University Hospital and three general hospitals in Aquitaine, southwest France. SUBJECTS: Since 1985, HIV-infected in- and outpatients aged > 13 years have been included in the Aquitaine cohort. Reported cases of pulmonary and extrapulmonary TB were investigated and records cross-referenced with the files of the TB reference laboratory. RESULTS: As of 30 June 1993, the Aquitaine cohort (3119 patients) accounted for 6409 person-years (PY) of follow-up. TB was diagnosed in 139 patients (average annual incidence, 2.17 per 100 PY) of whom 79 had bacteriological diagnosis, 13 histological diagnosis and 47 clinical and/or radiological diagnosis. Extrapulmonary TB accounted for 40% of the cases. Intravenous drug use was more frequent in the group who developed TB (50%) than in the rest of the cohort (40%) (P = 0.009). There was an increase in the incidence rate of TB in the cohort between 1985 (0.45 per 100 PY) and 1989 (2.67 per 100 PY) and a stabilization around 1.5-2.0 per 100 PY until 1993. Pulmonary TB was estimated to increase the AIDS cumulative incidence by 0.4% when performing a simulation with the 1993 AIDS case definition. Single drug resistance was documented in 3.4% of the cases and a multiple drug resistance in 5.1%. CONCLUSION: TB incidence has stabilized since 1990 in the Aquitaine cohort with a limited increase of the number of AIDS cases (1993 CDC criteria). Drug resistance was rare.

Increase in CD3+ CD4- T lymphocytes in patients with AIDS and disseminated Mycobacterium avium-intracellulare complex infection: a prospective study. GECSA. Groupe d'Epidemiologie Clinique du SIDA en Aquitaine.

In a retrospective study, an increase in double-negative (CD3+ CD4- CD8-) (DN) T lymphocytes has been shown to be an independent predictor of disseminated Mycobacterium avium complex (D.MAC) infection in patients with less than 100 CD4+ T cells per mm3. To better characterize this cell expansion, a prospective study was designed. From July 1995 to April 1997, 206 HIV-infected patients with less than 100 CD4+ T cells per mm3 were prospectively followed up and immunophenotyped. The median followup was 1.1 year (+/-0.5 year), and 14 new D.MAC infections were diagnosed among 84 first AIDS-defining events. In univariate and multivariate analyses, D.MAC infections were the only opportunistic infection with a significant increase in DN T-cell percentage (median = 6.6; range = 1.7 to 24.5, P = 0.004) compared with patients without any opportunistic infection. This alteration in T-lymphocyte count could constitute a predictor for D.MAC infection in clinical practice.

Is a 24-h cyclic closed enteral feeding system microbiologically safe in geriatric patients?

BACKGROUND AND AIMS: The microbiological quality of a 1-l closed enteral feeding system (CS) was prospectively monitored under clinical conditions simulating cyclic feeding over a 24-h period in geriatric patients. METHOD: The set was connected after diet sampling (T0). After 5-h feeding, the set was disconnected and a sample taken (T5). Diet was sampled after 12 h before (T12A) and after a 10 ml diet-flush of the set (T12B), after 24-h (T24) and in the pouch (P24). Concentrations of micro-organisms were considered significant when above 10(4) colony-forming units per millilitre. RESULTS: Twenty-one CS were examined. T0 samples were all sterile; 10 out of 21 T5 were contaminated. The microbiological content of the diet was lower in T12B, compared to T12A (P=0.002). None of the P24 samples was contaminated; 19 were sterile and two contained low levels of micro-organisms that had been previously found in the sets. CONCLUSION: The CS was sterile before connecting to the patient. Retrograde contamination of the set was observed without contamination of the pouch after 24-h hanging time. Performing a diet-flush decreased the rate of diet contamination at the distal extremity of the set. Thus, cyclic enteral nutrition using the same pouch during a 24-h period seems to be safe in geriatric patients.

[Annual incidence and risk factors for nosocomial bacterial infections in an acute care geriatric unit]. / Incidence sur un an et facteurs de risque des infections nosocomiales bactériennes dans un service de médecine interne gériatrique.

PURPOSE: Elderly inpatients are particularly exposed to the risk of nosocomial infections, thus the study of their risk factors and consequences is of interest. METHODS: Among 1,565 subjects referred to a short-term geriatric unit, patients hospitalised for a year for an acute event and unable to move themselves were followed up for the occurrence of nosocomial infections. RESULTS: Among these 402 immobilised patients (age: 86.3 +/- 7.6 years), 102 nosocomial infections occurred in 91 patients (22.6%), whereas the estimation of the incidence in the total hospitalised population (1,565 subjects, age: 85.1 +/- 6.2 years) was 9.4% (95% confidence interval [CI] 8.3-11.2). Forty-seven point seven percent of nosocomial infections were urinary tract nosocomial infections, 27.5% were lower respiratory nosocomial infections, 9.2% were cutaneous nosocomial infections, 7.3% were septicaemia and 8.2% were of unknown origin. The relative risk (RR) of NI linked to functional dependency for mobility was 5.5 (95% CI: 3.93-7.7, P < 0.001). Other risk factors were: for all nosocomial infections: cancer diagnosis (RR 1.1, 95% CI: 1.1-1.2, P = 0.01); and respectively for urinary tract NI: bladder indwelling (RR 4.8, 95% CI: 2.9-7.7, P < 0.001), pulmonary NI: swallowing disorders (RR 5.4, 95% CI: 2.8-10.5, P < 0.001); and septicaemia: venous catheter (RR 5.4, 95% CI: 1.3-23.3, P = 0.002). NI were associated with an increased length of stay (22.1 +/- 11.7 days in infected patients vs 16.3 +/- 9.5 days in immobilised non-infected subjects, P < 0.001). The mean length of stay for the 1,565 subjects was 10.3 +/- 7.6 days. Death was attributed to nosocomial infections in 13 subjects. In conclusion, functional dependency for mobility, bladder indwelling, venous catheter, swallowing disorders and diagnosis of cancer were risk factors for nosocomial infections in hospitalised elderly subjects in an acutecare setting.

[Comparison of cases of isolated pulmonary tuberculosis with cases of other localizations of tuberculosis in the course of an active surveillance (Gironde, 1995-1996)]. / Comparaison des cas de tuberculose pulmonaire isolée aux cas de tuberculose d'autre localisation dans un système de surveillance active (Gironde, 1995-1996).

PURPOSE: Data collected during the years 1995 and 1996 in the course of an epidemiological survey of tuberculosis in Gironde allowed comparison of pulmonary tuberculosis with extrapulmonary localizations, evaluation of the importance of each localization and highlighting of potential risk factors. METHODS: Patients living in Gironde who had evidence of either clinical, radiological or bacteriological expression of tuberculosis were included in the survey. Statistical comparisons were done using either Pearson's Chi 2 or Fisher's exact test. RESULTS: The survey included 292 cases subdivided into 183 cases of pulmonary tuberculosis (63%) and 109 cases in which another localization had been diagnosed (37%). Extrapulmonary localizations that were the most often encountered either alone or in association with pulmonary localization were the following: lymphadenopathy (32%), pleural (28%), genito-urinary (12%) and osteo-articular localizations (7%). The survey showed that patients in whom tuberculosis localization was extra-pulmonary were more frequently under 20 years of age or over 60 years of age (P < 0.04). These patients also presented more often with HIV-infection (P < 0.02). CONCLUSION: Extrapulmonary localizations of tuberculosis should be systematically investigated in young and elderly patients as well as in HIV-infected patients.

[Incidence and severity of cardiac involvement in Streptococcus bovis septicemia. Report of 10 cases]. / Fréquence et gravité de l'atteinte cardiaque dans les septicémies à Streptocoque bovis. A propos de 10 cas.

Endocarditis due to the streptococcus Bovis is an affection which is more and more often recognized and whose link with the colic tumor pathology has been well established those last few years and confirmed in this study with a frequency of 60 p. cent. However, few studies have stated the gravity of the heart affection in streptococcus Bovis septicaemias. In this series of 10 streptococcus Bovis septicaemias, the valvular affection is frequent and serious. The vegetations are found in 9 cases out of 10. The aortic affection is slightly more frequent (8 times out of 10), against 7 times out of 10 for the mitral affection (double mitroaortic affection, 6 times). A valve replacement due to sub-acute or chronic cardiac failure was necessary in 6 cases out of 9, that is 66 p. cent. The mortality was nil.

[Randomized prospective study of ceftazidime versus a cefotaxime-tobramycin combination in acute leukemia in therapeutic aplasia]. / Etude prospective randomisée, de la ceftazidime versus l'association céfotaxime-tobramycine, dans les leucémies aiguës en aplasie thérapeutique.

In a prospective study, 157 patients with prolonged aplasia (PMN less than 500/mm3 during more than 21 days), hospitalized in a protected environment unit, were randomly assigned to receive ceftazidime alone or cefotaxime + tobramycin for initial febrile episodes. Age, sex, underlying diseases, duration of neutropenia, digestive decontamination regimen, clinical and microbiological characteristics of infections were similar in the two groups. Patients were evaluated for their initial response to antibiotics (defervescence in 48 hours, maintained 7 days) and long term response (prevention of another infection during aplasia). The overall initial response to ceftazidime was 48/71 (68 per cent) and to cefotaxime + tobramycin 55/86 (64 per cent). The long term response to ceftazidime was 33/71 (46.5 per cent) and to cefotaxime + tobramycin 31/86 (36 per cent). In conclusion, ceftazidime alone was as effective as cefotaxime + tobramycin in the first line treatment of febrile episodes in neutropenic patients.

[Is length of stay in the recovery room a risk factor for cross infections?]. / Le séjour en salle de surveillance postinterventionnelle peut-il être à l'origine de transmissions croisées?

OBJECTIVE: To assess cross contamination for patients at the time of their stay in the recovery room (RR). STUDY DESIGN: Prospective study. PATIENTS AND METHODS: A prospective survey over 3 weeks with 75 adult patients admitted to RR after thoracic or neck surgery. Samples for bacterial analysis were systematically taken from all patients before they left the operating theatre and just before discharge of RR (nose-throat and skin adjacent to the surgical wound). During this period, hand's health care workers (HCW) and environmental surfaces were sampled. RESULTS: There were 3 groups of patients: endoscopy (41%), thoracic surgery (39%). And thyroidectomy (20%), 392 samples were analysed. Potentially pathogenic floras were found on the admission for 25 patients and at discharge for 31 patients. A pathogenic flora was detected at discharge in 13 patients, whereas none was found at admission in RR. These patients were principally in the thyroidectomy group and their stay in RR was longer than 20 minutes. There is no significant difference concerning the nosocomial risk between 3 groups. Pathogenic flora was found in 19% of HCW (8 of 42). CONCLUSION: Cross contamination can exist in recovery room and educative measures are to be taken regarding handwhashing, isolation precautions and environmental cleaning.

[Mycobacterial bovis BCG cutaneous infections following mesotherapy: 2 cases]. / BCGite cutanée après mésothérapie: 2 cas.

INTRODUCTION: Infectious complications following mesotherapy are usually due to ordinary bacteria or atypical mycobacteria. We report two new cases of mycobacterial bovis BCG infections following mesotherapy. To our knowledge only one case has already been reported. CASES REPORTS: A 52 year-old woman developed vaccinal MERIEUX BCG cutaneous abscesses following mesotherapy. Identification was made by a novel class of repeated sequences: Mycobacterial interspersed repetitive units. Despite prolonged anti-tuberculous therapy, complete remission was not obtained and surgical excision was performed. The second case was a 49 year-old man who developed a mycobacterial bovis BCG cutaneous abscess (Connaught) after mesotherapy, the regression of which was obtained with anti-tuberculous therapy. DISCUSSION: The severity of these two mycobacterial infections following mesotherapy illustrate the potential risks of mesotherapy. Identification is possible by molecular biology techniques (PCR and sequencing). The origin of this infection is unclear and therapeutic decision is difficult. Some authors recommend anti-tuberculous therapy but surgical excision may be necessary as in our cases.

[Bacterial infectious agents implicated in lower respiratory tract infections in general practice]. / Agents infectieux bactériens en cause dans les infections respiratoires basses en pratique de ville.

The consensus of the French Society of Infectious Diseases established in 1991 states that Streptococcus pneumoniae and Haemophilus influenzae are the main causal agents of community-acquired lower airway infections and that antibiotics constitute the "prudent" solution in case of acute bronchitis which persists more than one week or in case of pneumonia in "fragile" at-risk adults. The efficacy of these "probabilistic" recommendations depends on the epidemiology of the infectious agents. The objective of this study was to identify the causal germs in lower airway infections and determine their sensitivity to the antibiotics recommended in the consensus statement. The study was conducted from December to March, in 1992 and 1993. Expectoration samples were obtained from 111 cases including 29 patients with chronic bronchitis. Seventy different strains were isolated including 24 strains of H. influenzae (3 betalactamase producers), 15 strains of S. pneumoniae (1 with reduced sensitivity to peni G: MIC = 1 mu/ml), 9 strains of S. aureus (2 methicillin resistant), and 8 strains of Branhamella catarrhalis (6 betalactamase producers). The number of positive serologies was very low: 5 Chlamydiae pneumoniae, 2 Chlamydiae trachomatis and 1 Mycoplasma pneumoniae. In conclusion H. influenzae is the most frequent germ; S. pneumoniae infections with reduced peni-G sensitivity and atypical germs are uncommon. The consensus recommendations appear to be adapted to the bacterial flore causing community-acquired lower airway infection in healthy and at-risk subjects.

Pharmacokinetics of free ertapenem in critically ill septic patients: intermittent versus continuous infusion.

BACKGROUND: The aim of this paper was to compare the pharmacokinetic and pharmacodynamic (PK/PD) parameters of continuous (CI) and intermittent infusion (ITI) of ertapenem into critically ill patients with severe abdominal infections. METHODS: Twenty septic patients hospitalized in a university hospital intensive care unit were enrolled in the study. Half of the patients received ertapenem as an ITI 1 g bolus once daily, and the other half of the patients received the same dose via CI over 24 h following a 1-g loading dose. Blood was drawn 1, 12 and 24 h after terminating ITI or on days 2, 3 and 5 after starting CI for each patient. After centrifugation, the drawn blood was frozen at -80 °C until being examined by high-performance liquid-chromatography analysis. RESULTS: Median serum-free ertapenem concentrations were as follows: ƒCmax = 98.9 mg/L and ƒCmin = 2.5 mg/L for ITI, and ƒCss=15.9 mg/L for CI. The ITI and CI median total clearance and volumes of distribution were 2.2 L/h vs. 2.5 L/h and 15.4 L vs. 21.0 L, respectively. The ertapenem MIC ranges were as follows: Escherichia coli (0.006 to 0.5 mg/L), Enterobacter cloacae (0.023 to 0.5 mg/L), Klebsiella oxytoca (0.023 to 0.5 mg/L), Staphylococcus aureus (0.38 to 3 mg/L), Streptococcus viridians (0.38 to 3 mg/L) and Enterococcus faecalis (0.38 to 3 mg/L). ITI and CI provided steady-state serum-free ertapenem concentrations constantly above the MIC for all bacteria. CONCLUSION: Ertapenem exhibited satisfactory PK/PD parameters and achieved serum-free concentrations 100% of the time, above even the high MIC of extracellular pathogens normally encountered during severe abdominal infections. CI administration resulted in equally effective PK/PD parameters as ITI in normal weight, good renal-function patients.

A 10-year prospective surveillance of Mycobacterium tuberculosis drug resistance in France 1995-2004.

Drug resistance surveillance and trend monitoring resistance rates bring some insights into tuberculosis (TB) control. The current study reports the characteristics of TB and drug resistance during a 10-yr prospective surveillance of culture-positive TB in France. Data for the current study was collected from 1995-2004 via a sentinel network of laboratories from university hospitals that complied with the international recommendations for the surveillance of drug resistance. Susceptibility test results were performed in each individual laboratory. Data on 13,283 patients were collected during the 10-yr period, 49% of whom had been born in France, 10% were HIV co-infected and 8% had previously been treated. As expected, previously treated and HIV co-infected patients were more likely to harbour resistant strains, especially rifampicin (RMP)-resistant strains. Among new patients, the mean resistance rate to at least one drug was 8.8%, and there was an upward trend in resistance to isoniazid and RMP (0.8-1%) related to the increase in the proportion of patients who had been born outside of France (38-53%). Among previously treated patients, the mean resistance rate to one drug was 20.6% and there was no significant time trend in resistance rates. The sentinel network provided valuable data on trends regarding the characteristics of tuberculosis and on drug resistance rates and reinforced the interest of analysing data by country of birth and history of treatment.

[Branhamella catarrhalis: incidence in pulmonary infections and determination of sensitivity to 5 antibiotics]. / Branhamella catarrhalis: incidence dans les infections pulmonaires et détermination de leur sensibilité à cinq antibiotiques.

This study reports 45 cases of respiratory tract infection associated with Branhamella catarrhalis, diagnosed by bacteriological examination out of 980 sputum samples studied over a 6 months period. These infections were observed mainly in patients with chronic respiratory disease (68.9%). More than half of the isolates were found in pure culture, others were isolated from mixed infections most often with Haemophilus influenzae, Streptococcus pneumoniae or H. influenzae plus S. pneumoniae. 64.7% of Branhamella catarrhalis isolates produced beta-lactamase. In vitro antimicrobial susceptibility testing demonstrated that the B. catarrhalis isolates, including beta-lactamase producing strains, were very susceptible to clavulanic acid plus amoxycillin (MIC90:0.12 microgram/ml) as well as to doxycycline and erythromycin (MIC90:0.5 microgram/ml).

[Evolution of bacterial resistance to five aminoglycosides. A study of 3,354 strains isolated in a hospital milieu]. / Evolution de la résistance bactérienne à cinq aminosides. Etude portant sur 3,354 souches isolées en milieu hospitalier.

The authors studied the susceptibility to 5 aminoglycosides (amikacin, dibekacin, gentamicin, netilmicin and tobramycin) of 3,354 strains isolated at the Centre Hospitalier Sud in Bordeaux during 1987. The results are compared to those obtained in 1984 on 2,818 strains. Amikacin remains the most active aminoside against the Enterobacteriaceae and Acinetobacter; against Pseudomonas, tobramycin has become the best one at that time, as well as netilmicin against Staphylococcus aureus. Evolution: no significative increase of Enterobacteriaceae resistance to aminoglycosides was observed during the last 3 years except for Providencia and Serratia. For Acinetobacter and Pseudomonas, percentage of resistant strains is respectively two-fold and three-fold higher. Although resistance increased in that species, netilmicin and amikacin showed a still good activity against Staphylococcus aureus.

Ureaplasma-urealyticum-induced bladder stones in rats and their prevention by flurofamide and doxycycline.

Struvite calculi can be produced in the bladder of Sprague-Dawley male rats after injection of ureaplasmas into the renal medulla. Calculi appear 3 to 6 days after ureaplasma injection. We have studied the inhibitory effect of flurofamide, a potent inhibitor of Ureaplasma urealyticum urease, and doxycycline, on the formation of bladder stones. Flurofamide given orally in five doses (total 125 mg) over 3 days and doxycycline in seven doses (total 20 mg) over 4 days partially prevented stone formation only when given at the time of inoculation. Ureaplasmas disappeared rapidly from the urine. The inhibitory effect of flurofamide was higher than that of doxycycline. However, doxycycline seemed to be efficient when given for a long period (5 weeks).

In vitro activity of four fluoroquinolones against eighty-six isolates of mycobacteria.

The in vitro activity of pefloxacin, norfloxacin, ofloxacin and ciprofloxacin against 86 strains of mycobacteria was evaluated by broth dilution. While Mycobacterium avium, Mycobacterium scrofulaceum and Mycobacterium chelonae were resistant to all four antibacterials, the susceptibility of the other species, Mycobacterium tuberculosis, Mycobacterium kansasii, Mycobacterium xenopi and Mycobacterium fortuitum, depended on the antibiotic. Ofloxacin and ciprofloxacin (MIC90: 0.5 - 2 mg/l) were more active than pefloxacin and norfloxacin (MIC90: 2 - 16 mg/l).

[Bacteriostatic activity of azlocillin, gentamycin, amikacin singly or in combination on 200 strains of Pseudomonas aeruginosa]. / Activité bactériostatique de l'azlocilline, gentamicine, amikacine seuls et en association sur 200 souches de Pseudomonas aeruginosa.

In vitro activity of azlocillin, gentamicin, and amikacin, alone or in combination was evaluated against 200 clinical isolates of Pseudomonas aeruginosa. The minimum inhibitory concentrations (MICs) were determined by a standard technique. For the evaluation of synergistic activities, one antibiotic was added in a concentration equivalent to one-fourth its MIC to increasing concentrations of the other antibiotic. The MIC for 50% of the strains was 3.25 micrograms/ml for gentamicin, 3 micrograms/ml for amikacin and 7 micrograms/ml for azlocillin. No significant difference could be seen between the two combinations, the percentage of synergy was 37% for azlocillin-gentamicin and 36% for azlocillin-amikacin. No antagonism was observed.

Incidence of bacteraemia or fever during transoesophageal echocardiography: a prospective study of 82 patients.

The incidence of bacteraemia during transoesophageal echocardiography (TEE) was evaluated in a prospective study of 82 consecutive patients. Three series of blood cultures were carried out for each patient: from group 1 (n = 44), prior to the examination, at the end of the examination and 15 min afterwards. For group 2 (n = 38), blood cultures were performed prior to the examination, 10 min after the start and immediately after the end. A single positive blood culture was detected in two patients. For the first patient, blood culture at the end of the examination demonstrated Corynebacteria, and for the second, Staphylococcus epidermidis was identified on cultures taken during the examination. During the first 24 h, a transient subfebrile temperature was recorded in 15% of the patients, including the patient with the Corynebacteria-positive blood culture. By mid-term (6 months) no patient had developed endocarditis. Our findings suggest that antibiotic prophylaxis during TEE is not warranted.