Long-term control of vancomycin-resistant Enterococcus faecium at the scale of a large multihospital institution: a seven-year experience.

Repeated outbreaks of vancomycin-resistant Enterococcus faecium (VRE) occurred between 2004 and 2010 in Assistance Publique--Hôpitaux de Paris (AP-HP), a 23,000-bed multi-hospital institution. From August 2004 to December 2005, the French guidelines for preventing cross-transmission of multiresistant bacteria were applied. Because the number of VRE cases continued to increase, an institutional control programme was implemented from January 2006 onwards: it foresees stopping transfer of VRE and contact patients, separating VRE and contact patients in distinct cohorts, intervention of a central infection control team to support local teams, and quick application of measures as soon as first VRE cases are identified. Between August 2004 and December 2010, 45 VRE outbreaks occurred in 21 of the 38 AP-HP hospitals, comprising 533 cases. Time series analysis showed that the mean number of cases increased by 0.8 cases per month (95% confidence interval (CI): 0.3 to 1.3, p=0.001) before, and decreased by 0.7 cases per month after implementation of the programme (95% CI: -0.9 to -0.5, p<0.001), resulting in a significant trend change of -1.5 cases per month (95% CI: -2.1 to -0.9, p<0.001). The number of cases per outbreak was significantly lower after implementation of the programme. A sustained and coordinated strategy can control emerging bacteria at the level of a large regional multihospital institution.

Practices of infectious control management during neutropenia: A survey from 149 French hospitals.

OBJECTIVE OF THE STUDY: Neutropenic patients represent a growing and fragile population in our hospitals. Numerous treatments induce neutropenia in haematology wards and elsewhere. Although strict isolation is recommended during post-haematopoietic stem cell transplantation neutropenia, this may not be the current practice in other situations. In this study, our objective was to analyse what protective measures are applied in neutropenic patients in a French survey. MATERIELS AND METHODS: A questionnaire was sent out to infection control teams of 400 public and private French hospitals to enquire about their local recommendations regarding infection prevention in neutropenic patients. RESULTS: Among the 166 (41%) responders, 134 (81%) managed neutropenic patients. All of the centres recommended protective isolation for neutropenic patients. However, only 46 (34%) had clearly defined patients warranting specific isolation measures in terms of the level of neutropenia. All of the centres recommended several barrier measures, but these were highly variable according to the type of air treatment in the wards (note that only 72% of haematology wards are equipped with air treatment). Gowns, gloves, masks, hats and shoe covers were respectively recommended in 128 (95%), 79 (59%), 132 (98%), 87 (65%), and 34 (25%) of the establishments. Surprisingly, the recommendations vary both among hospitals and within the same hospital among different clinical wards. CONCLUSION: In conclusion, protective measures for neutropenic patients are applied variably and urgently require a consensus to homogenize practices.

[French recommendations on control measures to reduce the infectious risk in immunocompromised patients]. / Quelles mesures pour maîtriser le risque infectieux chez les patients immunodéprimés ? Recommandations formalisées d'experts.

The increase use of immunosuppressive treatments in patients with solid cancer and/or inflammatory diseases requires revisiting our practices for the prevention of infectious risk in the care setting. A review of the literature by a multidisciplinary working group at the beginning of 2014 wished to answer the following 4 questions to improve healthcare immunocompromised patients: (I) How can we define immunocompromised patients with high, intermediate and low infectious risk, (II) which air treatment should be recommended for this specific population? (III) What additional precautions should be recommended for immunocompromised patients at risk for infection? (IV) Which global environmental control should be recommended? Based on data from the literature and using the GRADE method, we propose 15 recommendations that could help to reduce the risk of infection in these exposed populations.

[Cases of pertussis among healthcare workers in a maternity ward: management of a health alert]. / Cas de coqueluche parmi le personnel d'un service de maternité: gestion d'une alerte sanitaire.

UNLABELLED: Pertussis is a highly contagious acute respiratory tract infection, with a poor prognosis in non-vaccinated new-borns. OBJECTIVES: The authors had for aim to investigate an epidemic of 5 pertussis cases among health care workers (HCW) in our maternity ward with potential exposure of new-borns and to evaluate HCW compliance and experience gain. METHODS: A retrospective study was made using a questionnaire with HCW on preventive measures taken (antibiotic prophylaxis with erythromycin and wearing a mask). RESULTS: Two hundred and thirty-eight patients were warned of a potential pertussis contamination. No nosocomial case was detected among patients or their new borns. Ten proved or probable cases were identified among 101 HCW having answered (N=101/210, 48%). Sixty percent of HCW people followed the antibiotic treatment and 85% wore a mask among whom 46% adequately. Non-compliance factors were mainly related to adverse effects (41%), delayed information (41%), and false vaccine protection (22%). Crisis communication was felt as unsatisfactory for 72% of HCW and recommendations not adapted for 39% of the staff. CONCLUSION: This survey points out the difficulty of managing a pertussis alert in a medical ward.

Preparing and administering injectable antibiotics: How to avoid playing God.

The emergence of bacterial resistance and the lack of new antibiotics in the pipeline represent a public health priority. Maximizing the quality of antibiotic prescriptions is therefore of major importance in terms of adequate preparation and administration modalities. Adequate preparation prevents the inactivation of antibiotics and is a prerequisite to maximizing their efficacy (taking into account the pharmacokinetic/pharmacodynamic relationship) and to minimizing their toxicity. Many antibiotic guidelines address the choice of drugs and treatment duration but none of them exclusively address preparation and administration modalities. These guidelines are based on the available literature and offer essential data for a proper antibiotic preparation and administration by physicians and nurses. They may lead to a better efficacy and to a reduced antibiotic resistance. Such guidelines also contribute to a proper use of drugs and improve the interaction between inpatient and outpatient care for a better overall management of patients.

[Cardiac hydatidosis: contribution of magnetic resonance imaging. Report of a case]. / Hydatidose cardiaque: apport de l'imagerie par résonance magnétique. A propos d'un cas.

Cardiac hydatid cyst is a rare condition. The diagnosis is difficult and is based on a series of findings amongst which hydatid serology and cardiac imaging play important parts. The values and limitations of echocardiography, coronary angiography and CT scanning are well known. Nuclear magnetic resonance imaging is a recent technique which theoretically should provide valuable diagnostic information. The authors report a case in which this technology, though confirming the presence of a polycystic intrapericardial mass, did not show the true extension of the disease.

[Infectious endocarditis of the tricuspid valve in patients with endocardial pacemakers]. / Endocardites infectieuses tricuspidiennes sur sonde de stimulation permanente endocavitaire.

Right heart endocarditis in patients with permanent cardiac pacing catheters is uncommon but not an exceptionally rare complication. Two dimensional echocardiography provides diagnostic and prognostic information. The authors report two cases which illustrate the fact that many workers recommend explanation of the pacing catheter and that tricuspidectomy with or without valve replacement may sometimes be necessary.

[Fulminant hepatitis induced by disulfiram in a patient with alcoholic cirrhosis. Survival after liver transplantation]. / Hépatite fulminante au disulfirame chez un malade atteint de cirrhose alcoolique. Survie après transplantation hépatique.

Fulminant hepatitis was observed in a 44-year-old patient with cirrhosis, 38 days after the beginning of a treatment by disulfiram. Hepatitis was associated with fever and hypereosinophilia. Liver transplantation was performed with success. We reviewed 15 previously published cases of disulfiram-induced hepatitis. They occurred from 10 to 180 days after the beginning of the treatment by disulfiram, aminotransferases were increased whereas alkaline phosphatases were not markedly changed; there was either focal or widespread necrosis. Fulminant hepatitis was observed mainly in patients with alcoholic chronic liver disease or in patients who continued to ingest disulfiram while jaundice was already present. An immunoallergic mechanism is thought to be responsible for disulfiram-induced hepatitis.

Clinical spectrum of urine cultures positive for ESBL-producing Escherichia coli in hospitalized patients and impact on antibiotic use.

OBJECTIVE: We wanted to describe the clinical features associated with urinalysis positive for ESBL-producing Escherichia coli and their impact on antibiotic use. METHODS: We performed a prospective observational study in 13 French hospitals of the Paris area for 3 consecutive months. We included all patients with urine cultures positive for ESBL-producing E. coli. RESULTS: One hundred and seventeen of the 218 patients (54%) presented with asymptomatic bacteriuria, 31 (14%) with cystitis, and 70 (32%) with a parenchymal infection. Nineteen patients with asymptomatic bacteriuria (16%) received antibiotics. Forty-one with parenchymal infections (59%) received a carbapenem. A carbapenem alternative could have been used in every patient treated with a carbapenem, according to antibiotic susceptibility testing results. CONCLUSIONS: Urinary tract infections accounted for 46% of E. coli ESBL positive urinalysis. Fifty percent of parenchymal infections were treated with a carbapenem.

Acceptance of the 2009 A(H1N1) influenza vaccine among hospital workers in two French cancer centers.

The aim of the study was to determine predictive factors influencing the acceptance of the 2009 A(H1N1) influenza vaccination among hospital workers (HW) in two French cancer centers. A standardized, anonymous, self-administered questionnaire was sent to HW of two cancer centers. The survey response rate was 26.2% (n=506). Main reasons for A(H1N1) vaccination acceptance were "to protect my relatives" (30.3%), "to protect myself" (30.3%). Main reasons for A(H1N1) vaccination refusal were the fear of side effects (43.1%), doubt about the vaccine's efficacy (25.8%). Vaccinated HW were more influenced by the institutional campaign (p<0.001) or colleagues' advice (p<0.001) whereas non-vaccinated HW were influenced by their family physician's advice (p=0.03), personal conviction (p<0.001) or the media (p<0.001). A multivariate analysis revealed age (>35 vs ≤ 35), prior seasonal influenza vaccination, professional category and source of information to be predictive factors of vaccination. Future vaccination campaigns will need to focus on young HW (≤ 35-year old), with no prior influenza vaccination and HW who are in contact with patients and who reported low seasonal influenza vaccination rates.

Intrahepatic cholestasis of pregnancy and acute fatty liver of pregnancy. An unusual but favorable association?

During the 26th week of a first pregnancy, a 25-year-old woman presented with pruritus suggesting an intrahepatic cholestasis of pregnancy. The pruritus, however, persisted despite the premature delivery of a normal newborn at the 35th week. Moreover, aspartate aminotransferase activity increased, reaching a maximum of 38 times normal level on the 17th day after the delivery. Thus, an acute fatty liver of pregnancy was suspected and confirmed by liver biopsy. This patient appeared to have both intrahepatic cholestasis of pregnancy and acute fatty liver of pregnancy, an association not previously reported. It is suggested that intrahepatic cholestasis of pregnancy caused premature delivery, which in turn may have prevented the onset of severe maternal and fetal complications caused by acute fatty liver of pregnancy.

Activity of beta-lactamase inhibitor combinations on Escherichia coli isolates exhibiting various patterns of resistance to beta-lactam agents.

The efficacy of the clinically available beta-lactam/beta-lactamase inhibitor combinations (amoxicillin/clavulanic acid (CA), ticarcillin/CA, amoxicillin/sulbactam, and piperacillin/tazobactam) was evaluated on 300 amoxicillin-resistant Escherichia coli isolates having the main patterns of beta-lactam resistance. The patterns, which reflect the production of various beta-lactamase enzymes, were analyzed by a principal component analysis of susceptibility to 11 beta-lactam antibiotics or beta-lactam/beta-lactamase inhibitor combinations. Sixty-two percent of strains were not very susceptible to penicillins, cephalothin, or any beta-lactam/beta-lactamase inhibitor combinations except for piperacillin/tazobactam; these strains may represent high-level broad-spectrum beta-lactamase (so-called penicillinase) production phenotype or inhibitor-resistant TEM-like enzyme production phenotype. Of the strains, 14.7% were resistant to amoxicillin and ticarcillin compatible with low-level broad-spectrum beta-lactamase production phenotype; 5.7% were cefoxitin resistant and were postulated to present a high-level cephalosporinase production phenotype; and 2.6% were resistant to cephalothin only, attributable to a low-level cephalosporinase production phenotype. Three percent of strains were intermediate or resistant to cefotaxime and may produce an extended-spectrum beta-lactamase, and the remaining strains (12 %), resistant to all tested antibiotics except for cefotaxime and piperacillin/tazobactam, were hypothesized to produce both broad-spectrum beta-lactamase plus cephalosporinase. The minimal inhibitory concentration (MIC) for these phenotype patterns indicated that combinations of CA plus amoxicillin or ticarcillin, or sulbactam plus amoxicillin, restored the activity of penicillins against phenotype 1 strains, whereas these combinations remained inactive against the other phenotype strains. Piperacillin plus tazobactam showed the best in vitro effect against the strains of all resistance phenotypes.

Outbreak of multiply resistant enterobacteriaceae in an intensive care unit: epidemiology and risk factors for acquisition.

A prospective study was initiated in an intensive care unit (ICU) where extended-spectrum beta-lactamase-producing enterobacteriaceae (ESBLPE) were endemic. From July 1990 to July 1991, patients hospitalized for > or = 5 days were screened for ESBLPE acquisition by means of weekly rectal sampling and clinical cultures. Baseline characteristics and various ICU procedures in 62 cases of ESBLPE were compared with those for 205 patients without ESBLPE, with use of Cox's model. Risk for acquiring ESBLPE (Klebsiella pneumoniae in most cases) increased during the ICU stay, from 4.2% in the first week to 24% in the fourth week. Baseline characteristics were not different between the two groups. Urinary catheterization (P = .04) and arterial catheterization (P = .03) were independent risk factors for acquiring ESBLPE and probably reflected frequency of health care manipulations. The first site of ESBLPE acquisition was the digestive tract in 58 of the 62 patients; 28 infections developed in 22 patients, and these followed or occurred simultaneously with rectal colonization in 18 of those 22. DNA macrorestriction analysis suggested that the same strain was responsible for most cases. In conclusion, ESBLPE acquisition depends on length of stay in the ICU and the use of invasive procedures. Colonization is a prerequisite for infection.

Septic shock in patients with cirrhosis: hemodynamic and metabolic characteristics and intensive care unit outcome.

OBJECTIVES: To examine the hemodynamic and metabolic characteristics and ICU outcome of septic shock in patients with cirrhosis. DESIGN: Prospective, comparative study. Measurements performed in the first 24 hrs of septic shock. SETTING: A general hospital ICU. PATIENTS: Twelve patients with cirrhosis and 23 patients without cirrhosis admitted for septic shock. MEASUREMENTS AND MAIN RESULTS: Arterial pressure was measured using an arterial catheter. Pulmonary arterial and right atrial pressures were measured by using a pulmonary artery catheter. Cardiac output was determined by using the thermodilution method. Pulmonary arterial L-lactate plasma concentrations were measured using an automated spectrophotometer, and blood temperature was measured using a cardiac output computer. Arterial and mixed venous PO2, PCO2, and pH values were measured by using specific electrodes. Oxygen saturations and hemoglobin concentrations were measured using a hemoximeter. Patients with cirrhosis had decompensated liver disease (grade C of the Child-Pugh classification). The number of Gram-negative infections and therapeutic interventions were similar in both groups. Patients with cirrhosis had higher cardiac indices (5.14 +/- 0.52 [SE] vs. 3.91 +/- 0.30 L/min/m2, p less than .05), plasma lactate concentrations (9.0 +/- 2.0 vs. 5.2 +/- 0.7 mmol/L, p less than .05) and ICU mortality rates (100% vs. 43%, p less than .05), and lower blood temperatures (35.5 +/- 0.6 vs. 37.6 +/- 0.2 degrees C, p less than .05) than patients without cirrhosis. Systemic vascular resistance, arterial pressure, pulmonary arterial pressure, oxygen delivery and consumption, and arterial and mixed venous acid-base status were not significantly different between the two groups. CONCLUSIONS: In patients with cirrhosis, septic shock was characterized by severe liver dysfunction, low blood temperature, marked increases in cardiac index and lactic acidemia, and a 100% ICU mortality rate. These findings should be taken into account if patients with cirrhosis are to be included in controlled studies on septic shock.