[Profile of bacterial resistance in pediatric urinary tract infections in 2014]. / Étude du profil des résistances bactériennes dans les pyélonéphrites de l'enfant en 2014.

In pediatric units, bacteria-producing extended-spectrum-betalactamase (ESBL) have an increasing prevalence among bacteria causing febrile urinary tract infections (UTIs). The purpose of this study was to evaluate the epidemiology of bacteria resistance patterns observed in UTIs, in order to assess the current antibiotic treatment protocols. This study is based upon a single-center retrospective chart review of the cytobacteriological urine cultures performed in UTIs between 1 January and 31 December 2014, in the medical pediatric unit of the Caen University Hospital. Out of the total of 219 cases of UTI, 26.9% were recurrences of UTI, 18.3% were infections in infants less than 3 months old, 21% of the patients suffered from underlying uropathy, and 16.4% of the patients had recently been exposed to antibiotics. In 80.3% of the cases, Escherichia coli was found, while Enterococcus faecalis was found in 5.6%. The antibiograms proved that 33.5% of the bacteria were sensitive. Half of E. coli were resistant to ampicillin, 4.9% to cefixime, 4.9% to ceftriaxone, 1.1% to gentamicin, and 27.8% to trimethoprim-sulfamethoxazole. Nine E. coli and one Enterobacter cloacae produced ESBL, accounting for 4.6% of the UTIs. We did not find any bacteria-producing high-level cephalosporinase. Cefixime resistance was statistically linked to ongoing antibiotic treatment (OR=5.98; 95% CI [1.44; 24.91], P=0.014) and underlying uropathy (OR=6.24; 95% CI [1.47; 26.42], P=0.013). Ceftriaxone resistance was statistically related to ongoing antibiotic treatment (OR=6.93; 95% CI [1.45; 33.13], P=0.015). These results argue in favor of maintaining intravenous ceftriaxone for probabilistic ambulatory treatment. However, in case of hospitalization, cefotaxime can replace ceftriaxone, due to its lower ecological impact. Moreover, it is necessary to continue monitoring bacterial resistance and regularly review our treatment protocols.

Decline in antibiotic resistance and changes in the serotype distribution of Streptococcus pneumoniae isolates from children with acute otitis media; a 2001-2011 survey by the French Pneumococcal Network.

Streptococcus pneumoniae is an important cause of acute otitis media (AOM). The aim of this study was to evaluate trends in antibiotic resistance and circulating serotypes of pneumococci isolated from middle ear fluid of French children with AOM during the period 2001-2011, before and after the introduction of the PCV-7 (2003) and PCV-13 (2010) vaccines. Between 2001 and 2011 the French pneumococcal surveillance network analysed the antibiotic susceptibility of 6683 S. pneumoniae isolated from children with AOM, of which 1569 were serotyped. We observed a significant overall increase in antibiotic susceptibility. Respective resistance (I+R) rates in 2001 and 2011 were 76.9% and 57.3% for penicillin, 43.0% and 29.8% for amoxicillin, and 28.6% and 13.0% for cefotaxime. We also found a marked reduction in vaccine serotypes after PCV-7 implementation, from 63.0% in 2001 to 13.2% in 2011, while the incidence of the additional six serotypes included in PCV-13 increased during the same period, with a particularly high proportion of 19A isolates. The proportion of some non-PCV-13 serotypes also increased between 2001 and 2011, especially 15A and 23A. Before PCV-7 implementation, most (70.8%) penicillin non-susceptible pneumococci belonged to PCV-7 serotypes, whereas in 2011, 56.8% of penicillin non-susceptible pneumococci belonged to serotype 19A. Between 2001 and 2011, antibiotic resistance among pneumococci responsible for AOM in France fell markedly, and PCV-7 serotypes were replaced by non-PCV-7 serotypes, especially 19A. We are continuing to assess the impact of PCV-13, introduced in France in 2010, on pneumococcal serotype circulation and antibiotic resistance.

Campylobacter coli cultured from the stools of a patient with immunoproliferative small intestinal disease.

Campylobacter has been associated with immunoproliferative small intestinal disease (IPSID), on the basis of 16S rDNA sequencing, in situ hybridization, and immunohistochemistry. Here, for the first time, we have cultured Campylobacter from the stools of a patient with IPSID. Phenotypic analysis and whole genome sequencing identified Campylobacter coli. PCR on a IPSID tissue biopsy sample was positive for Campylobacter coli and negative for Campylobacter jejuni. These findings further support a causative role for Campylobacter in the development of IPSID.

[Hemolytic and uremic syndrome and maternal-fetal Escherichia coli K1 infection]. / Syndrome hémolytique et urémique au décours d'une infection materno-fœtale àEscherichia coli K1.

Hemolytic uremic syndrome (HUS) is primarily a disease of infancy and early childhood. In its classic form, it is preceded by a prodrome of Escherichia coli-mediated bloody mucoid diarrhea. Typical HUS is commonly related to an infection by shiga-toxin producing E. coli. Stool cultures may detect this bacteria or its toxin, and PCRs can detect the shiga-toxin virulence genes. Atypical cases of HUS are mainly related to abnormalities of the alternative complement pathway and mutations of H, I, or B factors. Some atypical cases of HUS may also be related to von Willebrand factor or vitamin B12 metabolism abnormalities. A number of HUS cases related to invasive pneumococcal infections (pneumonia or meningitis) have been reported. We report a case of HUS associated with a bacterial E. coli K1 infection in a newborn baby, with a good clinical outcome: there was no need for dialysis and normal renal function was quickly regained. The workup did not favor a toxinic origin or an abnormality on the alternative complement pathway.

[Complete heart block and myocardial ischaemia during a severe anaphylactic reaction]. / Bloc auriculoventriculaire complet peranesthésique et ischémie myocardique contemporains d'un choc anaphylactique grave.

An 83-year-old man had to be operated under general anaesthesia for a head skin tumor. The preanaesthetic exam of the cardiovascular function was reassuring but a cardiac arrest with a complete heart block occurred a few minutes after induction of anaesthesia. Resuscitation managing was successful but a myocardial ischaemia appeared. Biological tests confirmed severe anaphylactic reaction. The electrocardiographic expression, pathophysiology and management of cardiac anaphylaxis are discussed.

Tracing of Enterobacter sakazakii isolates in infant milk formula processing by BOX-PCR genotyping.

AIMS: Enterobacter sakazakii is an emerging food-borne pathogen that can cause rare but severe neonatal meningitis, bacteraemia and necrotizing enterocolitis. Contaminated powder infant formulae (PIF) have been identified as one of various infection routes. In this study, E. sakazakii was monitored in the processing environment of a PIF factory to identify possible dissemination routes. METHODS AND RESULTS: The BOX-polymerase chain reaction (PCR), a fingerprinting technique which targets the repetitive BOX sequences, was used in routine to identify points of contamination and investigate clonal persistence. Two hundred E. sakazakii isolates were collected and typed. Most (70%) showed the same fingerprint that revealed the persistence of resident E. sakazakii strains in the processing environment. This method allowed to detect contamination of some PIF by dry-blending ingredients. CONCLUSIONS: Environment was the major cause for contamination of PIF and facilities. Some raw materials delivered as powder were also implicated. SIGNIFICANCE AND IMPACT OF THE STUDY: Routine BOX-PCR genotyping was very useful to trace and investigate in real-time dissemination of micro-organisms in the PIF plant and to implement a series of additional control measures to reduce the risk of final product contamination by E. sakazakii.

Genotypic characterization of Enterobacter sakazakii isolates by PFGE, BOX-PCR and sequencing of the fliC gene.

AIMS: Enterobacter sakazakii is an emerging food-borne pathogen that can cause rare but severe forms of neonatal meningitis, bacteraemia and necrotizing enterocolitis. A rapid typing method at the strain level is needed to determine the monoclonality or polyclonality of the isolates during outbreaks. METHODS AND RESULTS: The BOX-PCR fingerprinting technique, which targets the repetitive BOX sequences, and sequencing of the flagellin gene, fliC, were evaluated against a panel of 27 Ent. sakazakii strains from clinical and environmental sources. The typeability and discriminatory power of the techniques were compared with those of pulsed-field gel electrophoresis (PFGE), the reference genotyping method. BOX-PCR results yielded 92% agreement with PFGE results, whereas fliC gene sequencing was poorly discriminative. CONCLUSIONS: In our study, BOX-PCR and PFGE were similarly discriminatory to type Ent. sakazakii strains. The weak variability of the Ent. sakazakii fliC gene was related to the absence of the variable central domain present in most fliC genes of Enterobacteriaceae. SIGNIFICANCE AND IMPACT OF THE STUDY: The BOX-PCR typing provides an accurate discrimination and a rapid answer to identify clonal isolates of Ent. sakazakii.

[Legionella pneumonia in an immunocompetent child]. / La légionellose chez l'enfant immunocompétent: a propos d'un cas.

We report a case of Legionella pneumonia in an immunocompetent child. Legionella pneumonia is a rare pathology among children, and even rarer when they are immuno-competent; a few cases have been reported in the literature. This is explained by the fact that infection occurs primarily to immuno-suppressed patients. Legionella bacteria are not systematically sought for in front of child's atypical pneumonia, contrary to Mycoplasma or Chlamydiae. In addition, a number of cases are probably not even noticed because either not serious (Pontiac fever), spontaneously cured, or cured with macrolides prescribed in the case of suspected pneumonia with Mycoplasma.

Clinical and microbiological epidemiology of Streptococcus pneumoniae bacteremia in eight French counties.

OBJECTIVE: To describe the incidence of pneumococcal bacteremia not associated with infection of the central nervous system, investigate the susceptibility of bacterial isolates to beta-lactams, evaluate risk factors for antibiotic resistance, and determine factors predicting patient outcome. METHODS: Over a period of 1 year, 919 Streptococcus pneumoniae isolates were collected from 919 patients with bacteremia in eight French counties. Their clinical and microbiological features were recorded. Univariate and multivariate analyses were used to determine risk factors for penicillin-non-susceptible pneumococcal bacteremia and predictors of fatal outcome. RESULTS: Of the 919 patients in the study, 27% were infected with penicillin-non-susceptible pneumococci (PNSP): 17.8% of the isolates were intermediate to penicillin, 7.2% were resistant to penicillin, 16% were intermediate to amoxicillin, and 11% were intermediate to cefotaxime; no PNSP were resistant to either of the last two antibiotics. The most common PNSP serotypes isolated were 14 (41%) and 23 (24%). A statistically significant relationship between PNSP infection and age below 5 years or above 60 years in the different counties was observed by univariate and multivariate analysis. Gender, origin of bacteremia, co-morbidity, immunodeficiency, previous hospitalization and nosocomial infection were not predisposing factors associated with PNSP. The mortality rate was 20.6%: there was no increase in mortality among patients with PNSP bacteremia. Age was the strongest risk factor for mortality, but immunodeficiency also seemed to have had an impact on mortality. Clinical outcome was more closely related to clinical conditions than to the susceptibility status of S. pneumoniae. CONCLUSION: Among cases of bacteremia, 27% were caused by PNSP, but this level varies according to the counties and the age of the patients. Infection-related mortality was high, but there was no increase related to penicillin G non-susceptibility of the infecting strain.

[Pneumococcal antibiotic resistance. Results from 21 regional registries for 1999]. / Résistance du pneumocoque aux antibiotiques. Résultats de 21 observatoires régionaux pour l'année 1999.

IN ADULTS: The prevalence of reduced susceptibility to penicillin was an estimated 40% with rates of 23% for amoxicillin and 15% for cefotaxime. For resistant strains, the rates were 11% for penicillin, 1.3% for amoxicillin and 0.3% for cefotaxime. For respiratory tract samples grouped together, pneumococcal resistance to antibiotics, erythromycin excepted, has increased little in France since 1997. For lung samples, beta-lactam activity has remained stable with only rare strains exhibiting amoxicillin and cefotaxime resistance. IN CHILDREN: The prevalence of reduced susceptibility to penicillin was 53%, 32% for amoxicillin and 22% for cefotaxime. Despite a high rate of penicillin-G resistant strains (16%), amoxicillin and cefotaxime resistant strains remain rare, 2.8% and 1.2% respectively. For all samples grouped together, pneumococcal resistance to antibiotics, erythromycin excepted, has increased little in France since 1997. There has however been an alarming rise in resistance of strains isolated from blood cultures. Globally, beta-lactam activity has remained stable and only rare amoxicillin and cefotaxime resistant strains have been isolated, including middle ear fluid sample. SEROTYPE DISTRIBUTION: Among the strains with reduced susceptibility to penicillin isolated in 1999, the more frequent serotypes were serotypes 6, 9, 14, 15, 19 or 23.

Macrolide resistance phenotypes and genotypes in French clinical isolates of Streptococcus pneumoniae. Observatoire de Normandie du Pneumocoque.

The aim of this study was to analyze the mechanisms of macrolide resistance in French clinical isolates of Streptococcus pneumoniae. A total of 838 strains of pneumococci were isolated in 1997 in Normandy, a region of western France, by 19 microbiology laboratories. Fifty-three percent had displayed diminished susceptibility to penicillin G and 50% were resistant to erythromycin. From this collection, 92 penicillin-intermediate or -resistant and 18 penicillin-susceptible strains resistant to erythromycin were studied. The presence of erm genes coding for ribosomal methylases and of mefE-like genes responsible for macrolide efflux was screened by a multiplex polymerase chain reaction and confirmed by DNA/DNA hybridization. Of the 110 strains studied, 108 were cross-resistant to erythromycin, spiramycin and clindamycin, including 105 strains containing ermB-related genes and three strains that contained a combination of ermB- and mefE-related genes. Two strains apparently susceptible to clindamycin but resistant to spiramycin also contained ermB-related genes. No strain was resistant to erythromycin alone or contained only a mef-like gene. Therefore, resistance to erythromycin is mostly related to ribosomal methylation in this region of France.

In vitro activity of fusidic acid against streptococci isolated from skin and soft tissue infections.

The in vitro activity of fusidic acid was evaluated against 242 strains of streptococci isolated from skin and soft tissue infections during a prospective multicentre study. Nearly 90% of strains were isolated from dermatology, emergency and medicine units. Groups A, B, C and G streptococci represented, respectively, 41.9, 20.6, 4.4 and 27.8% of the strains. The activity of fusidic acid was dependent on the media used. MICs were generally one dilution lower with heart infusion agar than with Mueller-Hinton agar supplemented with 5% horse blood (MIC(90) for the whole streptococcal population = 8 mg/L and 16 mg/L, respectively). The distribution of MICs was unimodal and only two strains displayed MICs of fusidic acid >/= 64 mg/L. In both media, fusidic acid was moderately active against streptococci. However, antibiotic concentrations obtained in the skin exceed the MIC(90) of fusidic acid for streptococci, possibly explaining its clinical efficacy in the treatment of common cutaneous infections.

Mechanisms of severe, immediate reactions to iodinated contrast material.

PURPOSE: To measure and elucidate the mechanisms of presumed mediators of unexpected severe, immediate reactions to iodinated contrast materials. MATERIALS AND METHODS: In a multicenter study, 20 patients with mild to severe reactions to iodinated contrast material and 20 control subjects without reactions were evaluated. Ionic contrast material was associated with 18 (90%) of 20 reactions. Concentrations of plasma histamine, tryptase, urinary methylhistamine, specific immunoglobulin E (IgE) against ioxitalamate or ioxaglate, and the anaphylatoxins C3a and C4a were measured with radioimmunoassays; complement C3 and C4 levels were measured with nephelometry. RESULTS: Histamine levels were increased in 14 patients; tryptase levels, in 16; and methylhistamine levels, in six. Histamine and tryptase values correlated with the severity of the reaction (P < .02 and P < .004, respectively). Significantly higher levels of specific IgE against ioxaglate (P < .005) and ioxitalamate (P = .045) were found in patients. No differences were found for complement fractions. Skin test results in two patients with life-threatening reactions were positive for the administered contrast material. CONCLUSION: Histamine release and mast cell triggering are related to severe reactions. An IgE-related mechanism is strongly suspected. Radiologists should be trained to identify and treat anaphylactic shock in patients who react to iodinated contrast material.

Molecular study of nosocomial nocardiosis outbreak involving heart transplant recipients.

Randomly amplified polymorphic DNA analysis and rRNA gene restriction patterns (ribotyping) were compared as methods of investigating a nosocomial outbreak of nocardiosis involving three heart transplant recipients. No clear distinctions between three clinically related isolates and four unrelated strains were obtained by ribotyping. On the contrary, randomly amplified polymorphic DNA analysis with two selected primers, primers 2650 and DKU49, showed one pattern for the three related isolates and four patterns for the unrelated strains.

[Anaphylactoid reactions to an injectable solution of a cremophor-containing solution of multivitamins]. / Réactions anaphylactoïdes à une solution polyvitaminée injectable contenant un crémophore.

We report four anaphylactoid reactions after intravenous administration of a cremophor-containing multivitamin hydrosol (Hydrosol Polyvitaminé Roche), observed over an 8-month period in a small region of France. The reactions occurred immediately following intravenous infusion of either ionic solutions or parenteral nutrition mixture containing the multivitamin solution. In three cases, erythema and dyspnoea appeared within minutes. The infusion was rapidly stopped and corticosteroids were given to two patients. The fourth patient had erythema and swelling of the face within 30 min of infusion, and severe bronchoconstriction and hypotension within 60 min, before infusion was stopped. In-vivo histamine release from mast cell was proved. These reactions are highly suggestive of an anaphylactoid mechanism, due to the multivitamin solution, as all the other drugs were continued without subsequent reactions. The responsible agent is thought to be polyethoxylated castor oil (Cremophor EL), as it is known to produce such effects. Medical practitioners should evaluate the risk/benefit ratio each time they give this drug.