Surveillance of adverse events following vaccination in the French armed forces, 2011-2012.

OBJECTIVES: French military personnel are subject to a compulsory vaccination schedule. The aim of this study was to present the results of surveillance of vaccine adverse events (VAEs) reported from 2011 to 2012 in the French armed forces. STUDY DESIGN: VAEs were surveyed among all French armed forces from 2011 to 2012 by the epidemiological departments of the military health service. For each case, a notification form providing patient and clinical information was provided. METHODS: Case definitions were derived from the French drug safety guidelines. Three types of VAE were considered: non-serious, serious and unexpected. Incidence rates were calculated by relating VAEs to the number of vaccine doses delivered. RESULTS: In total, 161 VAE cases were reported. The overall VAE reporting rate was 24.6 VAEs per 100,000 doses, and the serious VAE rate was 1.3 per 100,000 doses (nine cases). The serious VAEs included two cases of Guillain-Barré syndrome, one case of optic neuritis, one case of a meningeal-like syndrome, one case of rheumatoid purpura, one case of acute asthma and three cases of fainting. The highest rates of VAE were observed with the Bacille Calmette-Guérin vaccine (BCG) (482.3 per 100,000 doses), inactivated diphtheria-tetanus-poliovirus with acellular pertussis vaccine (dTap-IPV) (106.1 per 100,000 doses) and meningococcal quadrivalent glycoconjugate vaccine (MenACWY-CRM) (39.3 per 100,000 doses). CONCLUSIONS: The global rates of VAE observed in 2011 and 2012 confirm the increase that has been observed since 2009 in the French armed forces, which could reflect improved practitioner awareness about VAEs and the use of certain vaccines added to the vaccination schedule recently (dTap-IPV in 2008 and MenACWY-CRM in 2010). VAEs appear to be relatively rare, particularly serious VAEs, which indicates acceptable tolerance of vaccines.

Multilocus variable number tandem repeat analysis for Salmonella enterica subspecies.

Genomic analysis of Salmonella enterica revealed the existence of a variable number of tandem repeats (VNTR) at multiple loci. Some S. enterica strains are considered as references (Typhi Ty2, Typhi CT18, Typhimurium LT2, Enteritidis LK5, PT4, and Enteritidis 07-2642, and Newport). These allowed the selection of markers to develop the genotyping technique, multiple-locus VNTR analysis (MLVA). These markers were used to discriminate S. enterica isolated from humans, food, or the environment. In this report, the characteristics and specifications of 58 salmonella markers described from 2003 to 2009 are analyzed. Some VNTR loci were used as markers. The markers were used to discriminate S. enterica isolates from different sources and geographical localizations. Among the VNTR loci described in the published reports, eight presented with a high diversity index (DI) of polymorphism of more than 0.80. The selection of several markers within a single locus validated their polymorphism characteristic. Despite unequal DI values, the use of a panel of markers is a powerful discriminatory tool for the surveillance and identification of the source of salmonella outbreak. Depending on the markers selected, MLVA should be used either for macro- or microepidemiological purposes. The main challenge in the future for this technique is standardization.

Changing species distribution and antimicrobial susceptibility pattern of Shigella over a 29-year period (1980-2008).

We studied changes in species distribution and antimicrobial resistance patterns of Shigella during 1980-2008, using the Diarrhoeal Diseases Surveillance system of Dhaka Hospital of ICDDR,B. In hospitalized patients Shigella prevalence decreased steadily from 8-12% in the 1980s to 3% in 2008. Endemic S. flexneri was the most commonly isolated species (54%). Epidemic S. dysenteriae type 1 had two peaks in 1984 and 1993, but was not found after 2000, except for one case in 2004. The therapeutic options are now limited: in 2008 a total of 33% of S. flexneri were resistant to ciprofloxacin and 57% to mecillinam. In the <5 years age group, severely underweight, wasted and stunted children were more at risk of shigellosis compared to well-nourished children (P<0·001). Although hospitalization for Shigella diarrhoea is decreasing, the high levels of antimicrobial resistance and increased susceptibility of malnourished children continue to pose an ongoing risk.

[Noroviruses: leading cause of gastroenteritis]. / Les norovirus: une cause majeure des gastro-entérites.

Although noroviruses were the first viral agents to be linked to gastrointestinal disease, they were long considered a secondary cause far behind rotaviruses. Development of molecular-based diagnostic techniques has provided clearer insight into the epidemiological impact of noroviruses that are now recognized not only as the leading cause of non-bacterial gastroenteritis outbreaks but also as an important cause of sporadic gastroenteritis in both children and adults. Norovirus infection is generally characterized by mild acute vomiting and diarrhea usually lasting for only a few days, but it can lead to more severe and potentially life-threatening symptoms in high-risk groups such as young children, elderly, and immunodeficient persons. It has been demonstrated that they are present in tropical countries. Molecular epidemiological studies have documented the great genetic diversity of noroviruses with regular emergence of variants. Since no vaccine is available, prevention on norovirus infection depends mainly on strict personal and community hygiene measures.

Noroviruses: a challenge for military forces.

For military forces, the control of infectious acute gastroenteritis constitutes an old, constant and unsolved concern. Recent epidemiological studies suggest that the common bacterial causes are being overtaken by viruses. Norviruses are the most alarming group and norovirus outbreaks in military forces are regularly reported. Illness is generally mild and characterised by acute vomiting and diarrhoea, which lasts for a few days on average, but may be severe and potentially life-threatening in subjects who are already dehydrated due to daily activity. Moreover, outbreaks may diminish operational effectiveness. Prevention of norovirus infection currently relies on strict application of personal and collective hygiene rules including isolation of the cases, to the greatest possible extent. Although noroviruses are frequently mentioned as the cause of gastroenteritis outbreaks in troops deployed overseas, laboratory diagnosis is rarely done. So their real burden in military forces remains unclear and further epidemiological studies are required to determine the full impact of norovirus gastroenteritis on troops.

A travel misadventure--visceral leishmaniasis in an immunocompetent patient.

Visceral leishmaniasis is one of the world's most neglected diseases. Over 90% of the 500,000 annual new cases occur in only five countries: India, Nepal, Bangladesh, Sudan and North-Eastern Brazil, but the disease remains endemic in Southern Europe. We report a case of visceral leishmaniasis in an immunocompetent serviceman after a seven-day stay in the Marseilles region of South-Eastern France. This case is intended to alert clinicians to the possibility of visceral leishmaniasis in patients who develop a febrile illness after returning from travel in Southern European countries.

[Diagnosis of tuberculosis in developing countries: new perspectives]. / Diagnostic biologique de la tuberculose dans les pays à faibles ressources: perspectives nouvelles.

Tuberculosis (TB) is still a major public health problem in the world despite the ambitious goals of the DOTS strategy, i.e., detection of 70% of new cases and successfully treatment of at least 85% of those cases. One of the main reasons for this relative failure is lack of a sensitive method for reliable diagnosis particularly in HIV-positive patients. Development of new diagnostic tools is a top priority in the WHO's "Global plan to stop TB, 2006-2015". Numerous avenues of research have been proposed including development of immunological tests to detect antigens and antibodies, cutaneous tests, respiratory tests, improved solid or liquid culture techniques, alternatives to culture techniques, molecular biology techniques, etc. Some of these techniques will require long-term development and others will probably never be suitable for routine diagnosis. However a few innovations such as optimization of direct microscopic examination using new lower-priced fluorescence microscopes are ready for rapid deployment. Another promising area of research involves immunoenzymatic testing on urine samples. In any event clinical trials will be necessary to demonstrate the efficacy of these new diagnostic tools. These trials must be conducted and controlled under field conditions in the geographical zones where they will be used, i.e. in low-income countries with high incidences of TB.

Assessment of vaccination coverage of adolescents aged 16-18 years with an innovative electronic immunization record system.

OBJECTIVES: To measure vaccine coverage among adolescents aged 16-18 years who participated in the National Defense Preparation Day in the Aquitaine region using the free electronic immunization record. PATIENTS AND METHODS: We considered adolescents aged 16-18 years who participated in the National Defense Preparation Day in the Aquitaine region from April to October 2013. All participants received a letter explaining how to create an electronic immunization record. Those records were then validated by checking data against the copies of the vaccination cards brought by participants on the day they attended. Vaccination coverage was estimated for eight vaccinations according to the cumulative number of doses registered and vaccines recommended during childhood. RESULTS: Among the 18,714 participants, 9636 agreed to create an electronic immunization record of which 2781 were validated. Vaccination coverage was˃90% for tuberculosis, diphtheria-tetanus-poliomyelitis, measles-mumps-rubella, and Haemophilus influenzae type B, and˂90% for pertussis, hepatitis B, meningococcal C disease, and human papillomavirus. These coverage rates were close to those reported in other available sources. CONCLUSION: Our study calls attention to the insufficient vaccination of adolescents for pertussis, HBV, meningococcal C disease, and HPV. The absence of a system that routinely provides the vaccination status of this population is a major public health issue in France. The use of an electronic immunization record was innovative, but this tool is not extensively used in the general population and has been evaluated by Santé publique France (the French national public health agency).

[Panton-Valentine leukocidin-producing Staphylococcus aureus responsible for necrotizing pneumonia]. / Pneumopathie nécrosante à Staphylococcus aureus producteur de la leucocidine de Panton-Valentine.

Panton-Valentine leukocidin-producing (PVL) Staphylococcus aureus is responsible for a highly lethal necrotizing pneumonia, which occurs predominantly in young immunocompetent patients. Hemoptysis and leucopenia often occur but are not always present. Detection of PVL gene on S. aureus strains responsible for pneumonia should help us to a better understanding of this disease, to improve its treatment with antibiotics capable of lower the toxin production and to prevent its diffusion to others persons by detection and elimination of a nasal S. aureus carriage.

[Contact tracing in a case of tuberculosis in a health care worker]. / Investigations autour d'un cas de tuberculose d'un soignant.

INTRODUCTION: Tuberculosis is a public health problem, of which the nosocomial transmission from a health care worker to patients has not been well documented. OBSERVATIONS: A Senegalese surgeon aged 32 was admitted to hospital on account of deterioration in his general health. He was found to have sputum positive tuberculosis and received standard treatment. We report the strategy employed for tracing the contacts of this health care worker. Of a total of 185 members of staff (permanent and temporary) and 91 patients who had been in contact with the index case, 180 (97.3%) and 71 (78%) respectively were screened. Of the 251 subjects screened, 5 staff (2.8%) and 11 patients (15.4%) showed evidence of latent tuberculous infection and 6 were treated. In total 97.3% of staff exposed were screened at the beginning of the study and 63% were reviewed at 3 months as opposed to 78% and 53% for the patients. CONCLUSION: This study shows poor compliance with the visit 3 months after exposure and the need to standardise the procedures in order to improve the screening and follow up of contacts.

[Bacillus licheniformis: an unusual cause of erysipelosis]. / Bacillus licheniformis: agent causal d'érysipèle.

The authors report a case of a cutaneous infection due to Bacillus licheniformis. It occurred after a wound due to a wicker splinter. The bacteriological identification was easy thanks to the very typical aspects of culture. First intention antibiotherapy given for bacterial dermo-hypodermatitis may be ineffective because Bacillus licheniformis secretes a biofilm and is frequently resistant to Beta-lactams.

[Maxillary sinus infection by Bacillus licheniformis: a case report from Djibouti]. / Sinusite maxillaire due à Bacillus licheniformis: à propos d'un cas survenu à Djibouti.

Aerobic, spore-forming gram-positive Bacillus spp infections are rare and reported mainly in immunocompromised hosts. We report a case of acute unilateral maxillary sinusitis, caused by Bacillus licheniformis, in a 35-year-old French soldier stationed in Djibouti. It was easily identifiable due to its typical culture and resistance profile. This case is interesting for two reasons: first, it is, to our knowledge, the first case of sinusitis attributed to this microbe, and second, it has rarely been described in immunocompetent patients without altered skin or mucous membranes.

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.

A plasmid-mediated CMY-2 beta-lactamase from an Algerian clinical isolate of Salmonella senftenberg.

Multiresistance to antibiotics including beta-lactams, e.g. cefoxitin, was transferred by conjugation to Escherichia coli strain C1a from a clinical isolate of Salmonella senftenberg recovered from stools of an Algerian child. The susceptibility pattern to beta-lactams was similar to the profile mediated by an AmpC-type beta-lactamase. By biochemical analysis, typical AmpC-type enzyme substrate and inhibition profiles were obtained. Finally, an ampC plasmid-encoded beta-lactamase gene was cloned and sequenced. Its deduced amino acid sequence confirmed its identity as a class C beta-lactamase. It showed 99.5% sequence identity with the plasmid-mediated beta-lactamase CMY-2. The differences in the amino acid sequences of the two enzymes were located in the signal peptide.

Surveillance of methicillin-resistant Staphylococcus aureus (MRSA) and Enterobacteriaceae producing extended-spectrum beta-lactamase (ESBLE) in Northern France: a five-year multicentre incidence study.

In order to measure the incidence of methicillin-resistant Staphylococcus aureus (MRSA) and of Enterobacteriaceae producing extended-spectrum beta-lactamase (ESBLE), and to evaluate the impact of the national guidelines for multidrug-resistant bacteria (MDRB) prevention in hospitals of Northern France, a multicentre study was conducted for three months every year starting in 1996, in volunteer hospital laboratories. All clinical specimens positive for MRSA and ESBLE were prospectively surveyed. During the five-year surveillance period, the overall proportion of MRSA was 38.4% in the 28,534 strains of S. aureus, and that of ESBLE was 11.4% in the 6121 strains of Klebsiella pneumoniae and 47.7% in the 2353 strains of Enterobacter aerogenes. The overall incidence rates of clinical specimens positive for MRSA, ESBL-K. pneumoniae and E. aerogenes were 0.84. 0.05 and 0.12/1000 hospital-days (HD), respectively. In the 23 hospitals that participated in the survey every year, the proportion and incidence of ESBLE decreased. Hence, despite recommendations as for isolation precautions, MRSA remains poorly controlled and requires more effective measures.

[Antibiotic sensitivity of aerobic gram-negative bacilli isolated from severe infections in 1992: results of a French multicenter study. Groupe d'Etude d'Infections à bacilles à Gram Négatif (GEIGN)]. / Sensibilité aux antibiotiques des bacilles à Gram négatif aérobies isolés d'infections sévères en 1992: résultats d'une étude multicentrique française. Groupe d'Etude d'Infections à bacilles à Gram Négatif (GEIGN).

OBJECTIVES: Antibiotic susceptibility of 649 gram-negative bacilli involved in severe infections and isolated in 18 teaching hospitals from January to December 1992 was evaluated. METHODS: Minimal Inhibitory Concentrations were determined by agar dilution method for piperacillin, piperacillin+ tazobactam and imipenem, and by a microdilution method for 11 other antibiotics (amoxicillin, amoxicillin + clavulanic acid, cefotaxime, ceftazidime, aztreonam, ticarcillin, ciprofloxacin, fosfomycin, tobramycin, gentamicin, amikacin). Criteria of Comité Français de l'Antibiogramme de la Société Française de Microbiologie were followed for interpretation. Betalactamases were identified by isoelectric focusing and overproduction of cephalosporinase was defined by the resistance phenotype. The main species isolated were Escherichia coli (45%), Pseudomonas aeruginosa (14%), Klebsiella pneumoniae (7.8%), Salmonella spp. (7.5%), Enterobacter cloacae (4%) and Klebsiella oxytoca (4%). Most of the strains were isolated from blood culture (72.3%), respiratory tract (11.4%) and intraabdominal infections (8.6%). Most of the enterobacteria isolates were susceptible to imipenem, aztreonam, amikacin and ciprofloxacin (percentages of susceptibility were respectively 99.3, 98, 98.3 and 96.3); in most of cases clavulanic acid did not entirely restore sensitivity to amoxicillin of penicillinase-producing strains. Among 89 P. aeruginosa strains, 82% were susceptible to imipenem and ceftazidime, 81% to the association piperacillin + tazobactam and 51% to ticarcillin. Resistance rates are very high for Acinetobacter baumannii except for imipenem. CONCLUSION: Production of TEM-type penicillinase and over-production of the chromosomal cephalosporinase are the most widely observed mechanisms of resistance (respectively 22% and 9% of 649 strains). Prevalence of extended spectrum betalactamases was low (1%) and essentially observed for K. pneumoniae.

[Sensitivity to antibiotics of bacteria from nosocomial infections. Evolution in resuscitation services of military hospitals]. / Sensibilité aux antibiotiques des bactéries d'infections nosocomiales. Evolution dans les services de réanimation des hôpitaux des armées.

OBJECTIVE: The aim of this study, conducted in the French Military hospitals, was to monitor the course of the antimicrobial sensibility of bacteria isolated from nosocomial infection in intensive care units. PATIENTS AND METHODS: A prospective study has been conducted from January to December 1998 in all the intensive care units of the French Army. All the non-repetitive strains isolated from nosocomial infection were collected and sent to a reference centre. Antimicrobial susceptibility was determined by the agar dilution method. Beta-lactamase were identified by iso-electro-focalisation. Antibiotics choice and interpretative criteria were those of the "Comité Français de l'Antibiogramme de la Société Française de Microbiologie". RESULTS: A total of 849 strains are included in this study. Pseudomonas aeruginosa was the most frequently isolated bacterium (20%) followed by Escherichia coli (19%) Staphylococcus aureus (15%), coagulase-negative Staphylococci (CoNS) (11%) and Enterococci (7%). Imipenem was the most effective antibiotic against enterobacteriaceae (336 isolates; 100% susceptibility). Gentamicin (92%), amikacin (92%) third generation cephalosporins (83%), aztreonam (83%) and ciprofloxacin (78%) were also very effective. Resistance to III generation cephalosporins was correlated with an extended spectrum beta-lactamase (BLSE) in 36% of cases. This BLSE could be associated with an over production of the constitutive cephalosporinase. The most frequent species producing BLSE were Enterobacter aerogenes (75% of BLSE) and Klebsiella pneumoniae (17%). Among the 172 P. aeruginosa isolated, antimicrobial susceptibility were respectively: 71% for imipenem, 62%: tobramycin, 60%: amikacin 59%: ciprofloxacin 59% piperacillin + tazobactam, 55% piperacillin, 53%: ceftazidime and 44% for ticarcillin. Seventy per cent of the 96 CoNS and 50.2% of the 126 S. aureus isolated were resistant to methicillin. A strain of S. aureus and 2 CoNS strains had intermediate resistance to teicoplanin. Twenty per cent of the 59 Enterococci strains isolated were resistant to aminopenicillins (10/11 strains of E. faecium), and 9% presented a high level of resistance to gentamicine. One strain of E. faecium was resistant to vancomycin. CONCLUSION: The evolution of the susceptibility to antibiotics in intensive care units reflects the antibiotic pressure and level of cross-transmission. High rates of meticillin-resistance among staphylococci, of resistance to beta-lactams antibiotics among P. aeruginosa and of ciprofloxacin among Enterobacteriaceae are shown in this study. The implementation of appropriate strategies for surveillance and prevention is necessary.

[Antibiotic sensitivity of Salmonella isolated in army hospitals between 1998-1999]. / Sensibilité aux antibiotiques des salmonelles isolées dans les hôpitaux des armées en 1998-1999.

OBJECTIVES: Monitor the evolution in France of antibiotic sensitivity of non-typhoid salmonella isolated in fecal cultures conducted in army hospital laboratories. METHODS: A prospective study was performed from January 1998 to December 1999 in all the biology departments of the 11 army hospitals in France. All the non-repetitive strains were sent to an official center for serotyping and determination of the minimum inhibiting concentrations, by dilution in Mueller Hinton's gelose. The antibiotics currently used in treatment were tested and interpretation endpoints followed the recent recommendations of the Antibiogram committee of the French society of microbiology. Identification of beta-lactamase was conducted by iso-electric focalization and polymerization by chain reaction (PCR). For Salmonella Typhimurium, research for the specific resistance locus of the DT104 clone was made using PCR. RESULTS: Two hundred and twenty-two non-repetitive salmonella strains were isolated. The principle serotypes found were: Salmonella Enterididis (23.9%), S. Typhimurium (21.2%) and S. Hadar (10.8%). All the strains were sensitive to ciprofloxacin and cefotaxim, whereas one third exhibited reduced sensitivity to aminopenicillin. Depending on the serotype, Typhimurium and Hadar serotypes exhibited significantly lesser sensitivity to aminopenicillin, nalidixic acid and tetracycline. For S. Typhimurium, resistance is related to the diffusion of the multiresistant DT104 clone, which involves half of the strains of this serotype. For S. Hadar, 18 out of 24 strains (75%) were resistance to nalidixic acid, and 5 of them exhibited reduced resistance to ciprofloxacin. There was no difference in sensitivity to antibiotics between the strains responsible for diarrhea and those isolated in systematic examinations for capacity to work in the food trade (respectively 54 and 46% of strains). CONCLUSION: Non-typhoid salmonella are frequently isolated in diarrhea of infectious origin. The increasing resistance to antibiotics is primarily related to the diffusion of the DT104 clone, regarding S. Typhimurium and to the increase in resistance to quinolone, regarding S. Hadar.