[Septic arthritis in children with normal initial C-reactive protein: clinical and biological features]. / Arthrite septique de l'enfant à protéine C-réactive initialement normale : description clinique et biologique.

Septic arthritis has to be suspected in children with joint effusion and fever so as to perform joint aspiration, which will confirm the diagnosis by bacteriological methods, and to perform surgical treatment by joint lavage. Since development of current molecular methods, such as real-time PCR, Kingella kingae has become the first microbial agent of osteoarticular infections in young children, whereas Staphylococcus aureus is second. C-reactive protein (CRP) is an aid used to diagnose septic arthritis, but its elevation could be moderate. In a previous study, conducted at our hospital, 10% of children hospitalized for S. aureus or K. kingae septic arthritis had a CRP level<10 mg/L. To determine if diagnosis of septic arthritis could be made by other parameters, we analyzed the clinical and biologic features of these patients and compared them to those of children hospitalized for septic arthritis with initial CRP ≥10 mg/L. Among the 89 children with septic arthritis, 10% (n=9) had initial CRP<10 mg/L (K. kingae, n=5/63 ; S. aureus, n=4/26). Initial temperature and fibrinogen were significantly lower in the CRP<10 mg/L group than in the other (37.3°C vs. 37.9°C, P=0.039 and 4.19 vs. 5.72 g/L, P=0.003, respectively). Age, symptom duration before diagnosis, as well as leukocyte and platelet counts were similar in both groups. Two children (2/89=2.2%) with S. aureus septic arthritis had no fever, CRP elevation, or fibrinogen elevation. In the CRP-negative group, three of four children with S. aureus arthritis and one of five with K. kingae arthritis had a high CRP level (34, 40, 61, and 13 mg/L, respectively) 3 days after surgery and antibiotic treatment. One child with K. kingae septic arthritis and initial CRP<10 mg/L needed a second surgical drainage because of relapse of arthritis. In the S. aureus arthritis group, none of the children with initial CRP<10 mg/L experienced complications, while six of those with initial CRP≥10 mg/L needed a second surgical act or hospitalization in an intensive care unit. While CRP is most often>10 mg/L during septic arthritis in children, it could be negative in up to 20% of patients in different studies. However, a mild inflammatory syndrome or even a CRP<10 mg/L cannot exclude diagnosis of septic arthritis. Therefore, a first episode of monoarthritis in children has to be considered as septic arthritis and treatment should not be delayed.

[Study of nasopharyngeal colonization by Streptococcus pneumoniae and its antibiotics resistance in healthy children less than 2 years of age in the Marrakech region (Morocco)]. / Étude du portage rhinopharyngé de Streptococcus pneumoniae et de sa sensibilité aux antibiotiques chez les enfants en bonne santé âgés de moins de 2 ans dans la région de Marrakech (Maroc).

UNLABELLED: The healthy carrier of Streptococcus pneumoniae (S. pneumoniae) has been studied very little at the national level. With the emergence of antibiotic-resistant strains worldwide, and the emergence of new serotypes, an epidemiological survey is needed before the vaccine can be introduced in Morocco. OBJECTIVES: This study's objective was to determine the prevalence and risk factors of pneumococcal nasopharyngeal carriage in children less than 2 years of age in the Marrakech region and to assess the antibiotic susceptibility of the isolates and the serotypes present prior to the introduction of the conjugate pneumococcal vaccine. PATIENTS AND METHODS: From 2008 to 2009, 660 nasopharyngeal samples were collected on children under 2 years of age during scheduled visits to dispensaries for routine immunization in the Marrakech region. RESULTS: S. pneumoniae carriage was found in 45.8% of children. Of the 660 samples, 302 strains were isolated. The percentage of pneumococcal strains with reduced susceptibility to penicillin (PRSP) was 34.7%. Among these strains, 87.1% showed low-level resistance and 12.9% high-level resistance. Resistance to amoxicillin was found in 3.3% of the strains and no strains were resistant to cefotaxime. Several risk factors for pneumococcal carriage were identified, the main ones being breastfeeding less than 2 months, the presence of more than one sibling, passive smoking, and low socioeconomic level. The most frequent serotypes were 19F, 6, 14, 23, 18, and 9. The study of the vaccine serotype distribution showed that the theoretical vaccine coverage of the 7 valent vaccines was at 57% for all the isolates. CONCLUSION: These data show the frequency and the risk factors on nasopharyngeal carriage, and report the status of penicillin resistance of strains carrying children less than 2 years of age in the Marrakech region. The fluctuation of circulating serotypes at the national level underscores the importance of epidemiological surveillance carried out before the introduction of the heptavalent vaccine in Morocco.

[Extended-spectrum beta-lactamase producing-enterobacteriaceae]. / Entérobactéries productrices de bêta-lactamases à spectre étendu.

Extended-spectrum beta-lactamase (ESBLs) are defined as ß-lactamase capable of hydrolyzine oximino-cephalosporins and aztreonam and are encoded by mobile genes. The most frequently encountered ESBLs belong to the CTX-M, SHV, and TEM families. ESBLs were found first in Klebsiella pneumonia and then predominantly in E. coli. The incidence of patients with ESBLs E. coli increase since 2000 in Robert Debré Hospital. They were responsible of cystitis or pyelopnephritis and rarely of materno-foetal infections or neonatal meningitis. These strains were susceptible to colimycin, carbapenems and fosfomycin.

[Ureaplasma urealyticum and Mycoplasma hominis infections in newborns: personal data and review of the literature]. / Ureaplasma urealyticum, Mycoplasma hominis et pathologies néonatales: Données personnelles et revue de la littérature.

Ureaplasma urealyticum and Mycoplasma hominis colonized 20-40% of newborns and are more frequent in premature. They are responsible for localized infections such as pleural effusion, pneumopathy, adenopathy, abscess or systemic sepsis. An important hyperleukocytosis is often associated with pulmonary infections. Their responsibility, as pathogen agents, is questionable in some non bacterial meningitis. There is large controversy for their role as cofactor, in chronic lung disease (bronchopulmonary dysplasia) and periventricular leukomalacia, because of a too low number of newborns in prospective trials. Genital mycoplamas are resistant to beta lactamines. Macrolides have a good sensitivity, particularly josamycine, but Mycoplasma hominis is resistant to erythromycin. For systemic sepsis, fluoroquinolones such as ciprofloxacine have less deleterious effects than IV erythromycin.

[Current Streptococcus pyogenes sensitivity responsible for acute tonsillopharyngitis in France]. / Sensibilité actuelle en France de Streptococcus pyogenes responsable d'angine aiguë.

OBJECTIVE: Current guidelines recommend that only tonsillopharyngitis due to group A beta-haemolytic streptococcus (GABHS) diagnosed by rapid diagnostic test should be treated with antibiotics. Empirical antibiotic therapy must be based on epidemiological surveillance of resistance of GABHS to antibiotics. The aim of our study was to assess the activity of antimicrobial agents currently recommended for the treatment of GABHS tonsillopharyngitis. Method The activity of penicillin G, amoxicillin, cefaclor, cefpodoxime, cefuroxime, erythromycin, clarithromycin and clindamycin was determined against 93 consecutive GABHS isolates collected in 2002. MIC50 and MIC90 of antibiotics tested were determined by agar dilution method according to CA-SFM guidelines. Macrolide resistance genes (ermA, ermB, mef) were detected by PCR. Genetic diversity of erythromycin-resistant isolates was analysed by pulsotypic method after digestion by SmaI (Finger-printing II, Biorad). RESULTS: The activity of beta-lactam agents tested was similar and no resistant strain was detected (0%). Nevertheless, this study shows an increasing emergence of erythromycin-resistant GABHS strains reaching 14% in 2002 (vs. 6.2% in a previous study carried out in 1996-1999). CONCLUSION: The empirical antibiotic therapy of tonsillopharyngitis must consider, on the one hand, the high risk of GABHS eradication failure associated with in vitro resistance to erythromycin and clarithromycin, and on the other hand, the sustained susceptibility of GABHS to beta-lactam agents. These results reinforce the recommendations to use beta-lactam agents as first line treatment of GABHS tonsillopharyngitis.

Mechanisms of macrolide resistance in clinical pneumococcal isolates in France.

The genetic basis of macrolide resistance was investigated in a collection of 48 genotypically unrelated clinical isolates of Streptococcus pneumoniae obtained between 1987 and 1997 in France. All strains were resistant to erythromycin, clindamycin, and streptogramin B, exhibiting a macrolide-lincosamide-streptogramin B resistance phenotype, and harbored the erm(B) gene. None of the strains carried the mef(A) or erm(A) subclass erm(TR) gene.

[Pediatric nosocomial diarrhea]. / Diarrhées nosocomiales en pédiatrie.

Nosocomial diarrhea are an important cause of childhood morbidity and mortality. Rotavirus has been recognized as the most important cause of nosocomial gastroenteritidis particularly in infants during winter months. Nosocomial diarrhea are also, caused by bacterial pathogen like Clostridium difficile, Salmonella, Shigella, Campylobacter. Clostridium difficile toxin assay should be considered for patients who are receiving antibiotics. Modifications of hygiene procedures and preventive measures are necessary in order to reduce nosocomial infection.

In situ management and molecular analysis of candidaemia related to a totally implantable vascular access in a cystic fibrosis patient.

We describe a case of candidaemia in a paediatric cystic fibrosis (CF) patient with a totally implantable vascular access (TIVA). Serial quantitative blood cultures during therapy with amphotericin B delivered via the catheter suggested that the patient was responding to therapy. The TIVA was finally removed because of persistent fever, but its culture remained sterile. Randomly amplified polymorphic DNA (RAPD) analysis of Candida albicans from various anatomical sites showed that the patient's sputum was the most likely source of TIVA contamination. Investigation of TIVA-related candidaemia by molecular analysis could guide rational antifungal chemoprophylaxis of TIVA-related candidaemia.

Imbalance between 95 kDa type IV collagenase and tissue inhibitor of metalloproteinases in sputum of patients with cystic fibrosis.

A growing body of evidence suggests that neutrophil-derived proteinases play a major role in lung tissue damage in cystic fibrosis (CF). Most previous studies have focused on serine proteinases such as neutrophil elastase, providing no information on the extent to which metalloproteinases participate in proteolytic processes in CF. To address this issue, we evaluated the contribution of one of the major neutrophil metalloproteinases, i.e., 95 kDa gelatinase (type IV collagenase), to the total gelatinolytic activity measured in sputum specimens from 27 patients with CF. Compared with asthmatic children (n = 9), CF patients had a 6.7 times greater level of total gelatinase activity in sputum revealed by zymography. The 95 kDa gelatinase was increased 3.7-fold in the CF subjects (2,441 +/- 411 [SEM] arbitrary units [AU] x 10(6) per ml of sputum versus 665 +/- 201 in asthmatics) and the 88-kDa active form 23.2-fold (2,272 +/- 372 AU x 10(6) per ml of sputum versus 98 +/- 43, respectively). Using radiolabeled 3H-gelatin as the substrate, we demonstrated uninhibited gelatinolytic activity in all CF patients; this activity was significantly correlated to disease severity as assessed by pulmonary function tests. Western blotting using anti-tissue inhibitor of metalloproteinase (anti-TIMP) and anti-95/88-kDa gelatinase antibodies demonstrated a more than 10-fold excess of 95/88 kDa gelatinase over TIMP. Bacterial proteinases from Pseudomonas aeruginosa were shown to contribute little to the gelatinolytic activity measured in sputum supernatants from patients with CF, although culture supernatants from various P. aeruginosa strains expressed gelatinolytic activity in vitro. Finally, lung damage, as assessed by increased type IV collagen degradation products in sputum, was significantly correlated to concentrations of active 88 kDa gelatinase. These data argue for a significant role of 95/88 kDa gelatinase in airway damage in CF.

Bactericidal activity of daptomycin against vancomycin-resistant Enterococcus faecium in an in vitro pharmacokinetic model.

A dynamic in vitro model was used to determine the killing kinetics of daptomycin against 15 vancomycin-resistant clinical isolates of Enterococcus faecium. Concentration profiles simulating those observed in serum following administration of both low-dose (2 mg/kg) and high-dose (6 mg/kg) daptomycin were bactericidal within 5.5 and 2.8 h, respectively. In contrast, when albumin was added to the growth medium, the corresponding bacterial killing times were slowed to greater than 24 h and 7 h; these results suggest that in the clinical setting, daptomycin dosages of approximately 6 mg/kg are required to achieve bactericidal activity against vancomycin-resistant Enterococcus faecium.

Bactericidal activity of vancomycin, daptomycin, ampicillin and aminoglycosides against vancomycin-resistant Enterococcus faecium.

Daptomycin, vancomycin, ampicillin and aminoglycosides, alone or in combination, were tested for their bactericidal activity against 15 isolates of vancomycin-resistant Enterococcus faecium from immunocompromised children. The kill-kinetic studies at clinically achievable concentrations demonstrated that daptomycin alone or in combination with ampicillin had the greatest bactericidal activity.