In vitro antibacterial activity of doripenem against clinical isolates from French teaching hospitals: proposition of zone diameter breakpoints.

The aims of the study were to determine the in vitro activity of doripenem, a new carbapenem, against a large number of bacterial pathogens and to propose zone diameter breakpoints for clinical categorization in France according to the European Committee on Antimicrobial Susceptibility Testing (EUCAST) minimum inhibitory concentration (MIC) breakpoints. The MICs of doripenem were determined by the broth microdilution method against 1,547 clinical isolates from eight French hospitals. The disk diffusion test was performed (10-µg discs) according to the Comité de l'Antibiogramme de la Société Française de Microbiologie (CASFM) method. The MIC(50/90) (mg/L) values were as follows: methicillin-susceptible Staphylococcus aureus (MSSA) (0.03/0.25), methicillin-resistant Staphylococcus aureus (MRSA) (1/2), methicillin-susceptible coagulase-negative staphylococci (MSCoNS) (0.03/0.12), methicillin-resistant coagulase-negative staphylococci (MRCoNS) (2/8), Streptococcus pneumoniae (0.016/0.25), viridans group streptococci (0.016/2), ß-hemolytic streptococci (≤0.008/≤0.008), Enterococcus faecalis (2/4), Enterococcus faecium (128/>128), Enterobacteriaceae (0.06/0.25), Pseudomonas aeruginosa (0.5/8), Acinetobacter baumannii (0.25/2), Haemophilus influenzae (0.12/0.25), and Moraxella catarrhalis (0.03/0.06). According to the regression curve, the zone diameter breakpoints were 24 and 19 mm for MICs of 1 and 4 mg/L, respectively. This study confirms the potent in vitro activity of doripenem against Pseudomonas aeruginosa, Acinetobacter, Enterobacteriaceae, MSSA, MSCoNS, and respiratory pathogens. According to the EUCAST MIC breakpoints (mg/L) ≤1/>4 for Enterobacteriaceae, Pseudomonas aeruginosa, and Acinetobacter, and ≤1/>1 for streptococci, pneumococci, and Haemophilus, the zone diameter breakpoints could be (mm) ≥24/<19 and ≥24/<24, respectively.

Antibioprophylaxis in surgery and interventional medicine (adult patients). Update 2017.

Infection is a risk for any intervention. In surgery, for example, pathogenic bacteria are found in more than 90% of operative wounds during closure. This exists whatever the surgical technique and whatever the environment (the laminar flow does not entirely eliminate this risk). These bacteria are few in number but can proliferate. They find in the operative wound a favourable environment (haematoma, ischaemia, modification of oxido-reduction potential...) and the intervention induces anomalies of the immune defences. In the case of the installation of foreign material, the risk is increased. The objective of antibiotic prophylaxis (ABP) is to prevent bacterial growth in order to reduce the risk of infection at the site of the intervention. The preoperative consultation represents a privileged moment to decide on the prescription of a ABP. It is possible to define the type of intervention planned, the associated risk of infection (and therefore the necessity or not of ABP), the time of prescription before surgery and any allergic antecedents which may modify the choice of the selected antibiotic molecule.

[Pleural diffusion of amoxicillin 1 and vancomycin in patients treated for post-surgical empyema]. / Empyème après chirurgie d'exérèse pulmonaire: étude de la diffusion pleurale de l'amoxicilline et de la vancomycine.

INTRODUCTION: Treatment of post surgical thoracic empyema consists of chest tube drainage, antibiotic administration, and in some cases surgical lavage of infected spaces. Data in human on the diffusion of antibiotics in pleural cavity after post surgical empyema are lacking. METHODS: We studied on 9 patients with post surgical thoracic empyema (including 6 pneumonectomy) the diffusion of 2 antibiotics commonly used in this situation: amoxicillin (for 7 patients) and vancomycin (for 2 patients). Antibiotics concentrations were measured after at least 3 days of treatment (3-12 days), in order to reach a plateau concentration in the pleural space. RESULTS: The ratio pleural/plasma antibiotic concentration was 1.96 (range: 0.6-4.9). The pleural infection was cured for 8 on 9 patients. The last patients required thoracostomy, and the outcome was favorable after this procedure. CONCLUSION: That the penetration of amoxicillin and vancomycin in pleural space after post surgical empyema is good. Pleural antibiotics concentrations are in the majority of cases higher than plasmatic concentrations.

Monitoring of vancomycin serum levels for the treatment of staphylococcal infections.

Vancomycin serum concentrations were determined for 1,737 patients treated with either 2 x 1 g of vancomycin or 4 x 500 mg daily (780 patients), according to current nomograms, or by continuous infusion (957 patients) with a loading dose (1 g) and a total of 2-6 g daily. Trough serum concentrations were determined after 36-48 h. Adequate serum levels for the treatment of a normal methicillin-resistant Staphylococcus aureus (MRSA) and a glycopeptide-intermediate S. aureus (GISA) were observed in 81% and 20.9% of patients, respectively. The data support theoretical arguments that higher and more sustained serum levels of vancomycin, obtained by continuous infusion, may enhance clinical efficacy.

Total laparoscopic abdominal aortic aneurysms repair.

AIM: The aim of the study was to describe our experience of total laparoscopic abdominal aortic aneurysm (AAA) repair. METHODS: Between February 2002 and September 2004, we performed 49 total laparoscopic AAA repair in 45 men and 4 women. Median age was 73 years (range, 46-85 years). Median aneurysm size was 52 mm (range, 30-95 mm). ASA class of patients was II, III and IV in 16, 32 and 1 cases, respectively. We used the laparoscopic transperitoneal left retrocolic approach in 47 patients. Seven patients were operated via a tranperitoneal left retrorenal approach and one patient via a retroperitoneoscopic approach. RESULTS: We implanted tube grafts and bifurcated grafts in 19 and 30 patients, respectively. Median operative time was 290 min (range, 160-420 min). Median clamping time was 81.5 min (range, 35-230 min). Median blood loss was 1800 cc (range, 300-6900 cc). Mortality was 6.1% (3 patients). In our early experience, two patients died of myocardial infarction. The 3rd death was due to a multiple organ failure. Thirteen major non lethal postoperative complications were observed in 9 patients (18%). Four patients had local/vascular complications, which required reintervention (8%). Nasogastric tube is now removed at the end of procedure. Median duration of ileus, return to general diet, ambulation and hospital stay were 2, 3, 3 and 10 days. With a median follow-up of 19 months (range, 8-39 months), complete recovery with patent graft was observed in 44 patients. Two patients needed a crossover femoral graft for one iliac dissection and one graft limb occlusion. CONCLUSIONS: These results show that total laparoscopic AAA repair is feasible and worthwhile for patients once the learning curve is overcome. It remains technically demanding and a previous training in videoscopic sutures is essential. Initial learning curve in laparoscopic aortic surgery with aortoiliac occlusive lesions is preferable before to begin laparoscopic AAA repair.

Synergism and antagonism in double beta-lactam antibiotic combinations.

Combinations of two beta-lactam antibiotics may be advantageous in certain clinical situations, providing a synergistic activity against specific organisms or a broad spectrum of antibiotic coverage. Depending on the combination and the bacteria, synergism, indifference, or antagonism can be observed. Synergism may occur when two beta-lactam antibiotics, acting on different penicillin-binding proteins, are combined or when a penicillinase-susceptible beta-lactam antibiotic is protected by another beta-lactam antibiotic acting as a beta-lactamase inhibitor in strains producing a penicillinase (chromosomal or plasmidic). With different species, such as Enterobacter, Citrobacter, indole-positive Proteus, Serratia, Aeromonas, and Pseudomonas, which produce an inducible chromosome-encoded cephalosporinase, antagonism will appear if one of the two combined antibiotics causes induction of the beta-lactamase and the other becomes inactivated by the increased amount of the enzyme. Although most combinations of new beta-lactam antibiotics (ureido-penicillins, third-generation cephalosporins, monobactams) appear to be indifferent, antagonism and possible selection of resistant mutants are the drawbacks of such combinations. Nevertheless, highly active compounds, if used at doses above the minimal inhibitory concentrations, especially in the case of potential cephalosporinase-inducers, may be safe in vivo as far as avoiding antagonism is concerned, but not necessarily with respect to the selection of resistant mutants.

Interaction between roxithromycin and cyclosporin in heart transplant patients.

Cyclosporin is an immunosuppressive agent commonly used in transplant patients. It is actively metabolised by the cytochrome P450 system and interactions with drugs metabolised by the same system are predictable. This is particularly relevant since cyclosporin has a low therapeutic index and its renal toxicity is concentration-related. Roxithromycin, a new, well-tolerated macrolide with a weak interactive profile, uses the same isoenzyme of the P450 system as cyclosporin. To evaluate its interaction potential in clinical practice, 8 heart transplant recipients treated with cyclosporin for at least 1 month received roxithromycin for 11 days (150 mg twice daily). Bi-weekly controls of plasma cyclosporin concentrations and creatinine levels were carried out before, during and after roxithromycin treatment. A slight nonsignificant rise in cyclosporin concentrations was observed, but creatinine levels remained stable during roxithromycin treatment. Values of cyclosporin concentrations diminished after withdrawal of roxithromycin. Cyclosporin dosage adjustment was not necessary. There was a minor pharmacokinetic interaction, which can be considered safe for the usual therapeutic dosage of roxithromycin used.

Beta-lactamases in clinical isolates. Spectrum implications of sulbactam/ampicillin.

Combining ampicillin with an irreversible beta-lactamase inhibitor such as sulbactam is a promising technique for controlling infections due to resistant organisms. The combination not only restores the effectiveness of ampicillin against species that have acquired resistance to it, but it can extend the antimicrobial spectrum to species that have never exhibited susceptibility to ampicillin. However, the inhibition of beta-lactamases and the evaluation of inhibitors are still complicated by numerous factors known collectively as 'the epidemiology of beta-lactamases'. This refers to the distribution of enzymes in different bacterial species and in different geographical locations, the numerous types of enzymes, the variable number and amount of beta-lactamases that may exist in the same cell, and, of course, the potential for transfer of beta-lactamase resistance from one species to another.

[beta-Lactamases of Branhamella catarrhalis and their phenotypic implications]. / beta-Lactamases de Branhamella catarrhalis et leurs implications phénotypiques.

Of the 50 strains of beta-lactamase-producing Branhamella catarrhalis isolated at Saint Joseph's Hospital (Paris) that were studied, 94% produced BRO-1 type beta-lactamase and 6% produced the BRO-2 type. We examined the transfer of BRO-1 and BRO-2 genes and found that, among 7 donor strains producing BRO-1, all were able to transfer the gene for BRO-1 production by conjugation. Of the 4 donor strains producing BRO-2, 2 were able to transfer the gene for BRO-2 production by conjugation. Three BRO-1 beta-lactamase-producing transformants were obtained from total DNA extracted from 3 strains producing BRO-1. Plasmid bands were demonstrated in strains of B. catarrhalis, but no change in plasmid profiles was seen in beta-lactamase-positive recombinants, supporting previous studies that suggested the beta-lactamases are chromosomal. In vitro activity of oral beta-lactams was tested for 67 strains of B. catarrhalis (56 beta-lactamase-producing strains). Cefixime, cefpodoxime and the combination ampicillin-clavulanic acid were very active against the beta-lactamase-producing strains. BRO-1 beta-lactamase appears to affect the activity of cefaclor, cefuroxime and loracarbef. BRO-2 beta-lactamases have no effect on the activity of these cephalosporins. Cefixime and cefpodoxime seemed the least affected by beta-lactamase production.

Vancomycin-resistant Staphylococcus aureus: no apocalypse now.

The number of reports concerning vancomycin-resistant Staphylococcus aureus is much higher than the number of true resistant strains or unexpected clinical failures. Many confounding factors, including inadequate serum levels, severely ill patients, foreign devices or undrained abscesses, are more likely to be responsible for the clinical failures than resistance to vancomycin.

False synergy between vancomycin and beta-lactams against glycopeptide-intermediate Staphylococcus aureus (GISA) caused by inappropriate testing methods.

The combination of vancomycin and beta-lactams is often considered synergistic and has been recommended for the treatment of glycopeptide-intermediate Staphylococcus aureus (GISA) infections. In this study, the combination of vancomycin or teicoplanin with different beta-lactams was tested. When using NaCl 4% w/v, for better expression of heterogeneous resistance to beta-lactams, with a longer (48-h) incubation period and a higher (10(7) CFU/mL) inoculum, the association of vancomycin with beta-lactams was antagonistic. However, a synergistic effect was observed for teicoplanin under the same conditions.

Combined lung and heart extraction in clinical transplantation.

The anatomical conditions for single lung and double lung transplantation allow a heart transplant and one or two lung transplants to be performed in two or three different recipients from a single donor with healthy lungs. The extraction of the heart and lung block for the purposes of these separate transplantations is described on the basis of our experience of 6 single lung transplants with 6 extractions for cardiac transplantation in different recipients, of a total of 8 lung transplants. We report these 12 successful operations and the particular technical modalities of cardiopulmonary extraction for separate transplantation. After cannulation for cooling of the abdominal viscera (kidneys, liver, pancreas), thoracic and mediastinal dissection, cardioplegia and surface pulmonary cooling by iced saline on the collapsed lungs, the heart and lungs were extracted as a single block and were separated ex situ. After periods of cold ischaemia of 1 h to 3 h 30 min for the hearts and 1 h 30 min to 5 h for the lungs, the immediate and medium term functions were satisfactory. Logistical difficulties involved in matching the population of recipients have prevented the grafting of three different recipients up until now. These successes make it essential to preserve the lungs from donors with healthy lungs. A rigorous coordination between the various transplantation teams helps to avoid competition between the three types of transplantation: heart-lung, double lung and single lung.

Treatment of AIDS-associated heart disease.

Although the diagnosis of AIDS-associated heart disease is becoming routine, its treatment has not been reported except in anecdote. Also, it has been unclear whether the odds of successful treatment are altered because of the presence of cardiac involvement per se. This communication reports the authors' treatment of 18 patients with AIDS-associated heart disease. Their results are combined with the treatment results of all patients reported in the literature to date with AIDS-associated heart disease. Treatment success, defined as eradication of the organism and no relapse, was achieved in their patients with M. tuberculosis (M. tb), cardiac cryptococcosis, and Salmonella typhimurium. M. tb required emergency pericardiectomy (well tolerated in all patients), then administration of rifampin, isoniazid, and ethambutol. Cryptococcosis was treated acutely with amphotericin B and flucytosine, then with maintenance amphotericin B. The response, which included resolution of congestive heart failure, occurred within a week. Salmonella endocarditis was cured with administration of ampicillin and netilmicin for one month. When the patients' data were combined with those of patients from the literature, the authors found that the odds of successful treatment for tuberculous pericarditis were somewhat lower than if the tuberculosis was extracardiac (50% vs 67%). With cryptococcal heart disease, the odds of successful treatment were actually significantly better than when only extracardiac disease was present. The authors conclude that infectious forms of AIDS-associated heart disease are often treatable. Although some cardiac infections are less likely to respond to treatment if there is cardiac involvement, mostly the response to treatment is similar to the response with only extracardiac involvement.

The distribution of BrK alpha/RbK alpha peak intensity ratio in human whole blood samples. Comparison between normal and colorectal cancer cases.

A preliminary study was conducted to compare the BrK alpha/RbK alpha peak intensity ratio in colorectal cancer (CRC) patients and healthy subjects (controls) in Israel. Blood samples were obtained from 61 CRC patients and 124 controls. The controls represent a normal population from different areas in Israel. Three hundred microliters of wet whole blood samples were analyzed by the EDXRF method. A weighted mean of 2.45 +/- 0.38 Br/Rb ratio was obtained for CRC patients, as compared with 3.28 +/- 0.40 Br/Rb ratio for controls. The mean value for controls represents only 112 subjects, since 12 individuals of the control group suffered from some other diseases and therefore were not included for the mean value calculation in this group. The results indicate that the Br/Rb ratio in CRC patients is significantly lower (p < 0.05) than in controls. No significant difference was found in Br/Rb ratio correlated to age and sex. It was not possible to draw final conclusion concerning the relationship between the Br/Rb ratio and the malignancy stage, since there was a relatively small number of cases in each stage under investigation.

Evolution of enzymatic mechanisms of resistance among beta-lactam antibiotics.

Resistance to third-generation cephalosporins occurs as a result of either the production of high concentrations of chromosomal cephalosporinase or, increasingly, the presence of broad-spectrum plasmid-mediated beta-lactamases. Both cases represent the response of bacteria in the hospital setting to the selection pressure brought to bear by the use of these antibiotics. Continued evolution of the plasmid-mediated enzymes is occurring as new antibiotics are introduced, probably reflecting the process that began when the first beta-lactamase apparently evolved from the penicillin-binding proteins. beta-Lactamase inhibitors offer one approach to dealing with the evolution of resistance to previously beta-lactamase-stable antibiotics.

[Evaluation of bidimensional echography in the etiological orientation of pericardial disease. Apropos of 39 anatomo-echographic comparisons]. / Evaluation de l'échographie bidimensionnelle dans l'orientation étiologique des maladies du péricarde. A propos de 39 confrontations anatomo-échographiques.

Echocardiography provides a firm diagnosis of pericardial effusion and evaluates its repercussions on the cardiac cavities. The images obtained with two-dimensional echocardiography are of such quality that the anatomical lesions can be analyzed, but the predictive value of this examination for the aetiological diagnosis has not yet been established. To investigate this point we have compared the images recorded in 39 episodes of pericardial disease with the corresponding anatomical data provided by surgery (n = 38)) or necropsy (n = 1) less than 48 hours after the ultrasonic examination. In one case, the purely solid nature of the pericardial content, suspected on the presence of an echo-filled cavity with adherent membranes, was confirmed at surgery. Conversely, the totally or partly liquid nature of the effusion was ascertained whenever the two pericardial membranes were separated by an echo-free cavity in at least one portion of the region examined, and there was no false-positive result (n = 38). The images obtained could be compared with the anatomical lesions in 28 out of 38 cases of partly or totally liquid pericarditis. The pericardial cavity was entirely echo-free in 12 of these cases, and this was confirmed by the anatomical examination, except in one case where epicardial nodules were found at surgery. Abnormal intrapericardial images were detected in the other 16 echocardiographic examinations, viz.: round masses in 2 cases, linear echoes in 2 cases and mattress-like deposits in 12 cases. In 9 of these 16 cases corresponding intrapericardial formations were discovered at surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

[Intra-caval leiomyomatosis. Surgical treatment]. / Leiomyomatose intra-cave. Traitement chirurgical.

The authors report a case of intracaval leiomyomatosis diagnosed in a 11-year old female, who had been initially operated for a massive tumor of uterus (35 X 45 X 25) and who had had subtotal hysterectomy performed. The histologic diagnosis at was intravenous leiomyomatosis. Investigation of extent of neoplastic spread included echography, cavography and revealed inferior vena cava involvement. Cavotomy removed a tumor fragment. Intravenous leiomyomatosis has always its source in the uterus and spreads by progressive invasion of the vena cava. The right cardiac cavities and, at times, the pulmonary artery are also involved. Management of cardiac invasion is a determinant factor of the severity of the disease. Indication for surgery is systematic and should result in complete tumor excision.

["Logic" and doubts in the surgery of associated carotid and vertebral lesions]. / "Logique" et incertitudes dans la chirurgie des lésions associées carotidiennes et vertébrales.

Combined vertebral artery and carotid artery surgery may be performed in patients with proximal subclavian or vertebral artery stenosis provided that general anesthesia is not contraindicated? Others indications may be considered in patients with proved arterial thrombo-embolism or in patients for whom arteriography, cerebral angioscintigraphy and ultrasound velocimetry enable the physician to suspect a cerebral low flow and the lack of collateral pathways between the posterior and anterior cerebral system.

[Heparin-induced thrombopenia. Vascular complications in six cases (author's transl)]. / La thrombopénie induite par l'héparine. A propos de six cas et de leurs complications vasculaires.

The most frequent complication during heparin treatment is hemorrhage from overdosage. Heparin-induced thrombopenia is more rarely observed but is a more serious disorder. Six such cases are reported, of which three were complicated by gangrene of the limbs. Clinical findings are described, together with the methods of detecting the presence of heparin-induced antiplatelet antibodies. The affection becomes evident on the 9th day of treatment by the presence of a thrombopenia and accompanying clinical signs. These may be those of a hemorrhagic syndrome directly related to the thrombopenia, or manifestations of thrombotic lesions. The latter can cause worsening of the condition for which heparin was prescribed, arterial thrombosis of a large vessel, venous thromboses disappearing after interruption of heparin treatment, of distal thrombosis of the microcirculation with a rapidly irreversible onset of gangrene requiring amputation. The lesions are provoked by an immune mechanism and heparin has to be discontinued.

[Antibiotic prophylaxis in vascular surgery]. / Antibioprophylaxie en chirurgie vasculaire.

Vascular surgery includes various surgical procedures and sites. Infectious risk is low but with a high functional risk and a high mortality rate. Infection risk factors are numerous. Among them the incision in the Scarpa's triangle is at the first place. Antimicrobial prophylaxis in vascular surgery has shown its efficacy whatever the agent. The second generation cephalosporins are the most logical, with a duration of administration of less than 24 hours. In case of re-operation glycopeptides have shown their efficacy.