[Statistical study of the SIRSCAN computerised camera]. / Etude statistique de la caméra informatisée SIRSCAN.

The antibiograms of 1162 bacterial strains, including references, have been performed within four centres. They have been read manually and by the SIRSCAN camera, which yields to 30936 couples of diameters values. A non-concordance, at a 3 mm level, was observed fot 11.14% of the diameters. The mean of difference is 0.82 mm and the standard deviation 3.34 mm. Round Petri dishes gave results less reliable than those obtained with square dishes. A deviation in function of the centres is obtained for wild-strains as for the references. For the whole population a S/R discordance (sensible/résistant confusion) is obtained for 1.76% of the diameters. This value drops to 0.93% for enterobacteriaceae, P. aeruginosa and S. aureus (968 strains).

Effect of ventilator-associated pneumonia on mortality and morbidity.

The aim of this study was to evaluate the attributable mortality and excess intensive care unit (ICU) stay as linked to ventilator-associated pneumonia (VAP) in a medical-surgical ICU. We performed a matched cohort study. The diagnosis of VAP was established when clinical, biologic, and radiologic signs of VAP were associated with the presence of at least one microorganism at a concentration > or = 10(3) CFU/ml on the protected specimen brush sample. Each case patient with VAP was matched to one control patient on the basis of the following potential confounding factors: same diagnosis and same indication for mechanical ventilation, same age +/-5 yr, same sex, same APACHE II score +/-5 on admission. In addition, control patients had to be ventilated for at least as long as the case patient prior to the onset of VAP, and date of admission of the case and control patients had to be matched within 1 yr. In 85 of the 97 patients with VAP, we were able to match one case patient with one control patient. Mortality was similar in both case (40%) and control (38.8%) patients. The duration of mechanical ventilation was increased in survivor case patients (27.2 +/- 24.7 d) compared with survivor control patients (18.5 +/- 15.7 d) (p < 0.01). The duration of hospitalization in ICU was increased in survivor case patients (34.9 +/- 23.6 d) compared with survivor control patients (26.1 +/- 18.6 d) (p < 0.02). When confounding factors were controlled, VAP did not appear to increase mortality.

Bronchoscopic or blind sampling techniques for the diagnosis of ventilator-associated pneumonia.

The purpose of this prospective postmortem study was to assess the diagnostic accuracy of bronchoscopic techniques (bronchoalveolar lavage [BAL] and protected specimen brush [PSB]) and nonbronchoscopic techniques (blind bronchial sampling [BBS] and mini-BAL) in the diagnosis of ventilator-associated pneumonia (VAP). The results of each technique were compared with histology and culture of lung tissue specimens obtained by surgical pneumonectomies in 38 patients who died after at least 72 h of mechanical ventilation. Histology was positive for VAP in 18 patients and negative in 20 patients. There were 12 definite VAP (positive histology and positive lung cultures) and 6 histologic VAP (positive histology and negative cultures). Clinical pulmonary infection score (CPIS) at a threshold of 6 achieved a sensitivity of 72% and a specificity of 85%. When the CPIS was combined with the logarithmic concentration of the predominant microorganism obtained from the BBS sample culture, specificity was increased to 95%, for a threshold of 10. Using 10(3) cfu/ml as the threshold of positivity for cultures obtained with PSB and mini-BAL samples and 10(4) cfu/ml for cultures obtained with BBS and BAL, the respective sensitivities of these techniques for definite VAP were 42, 67, 83, and 58%. The sensitivity of BBS was significantly higher than that of PSB (p < 0.05). The area under the receiver operator characteristic curve was significantly greater for BBS than PSB (p < 0.05). Given that it is more sensitive and noninvasive, BBS is preferable to PSB for the diagnosis of VAP.

AIDS, a social dilemma: detection of seropositives.

At present, we can observe an evolution in ideas about the detection of HIV seropositivity through a qualitative analysis of specialised literature on the ethical aspects of AIDS. In the case of this disease, systematic screening of the population does not correspond to epidemiological criteria: it is wasteful, troublesome and costly. Whether it is voluntary, and therefore biased, or compulsory, and therefore controversial, systematic screening seems an unlikely option. This situation has prompted many versions of target-group screening, which correspond to two options: systematic screening of known risk-groups, discriminatory, confidential and anonymous; target-group screening linked to particular circumstances: recognised as necessary by blood-donors and well-accepted by pregnant mothers. This method can be institutionalised and applied in the armed forces and in prisons,.... Lastly, we consider measures taken by different countries and organisations.

Ethical problems raised by anti-HIV vaccination.

At present questions are being asked world-wide about the risk of the AIDS epidemic. The discovery of an anti-HIV vaccine has become an urgent priority, but it also raises a number of sensitive questions. Ethical problems in this field are particularly delicate, since the perspectives of individual health and public health do not seem to coincide. Our research team conducted a review of more than 400 articles on the ethical problems raised by AIDS. We concentrated particularly on the ethical and legal issues raised by research on anti-HIV vaccine. These problems fall into three main categories: therapeutic assays, which must be controlled by a strict agreement defined by international norms; manufacture of the future vaccine, raising legal difficulties which must be faced and solved now; distribution of the vaccine to the population, which should be conducted on a general basis, i.e. it should be offered to all individuals and not only to risk groups.

[Evaluation of ciprofloxacin versus amoxicillin + clavulanic acid or erythromycin for the empiric treatment of community-acquired pneumonia]. / Evaluation de la ciprofloxacine versus amoxicilline plus acide clavulanique ou érythromycine pour le traitement empirique des pneumonies communautaires. Groupe Multicentrique.

For the empiric management of community-acquired pneumonia, ciprofloxacin (750 mg b.i.d.) was compared with two antibiotics frequently used in this indication, i.e., amoxicillin + clavulanic acid and erythromycin. One hundred and forty-two patients were randomized in this prospective study. Among them, the 63 patients with bacteriologically documented disease were evaluated. Clinical recovery was achieved in 73.3% of patients in the ciprofloxacin group (22/30) versus 81.8% of patients in the amoxicillin + clavulanic acid or erythromycin group (27/33) (non-significant difference). Clinical failures seen with ciprofloxacin were found to be correlated with recovery of Streptococcus pneumoniae. Ciprofloxacin is effective in pneumonia but should be used only in cases where Streptococcus pneumoniae can be excluded as the causative agent.

The ethical approach to AIDS: a bibliographical review.

This bibliographical study involved first the exploitation of four data-banks: Medline, CNRS, Bioethics and AIDS, with the following key words (in conjunction with AIDS): ethics, human rights, confidentiality, legislation, jurisprudence. A total of 412 references were listed between 1983 and the end of 1987. Examination of the quantitative increase of articles over these years shows that, while references to AIDS and/or HIV infection--referred to as 'AIDS' for brevity--increased by about one third per year, the number of papers treating ethical problems linked to AIDS doubled each year. This increase makes it clear that these problems are important and pressing, that they are evolving rapidly and can be given no easy solution. After reading and analysis of accessible articles in readily comprehensible languages, the different themes can be classified in two categories: 1: Measures intended to protect society (starting with the most coercive); quarantine and isolation; discriminatory measures concerning specific groups; non-respect of the confidential nature of medical information; application of the penal code; screening; obligatory declaration and registration; testing of blood given by donors; vaccination and medical innovations, therapeutic assays; information, education. 2. Measures intended to protect the individual: fundamental rights of the patient: his/her right to confidentiality, to information and to treatment; civil rights: civil liberty, right to education, right to work, etc...; rights of the healthy individual: right of those in contact with the patients, safety of hospital staff, of those receiving blood-transfusions, etc... The legislation adopted in the various countries and the main opinions to be found in these articles are listed and analysed, and for each particular theme it is possible to refer to a list of the 232 most important articles. While the debate seems to concentrate on the conflict between the right of society to protect itself against the spread of infection and the 'civil' rights of the infected minorities, our conclusion tends to reduce this antagonism, showing that, particularly as far as the confidential nature of medical information is concerned, measures intended to protect the individual also protect society.

Phagocyte-pathogen in the infected host.

Phagocytosis is a major mechanism of defense against bacterial infections. The ingestion of different microorganisms by blood granulocytes or monocytes may involve a variety of cell membrane recognition structures (e.g., immunoglobulin or complement receptors, lectin-like structures or other nonspecific binding sites). It is of interest to know which mechanism plays a prominent role in the management of a particular type of infection. Forty-three pathogenic bacterial suspensions were obtained from patients under mechanical ventilation at the onset of nosocomial lower respiratory tract infections. They were coincubated with blood granulocytes from the same or other patients in the presence or absence of the corresponding serum. Phagocytosis and the oxidative burst were then assayed. We conclude the following: a) Substantial phagocytosis was found under serum-free conditions and the patients' sera did not dramatically enhance bacterial uptake during the first days after the onset of clinical symptoms. b) The phagocytes from an infected patient did not display any peculiar inability to bind to the bacteria that grew successfully in this subject. Hence, the occurrence of a particular infection might be dependent on a defect of intracellular killing of ingested pathogens or on the conditions of infection development.

Comparison of two methods of bacteriologic sampling of the lower respiratory tract: a study in ventilated patients with nosocomial bronchopneumonia.

The purpose of this prospective study was to compare the results of bacteriologic assessment of the lower respiratory tract in mechanically ventilated patients by two sampling techniques: fiberoptic protected brush biopsy or blind bronchial aspiration of secretions. Thirty-three mechanically ventilated patients with acute bronchopneumonia were studied. Paired samples were collected by both techniques 47 times. Identical results were obtained in 93% of the cases. In 28 pairs, one or several identical organisms were cultured. In 16 pairs, no bacteria were isolated; in the three remaining pairs, results were contradictory. In five patients with concomitant positive blood cultures, the same organisms were cultured from fiberoptic protected brush biopsy, blind bronchial sampling, and blood cultures. These findings support the fact that blind bronchial sampling can be recommended for bacteriologic assessment of the lower respiratory tract in mechanically ventilated patients with diffuse nosocomial bronchopneumonia.

[Treatment of nosocomial pneumopathies caused by Pseudomonas aeruginosa with ceftazidime. 50 cases in pulmonary resuscitation]. / Traitement des pneumopathies nosocomiales à Pseudomonas aeruginosa par la ceftazidime. Cinquante observations en réanimation pneumologique.

Fifty patients under prolonged mechanical ventilation who developed nosocomial lung infections caused by Pseudomonas aeruginosa were treated with ceftazidime. This cephalosporin was used alone in 18 cases and combined with another antibiotic (usually an aminoglycoside) in 32 cases. Favourable results were obtained in 40 cases, with regression of the clinical signs and eradication of the organism between the 5th and 10th days of treatment. Eight of the 10 failures occurred in patients with impaired ventilation due to chronic obstructive lung disease. Secondary superinfection was observed in 12 cases. Among the 257 strains of P. aeruginosa isolated in our respiratory intensive care unit over an 18-month period, 88 per cent were sensitive to ceftazidime, and this figure remained stable after the period when ceftazidime was given. These in vitro findings probably account for the remarkable results obtained in infections which up to now had mortality rates of 30 to 60 per cent, depending on the patient's underlaying condition.

[Application of the diagnostic ability coefficient to the comparison of 3 identification miniaturized systems for identifying anaerobic bacteria]. / Application du coefficient de capacité diagnostique à la comparaison de trois galeries miniaturisées d'identification des bactéries anaérobies.

The authors compare the performances of three identification systems for anaerobic bacteria. The computation of diagnosis ability coefficient (Descamps and Véron) made it possible to classify these systems to identify a batch of eighty strains coming from pathologic samples. The results are very close. This study shows profile catalogues' short coming and the disadvantages of their use which appears to be insufficiently critical. Every-day practice of these supplementary tests and the use of gas-liquid chromatography seem necessary to identify completely the anaerobic bacteria of the studied batch.

[Clinical and pharmacokinetic study of ceftriaxone in severe infections in adults in intensive care]. / Etude clinique et pharmacocinétique de la ceftriaxone dans les infections sévères de l'adulte en réanimation.

Twenty patients with severe nosocomial bacterial infections hospitalized in an intensive care unit were treated by ceftriaxone alone, in a single daily IV injection of 2 g. Clinical and bacteriological results show that ceftriaxone has good activity against enterobacteria. The four patients (20%) who failed to respond had superinfection by Pseudomonas aeruginosa, a finding that suggests that ceftriaxone should be used in combination with another antibiotic for the treatment of nosocomial infections. Pharmacokinetic results in our patients show that with the dosage used peak and trough serum levels are greater than the MICs of susceptible pathogens.