Impact of an assisted reassessment of antibiotic therapies on the quality of prescriptions in an intensive care unit.

OBJECTIVES: The study's objective was to assess the impact of a professional multifaceted intervention designed to improve the quality of inpatient empirical therapeutic antibiotic courses at the time of their reassessment, i.e. 24 to 96 hours after treatment initiation. DESIGN: We conducted a 5-month prospective pre- and post-intervention study in a medical Intensive Care Unit (ICU) in a teaching hospital, using time-series analysis. The intervention was a multifaceted professional intervention combining systematic 3-weekly visits of an infectious diseases specialist to discuss all antibiotic therapies, interactive teaching courses, and daily contact with a microbiologist. RESULTS: Eighty-one antibiotic prescriptions were assessed, 37 before and 44 after the intervention. The prevalence of adequate antibiotic prescriptions was high and not statistically different before and after the intervention (73% vs. 80%, P=0.31), both for sudden change (P=0.67) and linear trend (P=0.055), using interrupted time-series analysis. The intervention triggered a more frequent reassessment of the diagnosis between day 2 and day 4 (11% vs. 32%, P=0.02) and slightly improved the adaptation of antibiotic therapies to positive microbiology (25% before vs. 50% after, P=0.18). CONCLUSIONS: Our multifaceted intervention may have improved the quality of antibiotic therapies around day 3 of prescription, but the difference did not reach statistical significance, possibly because of a ceiling effect.

Outcome of exfoliative rejection after isolated intestinal transplantation in an adult: case report.

A 34-year-old-man with short-bowel syndrome received an isolated small bowel graft. On postoperative day (POD) 11, ileal biopsy specimen demonstrated mild to moderate rejection that did not respond to corticosteroid bolus therapy. On POD 14, endoscopy and histologic examination revealed exfoliative rejection that was not controlled after 14 days of therapy with thymoglobulin. On POD 95, the patient underwent surgery again because of intestinal obstruction. The graft was removed 6 months after transplantation because of continuous severe abdominal pain with weight loss. After enterectomy, the patient developed multiple-organ failure and died on POD day 8. This case underlines the severity of exfoliative rejection and suggests that early enterectomy be performed when the diagnosis is made, before deterioration of clinical status and development of infectious and nutritional complications.

[Outbreak of tropical phagedenic ulcers after the rainy season in Dijibouti]. / Recrudescence des ulcères phagédeniques a Djibouti pendant la saison des pluies.

The incidence of cutaneous ulcers was observed after the rainy season in Djibouti in 1997. Based on the study of epidemiologic, clinical, biological, and therapeutic features these lesion were classified as phagedenic ulcers. While direct examination showed numerous fusiform bacilli, cultures performed in one patient, led to isolation of numerous colonies of Prevotella loescheii. Though less common, two other anaerobic bacterial species were detected, i.e., Peptostreptococcus anaerobius and Peptostreptococcus sp.

[Lemierre's syndrome: a report of six cases]. / Syndrome de Lemierre : à propos de 6 cas.

OBJECTIVE: Lemierre's syndrome is a rare but severe condition combining pyrexia, cervical pain and pulmonary signs following a pharyngeal infection, usually tonsillitis. This infectious disease is still present in our country despite wide use of antibiotic therapy in pharyngeal infections. METHODS: In a retrospective study conducted between 1995 and 2000 in two departments (infectious diseases and critical care unit) of Nice university hospital (Nice, France), we collected and analysed six cases of Lemierre's syndrome. RESULTS: We describe a serie of 6 cases, all of them female patients of mean age 27. We enrolled healthy patients whose initial symptom was tonsillitis. Most of these patients showed signs of severe sepsis and one died of septic shock. All the others recovered with treatment. The mean time between tonsillitis and first sign of sepsis was seven days. In four cases, patients received a beta- lactam antimicrobial agent with metronidazole. In two cases, patients were treated with amoxicillin-clavulanate. All patients were investigated for the presence of internal jugular vein thrombosis and were treated by anticoagulants when research was positive. CONCLUSIONS: A strong presumptive diagnosis can be made on the basis of clinical presentation, secondarily confirmed by para-clinical data. The prognosis depends on the speed and quality of management. We therefore wished to raise awareness of this condition among our colleagues by reporting our personal experience.

Priming by microbial antigens from the intestinal flora determines the ability of CD4+ T cells to rapidly secrete IL-4 in BALB/c mice infected with Leishmania major.

Infection of BALB/c mice with Leishmania major results in the rapid accumulation of IL-4 transcripts within CD4(+) T cells that react to the parasite Leishmania homologue of mammalian RACK1 (LACK) Ag. Because memory/effector cells secrete IL-4 more rapidly than naive cells, we sought to analyze the phenotype of these lymphocytes before infection. Indeed, a fraction of LACK-specific CD4(+) T cells expressed a typical CD62 ligand(low)CD44(high)CD45RB(low) phenotype in uninfected mice. LACK-specific T cells were primed in gut-associated lymphoid tissues by cross-reactive microbial Ags as demonstrated by their reactivity with bacterial extracts and by the ability of APCs from the mesenteric LN of BALB/c mice to induce their proliferation. Also, mice in which the digestive tract has been decontaminated exhibited a reduced proportion of LACK-specific T cells expressing a memory/effector phenotype and did not exhibit the early accumulation of IL-4 transcripts induced by L. major. Thus, LACK-specific T cells represent a subset of CD4(+) T cells which have acquired the ability to rapidly secrete IL-4 as the result of their priming by cross-reactive microbial Ags. Tracking the fate of these cells may provide information about the regulation of cell-mediated immune responses to gut Ags in physiological and pathological situations.

Total artificial nutrition is associated with major changes in the fecal flora.

BACKGROUND: Animal studies have demonstrated dramatic changes in the intestinal flora during total enteral (TEN) or parenteral (TPN) nutrition. AIM OF THE STUDY: To assess the impact of TEN and TPN on human intestinal microflora. METHODS: Eight patients on fiber-free TEN, five patients on TPN, and ten controls were studied. Fecal bacteria were identified and numbered (logCFU/g feces), and fecal short-chain fatty acids (SCFAs) were measured in stool samples, by gas-liquid chromatography. RESULTS: In TEN patients, compared to controls (P < 0.01), aerobes were increased (8.46 +/- 0.24) while anaerobes were decreased (5.79 +/- 0.84). In TPN patients, both aerobes and anaerobes were decreased compared to controls (5.64 +/- 0.27 and 5.31 +/- 1.09 respectively, P < 0.01). Total SCFAs were lower in TPN patients than in TEN patients (48.3 +/- 16.6 vs 118.6 +/- 24.1 mmol/kg, P < 0.05). CONCLUSIONS: Both TPN and TEN induce modifications in the intestinal microflora. During TPN, a homogeneous decrease occurs in both aerobic and anaerobic bacteria. TEN decreases only anaerobic bacteria, while aerobic bacteria are increased. This imbalance may play a role in the pathophysiology of TEN-induced diarrhea.

Survey of anaerobic susceptibility patterns: a French multicentre study.

In 1996, the in vitro antibiotic susceptibility of 463 anaerobes was measured in five hospitals using the reference agar dilution method. None of the 209 B. fragilis group strains showed resistance to imipenem or ticarcillin-clavulanic acid. High resistance rates (29%) were observed for cefotetan and clindamycin. beta-Lactamase production was detected respectively in 64% of the Prevotella and 7% of the Fusobacterium strains. Because the same standardized methods were used for many years, the authors were able to evaluate the evolution of antibiotic resistance. Clindamycin resistance had increased within the B. fragilis group (from 14% in 1992 to 29% in 1996) and also among strains of clostridia (32%), P. acnes (18%) and Peptostreptococcus (28%). In the B. fragilis group multidrug resistance was unlikely to occur.

Acquired ciliary abnormalities of nasal mucosa in marrow recipients.

Respiratory symptoms are frequent after bone marrow transplantation (BMT). Most studies focus on lesions of the lower respiratory tract. However, sinusitis is also common in this setting, especially after allogeneic BMT. The nasal respiratory epithelium is the first line of airway defense and is very similar to the bronchial epithelium, especially in terms of ciliary beat frequency and ultrastructural pattern of ciliated cells. We have prospectively studied the nasal respiratory epithelium of 20 marrow recipients (four autologous, 16 allogeneic) with or without sinusitis, by brushing and biopsy of the median turbinate between 2.5 and 148 months after transplant. Samples were studied for ciliary beat frequency, cytology, ultrastructural pattern and HLA-DR expression. We found that 17 of our 20 patients had abnormalities of their nasal epithelium, mainly consisting of either squamous metaplasia or heterogeneous axonemal defects of peripheral and central microtubules. No relationship between these findings and the presence of acute or chronic sinus infection, previous irradiation, graft-versus-host disease or immunosuppressive therapy could be demonstrated in this preliminary study. These abnormalities probably have multiple causes. Prospective studies are needed to determine the respective roles of treatments, infections and immune disorders associated with BMT in these abnormalities, and to know their natural evolution over time and their impact on the occurrence of upper or lower respiratory tract infections.

Evolution of bacterial susceptibility to antibiotics during a six-year period in a haematology unit.

A knowledge of the bacterial ecology of a haematology unit should help in the management of the febrile patient with or without neutropenia. We studied the prevalence and the susceptibility profiles of bacteria isolated during a six-year period among patients hospitalized in a 44-bed haematology unit. Antibiotic use over this period was also studied. The most prevalent bacteria were coagulase-negative staphylococci (CNS) (35.1%), Escherichia coli (11.4%), Staphylococcus aureus (9.9%), Enterococcus spp. (8.2%), and Pseudomonas aeruginosa (7.5%). The susceptibility of CNS to oxacillin decreased from 67-44% over six years, while that of enterobacteriaceae to amoxycillin and piperacillin was reduced by about 50%. P. aeruginosa susceptibility to ceftazidime remained remarkably stable at around 90%, despite extensive empirical use. Imipenem and ciprofloxacin were used restrictively and ceftazidime-resistant P. aeruginosa remained susceptible to these two agents in most cases. Our antibiotic policy was found to be compatible with the frequency of the bacterial strains isolated in our department and with their susceptibility profiles.

[Susceptibility of strict anaerobic bacteria to antibiotics in France: a multicenter study]. / Sensibilité aux antibiotiques des anaérobies stricts en France: étude multicentrique.

During 1992, the in vitro antibiotic susceptibility of 462 anaerobic bacteria was performed in 7 hospitals, by the reference agar dilution method. Among the 222 Bacteroides fragilis group strains, only one Bacteroides fragilis strain was resistant to imipenem and all bêtalactams, even combined with bêtalactamase-inhibitors while metronidazole resistance could not be detected. One major outer membrane protein (probably a porin) was lacking in some of the six amoxicillin-clavulanic acid resistant Bacteroides fragilis group strains. Evolution in antibiotic resistance rates could be assessed only for clindamycin and piperacillin whose resistance rates increased to 14 and 15.8 p. cent, respectively. On the whole anaerobic strains resistance rates were: imipenem 0.2, ticarcillin-clavulanic acid 0.5, amoxicillin-clavulanic acid or metronidazole 1.5, piperacillin 9.1, cefotaxime-sulbactam 9.7, cefoxitin 12.8, clindamycin 13.7, cefotaxime 27.2, amoxicillin 45 and ciprofloxacin 70, respectively.

Nocardia asteroides septicemia in a pemphigus patient. Successful treatment with trimethoprim-sulfamethoxazole and amikacin association.

We report the case of a patient with pemphigus who presented Nocardia asteroides septicemia. The infection was controlled with an original association of trimethoprim-sulfamethoxazole and amikacin.

[Bacteriological, parasitological and virological study of the digestive flora in alpha-chain disease]. / Etude bactériologique, parasitologique et virologique de la flore digestive dans la maladie des chaînes alpha.

Intestinal flora was explored in twelve patients affected with alpha-chain disease at different stages (stage A: 2 cases; stage B: 6 cases; stage C: 4 cases). Bacterial overgrowth in the jejunum was observed in 11 cases, but intestinal flora was diverse and no one species was always present; although a 3-month oral antibiotic treatment induced complete remission in one patient (stage A) it was not possible to demonstrate any pathogenic bacterial species. Intestinal lambliasis was present in 40 p. 100 of cases. Virologic studies were negative. At stages A and B of the disease, antibiotic treatment was able to improve malabsorption and/or plasma protein digestive losses in 62 p. 100 of cases; this effect seemed related to the reduction of the bacterial flora and to giardiasis eradication.

Technical hazards of using nutritive mixtures in bags for cyclical intravenous nutrition: comparison with standard intravenous nutrition in 48 gastroenterological patients.

Three methods for dispensing nutritional solutions are compared in 48 patients with gastrointestinal diseases on intravenous nutrition during 3582 days. The protocol for intravenous nutrition applied by the nursing team and the solutions used were the same in the three groups. In group A standard bottles were used, while in group B, 31PVC-disposable bags were used--with fat emulsion included (group B1) or with fat excluded (group B2). When fat was excluded from the bags it was infused separately from a bottle. The mixtures were made under laminar flow by the nursing team who applied a strict protocol which included bacteriological testing. The infection rate observed in the bags was 0.046%. The rate of septic complications was not significantly reduced in group B2 or B1 compared with group A; the type of container used was therefore unimportant and the key was the aseptic handling of the intravenous solutions. The rate of mechanical complications, mainly due to catheter obstruction, was higher (p less than 0.001) when fat was included in the bags--that is, in group B1--than in groups B2 and A. For 26 patients a cyclical regime of intermittent feeding was easier to manage when bags were used. In group B, this system replaced the continuous method n 75% of all therapeutic days without adverse effect; it improved compliance and allowed ambulatory treatment. The use of cyclical feeding with separate fat infusions has further reduced the hazards of intravenous nutrition and allowed the development of a programme that can be implemented at home.