[Pneumocystis jirovecii pneumonia in non-HIV infected patients: a study of 41 cases]. / Pneumocystose pulmonaire chez des patients immunodéprimés non infectés par le VIH : étude de 41 cas.

BACKGROUND: The increasing use of immunosuppressive and cytotoxic therapies leads to a growing number of opportunistic infections especially Pneumocystis jirovecii pneumonia (PCP). The purpose of our study was to describe the population involved, and to assess clinical, biological, and mortality data. METHODS: We collected retrospectively the whole medical file of all PCP cases diagnosed in non-HIV infected patients, in two French University Hospitals in the last decade (1999-2009). Diagnosis was made on standard coloration and/or immunofluorescence analysis of bronchoalveolar lavage fluid (BAL). RESULTS: Forty-one patients were included in the study, mean age 56 (±12.5) years, sex ratio 0.71 men/woman. Underlying diseases were as follow: 12 patients (29%) were renal transplant recipients, 13 (32%) were treated for solid cancers, and 16 (39%) suffered from various diseases (three allogenic bone-marrow transplantation, 11 hematological malignancies, one pulmonary transplantation, one vasculitis). Twelve patients died (i.e. 29%). Median lymphocyte count was 542/mm(3). More than 85% patients received corticosteroids at a median cumulative 6-month dose of 2700mg. Seven patients (17%) had a PCP prophylaxis. Clinical worsening at day 5 (P<0.003), poor control of the underlying disease (P<0.015), WHO performans status superior than 2 (P<0.025), high temperature (P<0.04), and high oxygen flow (P<0.042) were linked to a poor prognosis. DISCUSSION/CONCLUSION: The prognosis factors found are mostly linked to the patients' clinical severity. We would like to highlight: first, near to 30% mortality rate, secondly, a lack of prophylaxis in 34 patients, reflecting the difficulty to define PCP's risk in non HIV-infected patients.

[H1N1 (2009) influenza A infection in transplant recipient patients: a comparative study versus non-transplanted patients]. / Grippe A/H1N1 2009 chez des patients transplantés : étude comparative versus des patients non transplantés.

OBJECTIVE: To compare H1N1 (2009) influenza A infection characteristics between transplant recipient patients and non-transplanted patients. To assess the evolution of transplanted patients up to 6 months following infection. METHODS: Patients diagnosed with confirmed influenza A infection from three Parisian transplant centers between September 1st, 2009 and February 15th, 2010. Clinical symptoms, biological, and radiological findings, and management were analysed and retrospectively compared between transplanted (T) and non-transplanted patients (NT). The evolution was assessed by a follow-up questionnaire, CT results 1 to 3 months after influenza infection and FEV1 variation. RESULTS: Seventy patients were included. Thirteen patients had an allograft (lung: eight, kidney: four, stem cells: one): (1) hospitalization: 100% (13 out of 13) in group T, 54% (31 out of 57) in group NT (P=0.0013); (2) pneumonia: 62% (eight out of 13) in group T, 26% (eight out of 57) in group NT (P=0.004); (3) mortality rate among hospitalized patients: 7.7% (one out of 13) in the group T, 9.7% (three out of 57) in group NT (P=NS); (4) chest CT scan abnormalities remained in four lung transplanted patients; (5) a minimum 10% decrease in FEV1 was detected in four lung transplant recipients. CONCLUSION: Our results suggest that H1N1(2009) influenza A infection in transplant recipient patients compared to non-transplanted patients: (1) more often leads to hospitalization; (2) is more frequently associated with pneumonia; (3) is responsible for a persistent graft functional impairment in lung transplant recipients; (4) has a low mortality rate similar to admitted non-transplanted patients.

[Obesity, poor prognostic factor in pandemic influenza A (H1N1) 2009: the role of adipokines in the modulation of respiratory defenses]. / L'obésité, facteur de mauvais pronostic au cours de l'épidémie de grippe A (H1N1) 2009 : rôle des adipokines dans la modulation des défenses respiratoires.

Pandemic influenza A (H1N1), which occurred during 2009, revealed some unexpected epidemiologic characteristics, notably the high number of obese subjects among the severe cases of influenza. Generally, obesity seems to be associated with a weakness when it comes to respiratory infections. This susceptibility may be the result of a concurrence of mechanical and hormonal factors due to the excess weight. Obesity leads to changes in the ventilatory mechanics and an increase in the metabolic load during exercise. It is associated with immune system changes. Adipokines, cytokines produced by adipocytes, including leptin, play a central role by modulating the activity of all the cells of the immune system. Finally, obesity is associated with an increased risk of thrombosis, which has an adverse effect on the prognosis of infections. All of these observations can explain that obesity has been a risk factor in serious cases of influenza.

[Pulmonary cystic adenomatoid malformation in an adult patient: an underdiagnosed disease]. / Malformation kystique adénomatoïde pulmonaire de l'adulte : une pathologie méconnue.

Currently, most congenital lower respiratory tract malformations are detected during pregnancy or at birth, thanks to antenatal imaging. However, a pulmonary congenital cystic adenomatoid disease may be found in adulthood. The diagnosis is difficult, due to its rarity. We present the case of a patient whose diagnosis of pulmonary cystic adenomatoid malformation was confirmed when she had tuberculosis. A lobectomy was performed, which enabled identification of tuberculosis and also multiple cysts of adenomatoid malformation. The risk posed by this malformation, i.e. the risk of developing bronchioloalveolar carcinoma and of infection or pneumothorax, is the incentive for proposing formal surgical removal.

Severe Aspergillus endocarditis in a lung transplant recipient with a five-year survival.

We report the case of a patient with cystic fibrosis who underwent lung transplant and developed Aspergillus endocarditis and cutaneous relapse. Long-term survival was achieved with surgical and prolonged antifungal treatment. This case report emphasizes the recommendation of life-long antifungal treatment in transplant recipients who survive an episode of fungal endocarditis.

[Evaluation of 6 years of group B streptococcus (GBS) screening in near-term pregnant women]. / Bilan bactériologique de six ans de dépistage du streptocoque de groupe B (SGB) au cours du dernier trimestre de la grossesse.

Streptococcus agalactiae (GBS) is a significant cause of morbidity and mortality among newborns. Colonization frequently occurs in pregnant women, nearly all international recommendations suggest that all pregnant women must be screened for vaginal colonization at 34 to 37 weeks of gestation. The microbiological diagnostic modalities used to combat GBS had to be accurate and in short time frame. We reported a 6 years experience of GBS screening, comparing results of culture swab of prenatal vaginal specimens and newborns colonization or infection. The carriage rate of 13 to 14% of GBS in newborn was unchanged during all the study period.

[Is aztreonam could become "a challenger" for treatment of Gram negative infections? May be an answer from microbiological data: in vitro study including 36,485 strains of enterobacteria and Pseudomonas]. / L'Aztréonam est-il "un challenger" possible pour le traitement des infections à Gram négatif? Tentative de réponse à partir des données microbiologiques: étude in vitro concernant 36,485 entérobactéries et Pseudomonas.

During 6 years, 2000 to 2006, we looked for evolution of antimicrobial resistance to beta-lactams of clinical isolates from patients with Gram negative infections. In vitro susceptibilities to piperacillin+tazobactam, ceftazidime, and aztreonam were followed along the period. Enterobacteriaceae of group 1 to 3 represent 24,884 strains and Pseudomonas spp. 11601. The global sensitivity of aztreonam was 85%, 87.1% for ceftazidime and 88.8% for pieracilline-tazobactam. Of course, aztreonam spectrum of activity is dedicated to Gram negative bacteria only but it is known to have a great penetration ratio in tissues and a half-live observed up to 6 times higher than in serum in experimental models. Antimicrobial rotation strategy is recommended in the prudent use of antibiotics. It seems that in our hospital a consistent increase of the use of aztreonam might be possible and proposed without increasing risk for infection control practices according to the microbiological laboratory results.

[Is there a change in ecology of Candida species incriminated in fungemia? A 7 years study at Foch Hospital]. / Y a-t-il un changement perceptible dans l'écologie des Candida species responsables de fungémie? Observation de 2000 à 2006 à l'hôpital Foch.

Some Candidemia studies have documented changes in epidemiology of Candida species and some species were reported as emerging species. We conducted a study over a 6 years period and until 2005 we do not noticed any change in epidemiology of Candida even if Candida albicans still the most common species followed by Candida glabrata. No increase of candidemia was observed from 2000 to 2005 and we observed a decrease during the year 2006, this fact have to be confirm and may be related to other data: reinforcement of hygienic measures in our hospital, changes in treatment or preemptive treatment of yeasts and fungi with new azoles or candines molecules. On another side, patients from intensive care units and patients suffering of cancer were, as expected, the most represented population in our study.

[Management of the pulmonary complications of haematological malignancy]. / Approche diagnostique d'une pneumopathie chez un malade atteint d'hémopathie maligne.

The high frequency of pulmonary complications of haematological malignancy and the increasing number of patients treated for these disorders make it important that the respiratory physician has a structured diagnostic approach according to: 1 the immune deficiency due to the malignancy and/or the treatment administered; 2 the factors that can modify the risk of infection (anti infection prophylaxis and/or pre-emptive treatment); 3 co-morbidities; 4 extra-pulmonary manifestations. Two main situations can be identified: The patient is aplasic: Initially the pneumonias are predominantly of bacterial origin but may be fungal if the neutropenia is prolonged. The respiratory physician is faced with two problems: 1 the diagnosis of pneumonia; this may be helped by CT scanning; 2 The choice of antibiotics; this will depend on previous investigations. The patient is not aplasic: The lung disease may have many causes, mainly infectious but also drug related, tumoral, haemorrhagic or embolic. The main problem is the correct choice of investigations to establish an aetiological diagnosis. The collection of data according to a pre-established protocol based on simple factors (study of the notes and clinical examination) is one of the key elements for improving the prognosis of these patients whose management should be multidisciplinary following a pre-defined plan.

[Uncomplicated urinary tract infections, what about fosfomycin and nitrofurantoin in 2006?]. / Quelle sensibilité aux antibiotiques pour les bactéries responsables d'infections urinaires ? Que penser de fosfomycine et nitrofuranes ?

Since 2000 to 2005 we assessed the prevalence of antimicrobial resistance among uropathogens causing acute uncomplicated urinary tract infections (UTI). A total of 19 618 bacteria were studied, fosfomycin, fluoroquinolones, nitrofurantoin were in vitro the most potent drugs with more than 80% of susceptibility. If we compare year 2000 to 2005 we observed a significant decrease of susceptibility for fluoroquinolones. For the same point of comparison, fosfomycin and nitrofurantoin showed a favourable evolution. Rationale and prudent use of antibiotics must now moved us to prescribe parsimoniously fluoroquinolones especially for some indications such as uncomplicated UTI though there are some others "old antibiotics" with a role may be underestimated for this specific indication.

[Simultaneous detection by multiplex PCR of atypical bacterial pathogens involved in infections of respiratory tract. Is it useful for the microbiological diagnosis of respiratory infections]. / La détection par une PCR multiplex de bactéries responsables de pneumopathies atypiques améliore-t-elle les performances du diagnostic microbiologique des infections du tractus respiratoire?

The aim was to evaluate the "strategical place" of the new commercial test Chlamylege (Argene-Biosoft-France) which allows the simultaneous detection in respiratory samples of Chlamydophila pneumoniae, Mycoplasma pneumoniae and most Legionella species using a PCR multiplex. 41 patients with an atypical pneumonia were included, all standard procedures of diagnosis were done and in addition the chamylege test. A pathogen was identified in 12 patients, an other microorganisms than the 3 targeted by our study was found in 8 patients. 4 positive PCR were obtained, 3 with M. pneumoniae and 1 with Legionella pneumophila 1. That means that for 29 patients no aetiology was found. Among them 23 clearly improved under antibiotic treatment. Though that PCR multiplex is an attractive test, easy to perform, sensitive, specific and convenient, we need further studies to approach the place of this PCR test in the diagnosis of multifaceted atypical pneumonia. We also need to know if the cost associated with the microbiological diagnosis (culture, serology, immunofluorescence, urinary antigen test, PCR...) for atypical pneumonia worth value? An algorithm as to be drawn to determine the value of intensive microbiological investigation. An other point to discuss, may be this kind of rapid and multiplex PCR technique could lead to spare the use of some antibiotics.

[Evaluation of a new E-test method for antimicrobial sensitivity testing of Pseudomonas aeruginosa isolates from cystic fibrosis]. / Etude multicentrique portant sur l'évaluation d'une méthode simplifiée d'analyse bactériologique dans la surveillance des infections bronchiques à Pseudomonas aeruginosa survenant au cours de la mucoviscidose.

BACKGROUND: Sputum bacteriological analysis of cystic fibrosis (CF) patients colonised by Pseudomonas aeruginosa is difficult. The bronchial persistence of these bacteria involves phenotypical modifications and the many antibiotic treatments result in emergence of multiresistant strains. The aim of this study is to evaluate a new fast identification and sensitivity testing method of P. aeruginosa and other pathogenic bacteria in sputum of CF patients. It is based on applying a gradient of antibiotic (E-test strip) onto an agar plate inoculated with the sputum. OBSERVATIONS: 310 sputum, collected from adults and children colonised by P. aeruginosa, were analysed by this new method. This method allowed a direct reading of the minimal concentration of antibiotic that inhibited the totality of Gram-negative strains and the detection of resistant pathogenic bacteria inside the ellipse of inhibition. Results obtained by this new method were compared with the conventional method for identification and antimicrobial sensitivity. CONCLUSION: This new method, studying with CF patient colonised by P. aeruginosa, appears interesting, with a sensibility equal or higher than 89% in detection of the bacteria and their sensitivity to antibiotics. Furthermore it allows a saving of time and simplified results.

Spontaneous resolution of hemophagocytic syndrome associated with acute parvovirus B19 infection and concomitant Epstein-Barr virus reactivation in an otherwise healthy adult.

Reported here is the case of a patient who spontaneously recovered from hemophagocytic syndrome associated with acute B19 infection and concomitant Epstein-Barr virus reactivation. The previously healthy 37-year-old-man was hospitalized after 10 days of high fever, arthralgia and arthritis and was determined to have hemophagocytic syndrome. Immunoglobulin (Ig) M antibodies to Epstein-Barr virus (EBV) capsid antigen, early antigen and parvovirus B19 (B19) were found. B19 DNA and low-level EBV DNA were detected in bone marrow, serum and peripheral blood mononuclear cells. The patient recovered spontaneously without any treatment. Two months later anti-B19 IgG antibodies were detected, while at 9-month follow-up, anti-B19 IgM antibodies were no longer detectable and B19 DNA had disappeared from serum. To the best of our knowledge, this is the first report of spontaneous resolution of hemophagocytic syndrome associated with acute B19 infection and concomitant EBV reactivation in an otherwise healthy adult.

[Microbiological diagnosis of bacteremia from a catheter: a simple method? Results of a retrospective study]. / Diagnostic microbiologique de bactériémie liée à une chambre implantable: une méthode simple? Résultats d'une étude rétrospective.

Diagnosing catheter-related bloodstream infections is important but not always easy and a failure to make the diagnosis may have serious consequences. A high rate of unnecessary catheter removal is noted. We retrospectively compared the clinical and usual methods of microbiological diagnoses of catheter-related sepsis to the speed of detection of the catheter versus peripheral blood cultures using the Bact-Alert system. We analyzed 50 files of patients with central indwelling devices: 16 single lumen catheters and 34 implanted ports. Twenty-one catheters were classified as infected, and we observed an earlier positivity of catheter versus peripheral blood in all cases, but significant for 19 patients. According to standard diagnosis methods, 29 catheters were estimated non-infected, a more rapid detection of peripheral culture was reported for 17 specimens and, for another eight patients, the time of detection was equal to blood culture drawn from the catheter. In this group, four discrepancies were recorded with a differential time in favor of sepsis related to catheters ranging from 0.5 to 2 hours. Because of its simplicity and low cost, we believed that this method could be the first step of a diagnosis of catheter-related sepsis and could, therefore, avoid unjustified removal, in particular for the implanted ports for which the diagnostic methods are less codified than for catheters. A prospective study is ongoing; the design of the study focuses only on implanted ports.

[Nitrofurans: a modern treatment for uncomplicated urinary infections?]. / Les nitrofuranes: un traitement moderne des infections urinaires non compliquées?

From January 1995 to December 1998, 2,912 strains of enteric bacilli were isolated from the urinary tract. Increasing antibiotic resistance in Enterobacteriaceae as a cause of urinary tract infection (UTI) led us to reevaluate first- and second-line therapies. We studied antimicrobial susceptibilities of these strains to norfloxacin (NOR), nalidixic acid (NAL), trimethoprim sulfamethoxazole (TS) and nitrofurantoin (FT) using the disk diffusion method. These results show no significant superiority of the activity of nitrofurantoin against Enterobacteriaceae compared with the other antibiotics with sustained concentration in urine. However, if we consider only multiresistant Enterobacteriaceae (cefotaxime resistant), this molecule appears to be very active. These results show a significant superiority of nitrofurantoin in vitro against these multiresistant Enterobacteriaceae. Thus, this molecule could once again become a good choice for the treatment of uncomplicated UTI.

Emergence of multidrug-resistant Enterobacter cloacae: nosocomial outbreak or change of microbial ecology?

Frequent selection of mutants resistant to extended and broad spectrum cephalosporins in Enterobacter cloacae is observed in hospital. As we noticed an unusual number of isolates of these strains and to answer the question arose whether these Enterobacter had a common source, we retrospectivally studied 56 strains collected in 11 wards of the hospital. Using PFGE with Spe 1 restriction analysis we identified a prevalent clone (11 patients) dispatched in 8 wards. We also obviously proved cross-contamination patients to patients with other clones. PFGE allow us to point out that clonal Enterobacter cloacae has taken place in our hospital, even if there is no real outbreak. A reinforcement of basic hygienic measures and a control of antibiotics prescription seemed very important to jugulate the sudden increase of multiresistant Enterobacter cloacae prevalence.

[Utilization of Bichrolatex albicans test for the rapid identification of Candida albicans in blood culture bottles in fungemia: preliminary results from a multicenter study]. / Utilisation du réactif Bichrolatex albicans pour l'identification rapide de Candida albicans dans les flacons d'hémoculture au cours des fongémies: résultats préliminaires d'une étude multicentrique.

In patients with fungemia, reliable and rapid identification of the causative organism has a large impact on treatment decisions. The Bichrolatex albicans test (Fumouze, Levallois-Perret, France) allows rapid identification of Candida albicans in colonies. Its usefulness for identifying C. albicans in liquid blood culture media was evaluated using a previously published protocol. Ninety-seven blood culture bottles from 86 fungemia episodes in 13 study centers were studied. C. albicans contributed 52% of the fungemia episodes, whereas C. glabata and C. tropicalis contributed 15% and 11.5%, respectively. The 48 bottles containing a yeast other than C. albicans were all negative by the Bichrolatex albicans test. Of the remaining 48 bottles, which were positive for C. albicans, 33 produced marked to moderate agglutination and 15 were negative. In one case of mixed fungemia (C. albicans plus C. glabata), weak agglutination was seen. Sensitivity of the test was 69%, negative predictive value was 76%, specificity was 100%, and positive predictive value was 100%. Because of its limited sensitivity, the Bichrolatex albicans test cannot be recommended as a confirmation test for C. albicans fungemia. In contrast, the specificity and positive predictive value of the test are excellent.

Interpretation of high levels of HIV-1 RNA in the cerebrospinal fluid (CSF) using amplicor HIV-1 monitor test.

A retrospective study of 19 cerebrospinal fluid (CSF) specimens from 14 HIV-positive subjects with subacute encephalopathy, neuropathy, or unexplained peripheral myelopathy was done comparatively with plasma specimens collected on the same day and tested in the same run as the corresponding CSF specimen. A single patient had a high HIV RNA level in CSF as compared to plasma (CSF/plasma ratio > 10), which seemed correlated with the clinical course. Further studies are needed to confirm that a high CSF/plasma HIV RNA ratio is associated with greater symptom severity.

[Systematic detection of toxigenic strains of Clostridium difficile--is it useful?]. / La détection systématique des souches toxinogénes de Clostridium difficile est-elle utile?

The incidence of Clostridium difficile (Cd) infection is rising and Cd in fact is now endemic in many hospitals. During the past 4 years we analyzed our data concerning diarrhea caused by Cd in our 700 beds hospital. A positive case was defined as a Cd cytotoxine positive with or without positive culture for Cd. In the present study 120 episodes of Cd associated diarrhea occurred in 102 patients. 1101 stools were cultured from 921 patients. Since 1995 we choose to systematically evaluate Cd in diarrheal stools from hospitalized patients. 120 stool were positives (102 patients), we observed a significant difference between the 2 study periods: Cd was recovered from 16.9% of stool specimen during 1993-1994 and from 9.6% since 1995. This study clearly confirm the common role of Cd in our hospitalized patients as in all positive case, Cd was the only enteropathogen isolated. We suggest the systematic investigation of Cd in hospitalized patients.