Cefotaxime resistance in bile samples is an independent predictor of deep infectious complications after pancreaticoduodenectomy in patients with endoprosthesis.

BACKGROUND: Bacteriobilia may increase the rate of deep infectious complications (DIC) after pancreaticoduodenectomy. To better adjust prophylactic and empirical antibacterial treatment, we aimed to characterize bacteriobilia in patients with preoperative endoprosthesis, and its association with postoperative DIC. METHODS: All patients who underwent pancreaticoduodenectomy in our center between 2010 and 2019 were included. The association between microbiological findings from bile samples, and postoperative DIC was analyzed, and we compared microbiology data between 2010-2014 and 2015-2019 periods. RESULTS: We enrolled 578 patients (median age 67 years [59-72], 58.7% males), of whom 220 (38.1%) had preoperative biliary endoprosthesis, with 197 (89.5%) positive preoperative bile samples pathogens were Enterobacterales, enterococci, and Candida albicans. The incidence of DIC was similar in patients with or without endoprosthesis (20.4% vs 17.8%, P = .352). Bacterial isolates collected during 2015-2019 were more resistant to cefotaxime than those recovered from 2010-2014 (45.5% vs 25.5%, P = .009). The only independent risk factor for DIC in patients with endoprosthesis was cefotaxime resistance in bile (hazard ratio 3.027 [1.115-8.216], P = .03). CONCLUSIONS: The incidence of DIC is high after pancreaticoduodenectomy, with or without endoprosthesis, despite routine postoperative treatment. Cefotaxime resistance, the only independent predictor of DIC in patients with endoprosthesis, has increased over time. Hence, cefotaxime may no longer be an appropriate empirical treatment.

Chromoblastomycosis Due to a Never-before-Seen Dematiaceous Fungus in a Kidney Transplant Patient.

Chromoblastomycosis is a neglected fungal infection of the epidermis and subcutaneous tissue that predominates in tropical areas and results from the traumatic inoculation of environmental dematiaceous filamentous fungi. We describe the case of an immunosuppressed patient diagnosed with foot chromoblastomycosis due to an uncommon dematiaceous fungus. A 52-year-old Congolese kidney transplant woman presented with a painful lesion located on the foot. No trauma to the lower limbs was reported during the previous months. She lived in France and had not returned to the Congo over the previous eight years. Histology and mycological examination from skin biopsy revealed swollen dark filaments associated with dematiaceous muriform cells, pathognomonic of chromoblastomycosis. Cultures grew with dark pigmented colonies, yielding poor microscopic features. The phylogenetic analysis confirmed that the isolate was a member of Kirschsteiniotheliales (Dothideomycetes) and unrelated to the Chaetotyriales, of which most species commonly responsible for chromoblastomycosis belong. As there was no bone spreading, excision surgery of the entire lesion followed by liposomal amphotericin B therapy resulted in complete healing after six months. This original case illustrates the potential diversity of environmental dematiaceous fungi responsible for phaeohyphomycosis, especially chromoblastomycosis, and the need to send samples to mycology labs for appropriate diagnosis.

Impact of a multiplex PCR assay (FilmArray®) on the management of patients with suspected central nervous system infections.

Microbiological diagnosis of central nervous system (CNS) infections is challenging due to limited access to CNS samples, overlap between meningitis and encephalitis, and the multiplicity of pathogens potentially involved. We aimed to estimate the impact of a commercial multiplex PCR assay (FilmArray® meningitis/encephalitis) on the management of patients with suspicion of meningitis or encephalitis, in terms of time to diagnosis, antimicrobial agents use, duration of hospitalization, and costs. This prospective observational study was conducted at Saint Joseph Hospital (Paris, France) from December 2016 to December 2017. All CSF samples sent to the microbiology laboratory for suspicion of meningitis and/or encephalitis, with CSF cells count > 5 cells/µL, were tested by meningitis/encephalitis multiplex PCR assay. One hundred thirty patients were included. The multiplex PCR assay was positive in 33 patients (25%). Main pathogens found were Enterovirus (n = 12), Varicella-Zoster virus (n = 7), Herpes simplex virus-2 (n = 6), and Listeria monocytogenes (n = 3) as main pathogens. The multiplex PCR assay reduced time to microbiological diagnosis by 3.3 ± 1.6 days and allowed an earlier discontinuation of empirical anti-infective drugs in 42 patients (32%) and an earlier hospital discharge in 23 patients (18%), with an estimated saving of 82 hospital days overall, and a management cost reduction of 26,242 € (201 €/patient). The systematic use of the FilmArray® meningitis/encephalitis multiplex PCR assay may allow earlier diagnosis, earlier discontinuation of empirical treatment, reduced duration of stay, and costs reduction.

Rickettsia sibirica mongolitimonae infection, Sri Lanka.

INTRODUCTION: Rickettsia sibirica mongolitimonae was recently reported as a common rickettsiosis in France. Current serological evidence suggests the presence of scrub typhus and spotted fever group rickettsiosis in Sri Lanka. We detected a human case of R. sibirica mongolitimonae in Sri Lanka. METHODOLOGY: A skin biopsy of the eschar was tested for the presence of Rickettsia spp. using qPCR assay targeting a 109-bp fragment of a hypothetical protein and by PCR amplification and sequencing targeting the ompA gene. RESULTS: A 30-year-old woman who had just returned from travel to a jungle in Sri Lanka was evaluated as an outpatient for fever. Examination revealed an enlarged axillary lymph node, a maculopapular rash and an eschar at her left flank and a skin biopsy of the eschar was performed. The skin biopsy was positive for the presence of Rickettsia spp. by qPCR and PCR amplification and sequencing targeting the ompA gene revealed R. sibirica mongolitimonae. Immunofluorescence assay on an acute serum sample for spotted fever group rickettsial antigens (Rickettsia conorii conorii, R. sibirica mongolitimonae, Rickettsia felis) and typhus group rickettsiae (Rickettsia typhi) was negative. The patient was treated by oral doxycycline (200 mg/day) for one week. CONCLUSIONS: R. sibirica mongolitimonae should be considered in the differential diagnosis of patients with suspected rickettsiosis in, or returning from, Sri Lanka.