Clinical practice recommendations for infectious disease management of diabetic foot infection (DFI) - 2023 SPILF.

In march 2020, the International Working Group on the Diabetic Foot (IWGDF) published an update of the 2015 guidelines on the diagnosis and management of diabetic foot infection (DFI). While we (the French ID society, SPILF) endorsed some of these recommendations, we wanted to update our own 2006 guidelines and specifically provide informative elements on modalities of microbiological diagnosis and antibiotic treatment (especially first- and second-line regiments, oral switch and duration). The recommendations put forward in the present guidelines are addressed to healthcare professionals managing patients with DFI and more specifically focused on infectious disease management of this type of infection, which clearly needs a multidisciplinary approach. Staging of the severity of the infection is mandatory using the classification drawn up by the IWGDF. Microbiological samples should be taken only in the event of clinical signs suggesting infection in accordance with a strict preliminarily established protocol. Empirical antibiotic therapy should be chosen according to the IWGDF grade of infection and duration of the wound, but must always cover methicillin-sensitive Staphylococcus aureus. Early reevaluation of the patient is a fundamental step, and duration of antibiotic therapy can be shortened in many situations. When osteomyelitis is suspected, standard foot radiograph is the first-line imagery examination and a bone biopsy should be performed for microbiological documentation. Histological analysis of the bone sample is no longer recommended. High dosages of antibiotics are recommended in cases of confirmed osteomyelitis.

Can we rely on histopathological results for the diagnosis of prosthetic joint infection?

BACKGROUND: Histopathology is one of the diagnostic criteria for prosthetic joint infection (PJI) proposed by all academic societies. The aim of this study was to compare histopathological and microbiological results from samples taken intraoperatively at the same site in patients with suspected or proven PJI. PATIENTS AND METHODS: We conducted a monocenter retrospective study including all patients having undergone surgery from 2007 to 2015 with suspected or proven PJI. During surgery, both histopathological and microbiological samples were taken. Patients with a history of antimicrobial treatment 2 weeks prior to surgery were excluded. We considered as major criteria and gold standard for PJI diagnosis the presence of a sinus tract communication and/or the same microorganism in at least two cultures. RESULTS: Finally, 181 patients who underwent 309 surgeries were included. The median number of samples per surgery was 4 (interquartile range (IQR) = 3-5) for histopathology and 5 (IQR = 4-6) for microbiology. Major criteria were observed in 177 patients (57.3%), while positive histology in at least one intraoperative sample was present in 119 (38.5%). The concordance was 74%. The sensitivity and specificity of histopathology were 61% and 92% respectively. Available "histopathology-culture" sample pairs numbered 1247. Among them, positive histopathology was found in 292 samples (23%) and culture in 563 (45%). Concordance was 64%. The highest correlation was observed for very early infection (<1 month) (OR: 9.1, 95% CI: 3.6-23) and for virulent microorganisms, such as Staphylococcus aureus (OR: 7.8, 95% CI: 5.2-11.8), Streptococci (OR:7.8; 95% CI: 4-15.2) or Enterobacterales (OR: 7.4; 95% CI: 4.2-13.1). CONCLUSION: Histopathologic examination is a valuable criterion for PJI diagnosis, but it may lack sensitivity for chronic infections or due to low-virulence pathogens.

Characteristics of Enterobacter cloacae prosthetic joint infections.

OBJECTIVES: Enterobacter cloacae prosthetic joint infections (PJI) are rare and poorly documented. PATIENTS AND METHODS: We conducted a retrospective and monocentric study in an orthopedic unit supporting complex bone and joint infections. Between 2012 and 2016 we collected background, clinical, biological, and microbiological data from 20 patients presenting with prosthetic joint infection and positive for E. cloacae, as well as data on their surgical and medical treatment and outcome. RESULTS: Infections were localized in the hip (n=14), knee (n=5), or ankle (n=1). The median time between arthroplasty and septic revision was three years. Fourteen patients (70%) had undergone at least two surgeries due to previous prosthetic joint infections. The median time between the last surgery and the revision for E. cloacae infection was 31 days. Eleven patients (55%) were infected with ESBL-producing strains. The most frequently used antibiotics were carbapenems (n=9), cefepime (n=7), quinolones (n=7), and fosfomycin (n=4). The infection was cured in 15 patients (78.9%) after a 24-month follow-up. Five patients had a recurrent infection with another microorganism and four patients had a relapse of E. cloacae infection. The global success rate was 52.7% (58.3% for DAIR and 75% for DAIR+ciprofloxacin). CONCLUSION: Prosthetic joint infections due to E. cloacae usually occur early after the last prosthetic surgery, typically in patients with complex surgical and medical histories. The success rate seems to be increased when DAIR is associated with ciprofloxacin.

Bacillus cereus infection: 57 case patients and a literature review.

OBJECTIVES: We aimed to study the characteristics of patients presenting with a Bacillus cereus infection in a university hospital. METHODS: We performed a retrospective analysis of the clinical, biological, and treatment-related data of patients hospitalized in our university hospital between January 1st, 2008 and December 31st, 2012 and diagnosed with a B. cereus infection. We identified a subgroup of patients presenting with bacteremia and looked for risk factors for death within that group of patients. RESULTS: We included 57 patients in our study; 31 (54.4%) were hospitalized in a medical ward. We identified 24 bacteremia case patients, including 17 patients presenting with bacteremia alone (29.8%). Other frequently observed infection sites were skin infections (16; 28.1%) and bone and joint infections (10; 17.5%). We recorded 9 deaths (11.8%); 2 patients, despite being on an appropriate antibiotic therapy, died from a medical device-related infection that had not been removed. The empirical administration of a beta-lactam antibiotic was significantly associated with death (P=0.022). Three patients presenting with recurrent bacteremia were identified. The patients only recovered once the infected device had been removed. CONCLUSION: B. cereus infections may have various clinical presentations. Prospective data is needed to put forward a consensual treatment approach and guide physicians in choosing the appropriate antibiotic therapy and in removing the infected device.

A comparison of monomicrobial versus polymicrobial Enterococcus faecalis bacteriuria in a French University Hospital.

Enterococci are of considerable relevance in the hospital setting. Their most common location is the urinary tract, where they may be responsible for both colonization and infections. They are often associated with the presence of other microorganisms. The aim was to compare monomicrobial and polymicrobial Enterococcus faecalis bacteriuria. A retrospective study was performed on the demographic, clinical, and laboratory data of 299 patients who had presented with E. faecalis bacteriuria in 2012 at a University Hospital. The bacteriuria was polymicrobial in 46.1 % of cases and in 36.4 % of cases was responsible for a urinary tract infection. Infections appeared to be more prevalent in the polymicrobial than the monomicrobial group (42 % vs 32 %, p = 0.06). Half of the patients who presented with urinary tract colonization received antibiotic treatment (54/ out of 10). A multivariate analysis adjusted for age (adjusted odds ratio [AOR] = 1.02 per year, p = 0.006), gender (AOR = 2.2, p = 0.007), and clinical classification (colonization or infection, AOR = 1.6, p = 0.091), showed that diabetes mellitus (AOR = 2.0, p = 0.04), hospital length of stay exceeding 28 days (AOR = 2.0, p = 0.03), and presence of a urinary catheter (AOR = 2.4, p = 0.001) were all factors associated with polymicrobial E. faecalis bacteriuria. A reduction in the length of hospital stay and the use of urinary catheters would appear to be required to decrease the incidence of urinary tract colonization and infections by polymicrobial E. faecalis. Improper use of antibiotics to treat urinary tract colonization remains a major concern.

The features of infectious diseases departments and anti-infective practices in France and Turkey: a cross-sectional study.

The aim of this study was to assess the infectious diseases (ID) wards of tertiary hospitals in France and Turkey for technical capacity, infection control, characteristics of patients, infections, infecting organisms, and therapeutic approaches. This cross-sectional study was carried out on a single day on one of the weekdays of June 17-21, 2013. Overall, 36 ID departments from Turkey (n = 21) and France (n = 15) were involved. On the study day, 273 patients were hospitalized in Turkish and 324 patients were followed in French ID departments. The numbers of patients and beds in the hospitals, and presence of an intensive care unit (ICU) room in the ID ward was not different in both France and Turkey. Bed occupancy in the ID ward, single rooms, and negative pressure rooms were significantly higher in France. The presence of a laboratory inside the ID ward was more common in Turkish ID wards. The configuration of infection control committees, and their qualifications and surveillance types were quite similar in both countries. Although differences existed based on epidemiology, the distribution of infections were uniform on both sides. In Turkey, anti-Gram-positive agents, carbapenems, and tigecycline, and in France, cephalosporins, penicillins, aminoglycosides, and metronidazole were more frequently preferred. Enteric Gram-negatives and hepatitis B and C were more frequent in Turkey, while human immunodeficiency virus (HIV) and streptococci were more common in France (p < 0.05 for all significances). Various differences and similarities existed in France and Turkey in the ID wards. However, the current scene is that ID are managed with high standards in both countries.

[Non-antibiotic anti-infectious treatments in urology]. / Les médicaments anti-infectieux non antibiotiques en urologie.

OBJECTIVE: To define the terms of use of pesticides, antifungal, antiviral and antiseptic treatments in urology. MATERIALS AND METHODS: A literature search was conducted on MEDLINE for all these treatments used in urology. The molecules were classified by family. Modes of action, indications in urology and adverse effects have been detailed. Authorisation files were consulted and then complemented by a literature analysis. RESULTS: Although parasitic or viral diseases are uncommon in urology, their specific treatment deserves a thorough knowledge of pesticide and antiviral molecules. Antifungal treatments are regularly used in urology with special features to know to improve the efficacy/safety ratio. Antiseptics are used daily in urology and a better understanding of these molecules allows better use. CONCLUSION: Beyond antibiotics, antiviral, antiparasitic and antifungal deserve a thorough knowledge. Antiseptic although used daily have features little known.

[Reporting and interviewing delays in contact investigation of tuberculosis, Seine-Saint-Denis, from April to June 2008]. / Délais de signalement et d'entretien dans l'enquête autour d'un cas de tuberculose, Seine-Saint-Denis, avril-juin 2008.

BACKGROUND: In France, one of the main components of the tuberculosis control program is contact investigation around all tuberculosis cases. For this purpose, all cases of tuberculosis are to be reported to the health authorities (Centre de lutte antituberculeuse) within 48 hours of diagnosis. The Centre then conducts an initial patient interview within three days of the report in order to establish a list of contacts requiring evaluation. Given that a delay in action may play a role in the continued disease transmission, it appeared necessary to study more precisely this subject in a French area with a high annual new case rate, the Seine-Saint-Denis. METHODS: A descriptive and retrospective study included all tuberculosis cases reported and received between April and June 2008. The two periods were statistically analyzed with socio-demographic, clinical-biological and investigations data. RESULTS: For the 148 cases reported during this period, a first interview was required for 123. The average time period between initiation of anti-tuberculosis therapy and reception of the report was 11.08 days. The overly long delay could be explained in part by the inappropriate use of the notification form (45.5%) designed for non-urgent collection of epidemiological data, and in part by the underuse of telephone reporting (8.1%). The first interview was not performed for 19 cases and the average time between reception of the notification and the patient interview was 6.58 days. Having the patient's phone number appeared essential to meet the deadline (odds ratio: 5.3; 95% confidence interval [1.7-16.9]). Few interviews were made in person. Shortage in financial and human resources and the delayed case reporting could be part of the explanations. Deadlines were met much better for cases of pleuro-pulmonary tuberculosis compared with other localizations, for reporting (39.2% versus 13.5%, p<0.01) and for the first interview (48.8% versus 28.6%, p=0.03). CONCLUSION: This study reports some risk factors associated with delayed action and highlights the need for improved reporting of tuberculosis cases and contact investigations.

[Guidelines for blood transfusion teaching to medical laboratory technology students]. / Référentiel d'enseignement de la transfusion sanguine aux étudiants techniciens de laboratoire de biologie médicale.

PURPOSE OF THE STUDY: The new French law about clinical laboratory medicine, the requirements of the ISO/CEI 15189 standard, the numerous abilities expected from the medical laboratory technologists and their involvement in blood bank management has led the working group "Recherche et démarche qualité" of the French Society of Blood Transfusion to initiate an inventory of blood transfusion teaching syllabus for medical laboratory technology students and to propose transfusion medicine teaching guidelines. MATERIAL AND METHODS: Seven worksheets have been established for that purpose including red blood cell antigen typing and antibody screening, blood sampling in immunohaematology, automation, clinical practices, blood products, blood delivery and haemovigilance. RESULTS: These guidelines aim at contributing to the harmonization of transfusion medicine teaching and at providing objective elements to the medical laboratory managers regarding the practical and theoretical skills of theirs collaborators.

Lymphocyte volume and conductivity indices of the haematology analyser Coulter GEN.S in lymphoproliferative disorders and viral diseases.

The haematology analyser Coulter GEN.S gives a set of data -'positional parameters'- defining white blood cell (WBC) populations by mean of index values (mean and standard deviation of volume, conductivity and scatter, used to identify the WBC populations). The volume and conductivity parameters related to the lymphocytes were analysed at diagnosis in patients suffering from chronic B-lymphocytic leukaemia (B-CLL), other non-CLL lymphoproliferative disorders (OLPD) and viral diseases. The standard deviation of volume index (SDVI) is significantly higher in the three groups, whereas the mean volume index (MVI) is significantly lower in B-CLL, and increased in OLPD and viral diseases. These two groups could be distinguished by their mean conductivity index (MCI), which is significantly lower in viral disease group. Cut-offs were calculated for each parameter by the mean of Receiver Operating Characteristic (ROC) analysis. The study of the detection performances showed that the combination of lymphocyte count with SDVI, MVI and MCI could be used with a good sensitivity and specificity to discriminate between the most frequent lymphocyte pathologies, even in patients with normal lymphocyte count.

Automated detection of malaria by means of the haematology analyser Coulter GEN.S.

The haematology analysers Coulter(R) GEN.S(TM) and LH(TM) give a set of data--'positional parameters'--which define each WBC population by mean of index values, the mean and the standard deviation (SD) of volume, conductivity and scatter, used to identify the WBC populations. These parameters were analysed in patients investigated for suspicion of malaria, in order to show a difference between malaria negative and malaria positive patients and to use it for malaria detection. The six parameters exhibiting a significant difference between the two groups were submitted to a ROC analysis, which showed both sensitivity >90% and specificity >60% for two parameters, lymphocyte and monocyte SDs of volumes. A discriminator combining the two parameters showed a sensitivity of 96.9% and a specificity of 82.5%. The cut off of the discriminative value was calculated. Because of the good stability and reproducibility of the parameters selected, the test can be used in order to detect patients having a high probability to be malaria positive and to pay particular attention to these blood smears. For more extensive diagnostic use, a standard control procedure of the positional parameters should be introduced.

Agranular CD4+/CD56+ cutaneous neoplasm.

CD4+ CD56+ cutaneous neoplasm with hematological relapse is a rare malignant disease and has been described recently in the literature as blastic or agranular NK-cell leukemia/lymphoma. The origin of this neoplasm is uncertain. We describe a 75-year-old patient with a primary cutaneous neoplasm CD4+ CD56+ who evolved to leukemic phase despite standard lymphoma chemotherapy. Morphologically, the cells were undifferentiated without granules in the cytoplasm. The immunophenotype showed the expression of CD4, CD56, CD68, CD33, CD7, CD2, CD45RA, and CD38. Histological analysis revealed a cell infiltration mainly located in the dermis. T-cell receptor and immunoglobulin heavy chain genes were in germline configuration. Cytogenetic study showed complex structural abnormalities with a deletion of the chromosome 5 del(5q). The clinical course was aggressive with an early hematological relapse.

[Evaluation of the Beckman Coulter HmX hematology analyser at a general hospital]. / Evaluation de l'analyseur d'hématologie Beckman Coulter HmX dans un hôpital général.

The Beckman Coulter HmX is an hematological analyzer designed to provide a complete hematological profile including CBC, WBC differential (diff) and reticulocyte parameters. It has been evaluated in our laboratory over a two weeks period with three purposes: (1) a technical evaluation of the HmX performance, in regard to repeatability, linearity, carry over; (2) a comparison of numerical results (CBC, WBC diff) and analytical performance (flag sensitivity and specificity) with those obtained with the Coulter MaxM in use in our laboratory; (3) an analysis of the flagging algorithms using the blood smear as the reference method. The first part of the evaluation showed that the Beckman Coulter HmX is reproducible, and linear. The comparison between MaxM and HmX showed that the results given by the two instruments are similar and suggested that the Beckman Coulter HmX could replace the current hematology analyzer in use in our laboratory. The comparison of the flag system performance, between the Beckman Coulter HmX and the Coulter MaxM, has been performed with samples from three subgroups of patients (general departments, surgery and intensive care, hematological unit), and showed that the HmX is significantly more sensitive than the MaxM, with an higher global efficiency. The comparison of predictive values also showed a better performance of the HmX. In conclusion, the Beckman Coulter HmX is suited for an use in medium sized hospital laboratories (80 to 150 CBC diff/day), with good technical and analytical performance, a throughput of 75 samples/hr and a workstation allowing data management in accord with quality assurance guidelines in France.

Chronic lymphocytic leukemia associated with myelodysplastic syndrome and/or chronic myeloid leukemia: evidence for independent clonal chromosomal evolution.

We describe the cytogenetic findings of three cases with simultaneous or sequential development of a B-chronic lymphocytic leukemia (B-CLL) and either a myelodysplastic syndrome (MDS) in 2 cases or a chronic myeloid leukemia (CML) in one case. The coexistence of these two hematologic malignancies leads to questions about their cell of origin. Through analysis of the cytogenetic abnormalities, we studied the derivation of both malignancies. The cytogenetic analyses of these three patients were simultaneously studied from both peripheral blood and bone marrow. Furthermore unstimulated short-time (USSTC) and long-time (72-96 hours) stimulated cultures (LTSC) were systematically performed. In all cases, we have demonstrated the independent bi-clonal evolution. This is the first report ever described for patients with CLPD and MDS and/or MPD shown to arise from distinct chromosomal abnormalities.

CD3+ CD8+ CD56- clonal large granular lymphocyte leukaemia and HIV infection.

High-grade malignant lymphomas associated with HIV infection are usually derived from B lymphocytes. Although a broad spectrum of T-cell-derived malignancies has been described, no case of monoclonal T large granular lymphocyte leukaemia has been reported to date. We report a case of clonal T-LGL (CD3+, CD4-, CD8+, CD56-, CD57+) in an HIV-infected. HTLV1/2-negative individual. Large granular lymphocytes are thought to represent activated cytotoxic T lymphocytes. HIV infection, as previously reported for HTLV1/2, may represent a pathway of antigen activation and lead to clonal expansion of T large granular lymphocytes.

The 17p-syndrome: a distinct myelodysplastic syndrome entity?

The 17p- syndrome is a subset of myelodysplastic syndrome characterized by "typical" dysgranulopoïesis, combining a pseudo-Pelger-Hüet and a deletion of the short arm of chromosome 17. We describe two patients; one with de novo myelodysplastic syndrome (RAEB), one with secondary MDS (RAEB-T). Both showed a 17p- deletion resulting from tanslocations involving 17p associated with an additional complex cytogenetics, and both of them had a particular type of dysgranulopoiesis, combining pseudo-Pelger-Hüet anomaly.