No effect of vancomycin MIC ≥ 1.5 mg/L on treatment outcome in methicillin-susceptible Staphylococcus aureus bacteraemia.

The vancomycin minimum inhibitory concentration (MIC) has been shown to affect the outcome of methicillin-susceptible Staphylococcus aureus (MSSA) bacteraemia. In this study, the outcomes of patients with MSSA bacteraemia with a vancomycin MIC ≥ 1.5 mg/L were assessed. A prospective cohort of patients with MSSA bacteraemia in two tertiary-care hospitals was collected. The vancomycin MIC was determined by Etest. Staphylococcus aureus strains were categorised as low (<1.5 mg/L) or high (≥1.5 mg/L) vancomycin MIC. First- and second-line treatments were recorded and classified as optimal, appropriate and inappropriate. The primary endpoint was 30-day mortality. A total of 250 patients with S. aureus bacteraemia were analysed, of whom 64 (25.6%) had strains with a high vancomycin MIC. History of dialysis (P = 0.001) and ultimately fatal disease (P = 0.005) were associated with strains with a high vancomycin MIC. The 30-day mortality was 24.7% (46/186) in patients with a low vancomycin MIC versus 28.1% (18/64) in patients with a high vancomycin MIC (P = 0.592) and did not differ significantly after adjustment for the appropriateness of the antibiotic treatment. Patients with a high vancomycin MIC were less frequently associated with complicated bacteraemia (15.6% vs. 39.2%; P = 0.001). In conclusion, vancomycin MIC ≥ 1.5 mg/L was not associated with 30-day mortality but was associated with uncomplicated bacteraemia in MSSA bacteraemia, regardless of the first- and second-line treatment.

Nosocomial Infections with IMP-19-Producing Pseudomonas aeruginosa Linked to Contaminated Sinks, France.

We isolated IMP-19-producing Pseudomonas aeruginosa from 7 patients with nosocomial infections linked to contaminated sinks in France. We showed that blaIMP-19 was located on various class 1 integrons among 8 species of gram-negative bacilli detected in sinks: P. aeruginosa, Achromobacter xylosoxidans, A. aegrifaciens, P. putida, Stenotrophomonas maltophilia, P. mendocina, Comamonas testosteroni, and Sphingomonas sp.

Massilia timonae as cause of chronic endophthalmitis following cataract surgery.

UNLABELLED: This is the first report of chronic postoperative endophthalmitis caused by Massilia timonae. The gram-negative bacillus was isolated from a patient who developed chronic endophthalmitis after cataract extraction. The microorganism was cultured on brain-heart infusion broth and identified using the 16S rRNA sequence analysis. Biochemically, the organism was positive for catalase and oxidase and negative for arginine dihydrolase. It was pansensitive to ß-lactams, fluoroquinolones, aminoglycosides, and trimethoprim-sulfamethoxazole but resistant to aztreonam. Massilia timonae is a new bacterium implicated in postoperative chronic endophthalmitis. Eubacterial polymerase chain reaction was useful in identifying M timonae because phenotyping testing and conventional algorithms could not identify it. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Evolving epidemiology and antimicrobial resistance in spontaneous bacterial peritonitis: a two-year observational study.

BACKGROUND: Current recommendations for empirical antimicrobial therapy in spontaneous bacterial peritonitis (SBP) are based on quite old trials. Since microbial epidemiology and the management of patients have changed, whether these recommendations are still appropriate must be confirmed. METHODS: An observational study that exhaustively collected the clinical and biological data associated with positive ascitic fluid cultures was conducted in four French university hospitals in 2010-2011. RESULTS: Two hundred and sixty-eight documented positive cultures were observed in 190 cirrhotic patients (median age 61.5 years, 58.5% Child score C). Of these, 57 were classified as confirmed SBP and 140 as confirmed bacterascites. The predominant flora was Gram-positive cocci, whatever the situation (SBP, bacterascites, nosocomial/health-care related or not). Enteroccocci (27.7% E. faecium) were isolated in 24% of the episodes, and in 48% from patients receiving quinolone prophylaxis. E. coli were susceptible to amoxicillin-clavulanate and to third-generation cephalosporins in 62.5% and 89.5% of cases, respectively. No single antibiotic allowed antimicrobial coverage of more than 60%. Only combinations such as amoxicillin + third-generation cephalosporin or cotrimoxazole allowed coverage close to 75-80% in non-nosocomial episodes. Combinations based on broader spectrum antibiotics should be considered for empirical therapy of nosocomial infections. CONCLUSIONS: Our study confirmed the changing spectrum of pathogens in SBP and bacterascites, and the need for more complex antibiotic strategies than those previously recommended. Our findings also underline the need for new clinical trials conducted in the current epidemiological context.

Impact of prior statin therapy on the outcome of patients with suspected ventilator-associated pneumonia: an observational study.

INTRODUCTION: Ventilator-associated pneumonia (VAP) is the most commonly acquired infection in intensive care units (ICU). Its outcome is related, at least in part, to the host's response. Statins have anti-inflammatory effects and may thus improve the outcome. We aimed to assess the impact of prior statin use in the setting of VAP. METHODS: A six-year cohort study was conducted in a French ICU at a teaching hospital. All of the patients with suspected VAP were included. Baseline characteristics, outcomes, statin exposure, and the description of suspected episodes were collected prospectively. The primary endpoint was 30-day mortality. Patients who were taking statins before admission to the ICU whether or not treatment was continued thereafter ('previous users' group) were compared to those without prior statin therapy ('statin-naive' group). A survival analysis using a Cox model was conducted in the whole cohort and in the subgroup of prior statin users. RESULTS: Among the 349 patients included, 93 (26.6%) had taken statins. At baseline, these patients were at higher risk of complications than statin-naive ones (for example, older, more likely to be men and to have underlying diseases, greater simplified acute physiology score II (SAPS II)). There was, however, no difference regarding severity at the time VAP was suspected (sequential organ failure assessment (SOFA): 9.0 (4.0 to 16.0) versus 8.0 (4.0 to 17.0); P = 0.11). Nonetheless, 30-day mortality in statin users was not different from that in statin-naive patients (35.5% versus 26.2%, respectively; adjusted hazard ratio (HR) = 1.23 (0.79 to 1.90) 95% confidence interval (CI); P = 0.36). In contrast, after limiting analysis to prior statin users and adjusting for potential confounders, those who continued the treatment had better survival than those who did not (HR = 0.47; (0.22 to 0.97) 95% CI; P = 0.04). CONCLUSIONS: Statin continuation in prior users could provide protective effects in patients with suspected VAP.

A leukocyte score to improve clinical outcome predictions in bacteremic pneumococcal pneumonia in adults.

BACKGROUND: Bacteremic pneumococcal pneumonia (BPP) is associated with high and early mortality. A simple procedure to predict mortality is crucial. METHODS: All adult patients with BPP admitted from 2005 through 2013 to the University Hospital of Dijon, France, were enrolled to study 30-day mortality and associated factors, particularly leukocyte counts. A simple leukocyte score was created by adding 1 point each for neutropenia (<1500 cells/mm(3)), lymphopenia (<400), and monocytopenia (<200). RESULTS: One hundred and ninety-two adult patients (mean age, 69 years; standard deviation [SD], 19 years) who had developed and were hospitalized for BPP (58% community-acquired) were included. The 30-day crude mortality rate was 21%. The mean Pneumonia Severity Index score was high at 127.3 (SD = 41.3). Among the 182 patients who had a white blood cell count, 34 (19%) had a high leukocyte score (≥2). Multivariate analysis revealed that mortality was significantly associated with a high leukocyte score (odds ratio, 6.28; 95% confidence interval, 2.35-16.78), a high respiratory rate, a low serum bicarbonate level, and an altered mental status (all P < .05). The leukocyte score was not significantly dependent on the previous state of immunosuppression, alcoholism, or viral coinfection, but it did correlate with an acute respiratory distress syndrome and a low serum bicarbonate level. CONCLUSIONS: This new leukocyte score, in combination with the well known predictive factors, seems of interest in predicting the risk of death in BPP. A high score correlated with organ dysfunction and probably reflects the level of immunoparalysis. Its predictive value has to be confirmed in other cohorts.

Candida spp. airway colonization could promote antibiotic-resistant bacteria selection in patients with suspected ventilator-associated pneumonia.

OBJECTIVE: Candida spp. airway colonization could promote development of ventilator-associated pneumonia (VAP) caused by Pseudomonas aeruginosa, a potentially multidrug-resistant (MDR) bacteria, and worsen the outcome of VAP regardless of pathogen. We therefore address the question of the risk of MDR bacteria isolation within the airway of patients with suspected VAP, whether Candida spp. is present or not. DESIGN AND SETTING: Prospective observational study in a teaching hospital. PATIENTS AND METHODS: Consecutive patients with suspected VAP were included. Respiratory tract secretions were seeded on specific medium for yeast isolation in addition to standard culture. Outcome as well as presence of MDR bacteria were assessed according to fungal colonization. RESULTS: 323 suspected VAP were analysed. Among these, 181 (56 %) cases presented with Candida spp. airway colonization. Colonized and noncolonized patients were similar regarding baseline characteristics, prior exposure to antibiotics and VAP severity. However, mortality rate was greater in patients with fungal airway colonization than in those without (44.2 versus 31.0 %, respectively; p = 0.02). In addition, MDR bacteria isolation was 31.5 % in patients with Candida spp. colonization versus 23.2 % in those without (p = 0.13). Moreover, Candida spp. airway colonization was one independent risk factor for MDR bacteria isolation [odds ratio (OR) = 1.79, 95 % confidence interval 1.05-3.05; p = 0.03], in addition to the time elapsed between intensive care unit (ICU) admission and VAP suspicion. CONCLUSIONS: In patients with suspected VAP, Candida spp. airway colonization is frequent and associated with increased risk for MDR bacteria isolation. This could worsen outcome and should therefore be considered when choosing an empiric antibiotic therapy.

Relationship between baseline clinical data and microbiologic spectrum in 100 patients with acute postcataract endophthalmitis.

PURPOSE: To correlate the initial ocular presentation with bacterial identification in 100 patients with acute postcataract endophthalmitis. METHODS: This was a prospective multicenter study. Demographic data, medical history, and the initial eye examination data were recorded on a standardized form. The relationship between bacterial identification and clinical factors at baseline was studied using univariate and multivariate analyses. RESULTS: One hundred patients were admitted to the hospital with a median delay of 6 days after cataract surgery. The main symptoms were loss of vision (94.9%) and pain (75.5%). Major clinical signs were hypopyon (72%), pupillary fibrin membrane (77.5%), and loss of fundus visibility (90%). Baseline factors significantly associated with microbiologic identification were as follows: diabetes mellitus, a shorter delay of onset, initial visual acuity limited to light perception, higher intraocular pressure, chemosis, pupillary fibrin membrane, loss of the red reflex, and reduced fundus visibility. As compared with other bacteria, the identification of Streptococcus species (n = 19) was more frequently associated with male gender, diabetes mellitus, initial visual acuity limited to light perception, and pain. The Staphylococcus aureus and Staphylococcus lugdunensis group (n = 14) differed from other coagulase-negative Staphylococcus groups (n = 33) in that those patients had greater hypopyon height. CONCLUSION: The baseline features of acute endophthalmitis after cataract surgery in the era of phacoemulsification are similar to those reported in the Endophthalmitis Vitrectomy Study 15 years ago and differ according to the bacterial species. The association between the clinical signs and the microbiologic identification suggests that initial characteristics other than visual acuity may be useful in identifying patients presumed to be infected with a virulent species.

Epidemiology and antimicrobial resistance of Streptococcus pneumoniae in France in 2007: data from the pneumococcus surveillance network.

Antimicrobial resistance of Streptococcus pneumoniae in France is closely monitored by the pneumococcus surveillance network, founded in 1995, which collects data from regional observatories (Observatoire Régionaux du Pneumocoque [ORP]). In 2007, 23 ORPs analyzed the antibiotic susceptibility of 5,302 isolates of S. pneumoniae recovered in France from cerebrospinal fluid, blood, middle ear fluid, and pleural fluid, as well as from adult respiratory samples. The study showed that 38.2% of the strains were nonsusceptible to penicillin, 19.3% nonsusceptible to amoxicillin, and 10.5% nonsusceptible to cefotaxime. The percentage of pneumococcus nonsusceptible to penicillin varied according to both the sample and the age of the patient (child/adult): blood (27.8%/32.5%), cerebrospinal fluid (33.7%/34.6%), middle ear fluid (60.2%/27.5%), and pleural fluid (50.0%/31.0%). Between 2003 and 2007, the frequency of penicillin resistance in invasive pneumococcal disease gradually decreased from 46.4% to 29.0% in children and from 43.8% to 32.7% in adults. This decrease coincided with the introduction of a seven-valent pneumococcal conjugate vaccine into immunization programs and with a general reduction in levels of antibiotic consumption in France.

Bacterial epidemiology and antimicrobial resistance in ascitic fluid: a 2-year retrospective study.

The bacterial epidemiology of bacterascites and spontaneous bacterial peritonitis is evolving. Four hundred and eleven strains isolated from ascites in cirrhotic patients from 5 French hospitals were isolated in 2006 and 2007. Of these, 114 were definitely associated with spontaneous bacterial peritonitis. The proportion of Gram-positive and Gram-negative agents was quite similar, even after excluding coagulase-negative staphylococci, or when considering only definite spontaneous bacterial peritonitis or community-acquired strains. Staphylococci and Escherichia coli were the most frequent pathogens, but enterococci were also involved in nearly 15% of the cases. Among the E. coli, 28% were intermediate or resistant to amoxicillin+clavulanate, 5.3% expressed cephalosporinases or extended beta-lactamases and 17.3% were intermediate or resistant to fluoroquinolones. Resistance to methicillin was observed in 27% of Staphylococcus aureus. Cefotaxime and amoxicillin-clavulanate remained the most effective 'single' agents, however on less than 70% of isolates. Some combinations (such as cefotaxime+amoxicillin) extended coverage to a further 15% of strains. Since inadequate empiric antibiotic therapy is associated with increased mortality, these combinations may be of great interest as first-line treatment, even though they may also lead to the development of antimicrobial resistance. Repeated epidemiological surveys and new clinical trials are thus needed.

Analysis of diluted vitreous samples from vitrectomy is useful in eyes with severe acute postoperative endophthalmitis.

PURPOSE: This study was designed to compare the diagnostic yield of microbiological analysis performed on diluted and undiluted vitreous samples from pars plana vitrectomy (PPV) in patients with acute postcataract endophthalmitis. DESIGN: Cohort study, evaluation of diagnostic test or technology. PARTICIPANTS: Patients with acute postcataract endophthalmitis (<6 weeks). METHODS: Undiluted and diluted vitreous samples were taken from 34 consecutive patients at the beginning of PPV as part of the multicenter prospective study of the French Institutional Endophthalmitis Study (FRIENDS) group. Vitrectomy was performed after 1 (n = 12) or 2 (n = 22) intravitreous antibiotic injections. McNemar's nonparametric test was used to compare culture and polymerase chain reaction (PCR) results between diluted and undiluted samples. MAIN OUTCOME MEASURES: Rate of positivity of conventional culture (brain heart infusion broth) and eubacterial PCR tests from undiluted and diluted vitreous samples. RESULTS: The microbiological analysis of both undiluted and diluted vitreous samples detected and identified a bacterial pathogen in 26 out of 34 cases (76.4%). The analysis of undiluted and diluted vitreous at the time of PPV, using eubacterial PCR and conventional culture, gave similar results (P = 0.99; McNemar test). However, eubacterial PCR was more sensitive than culture in detecting bacteria in vitreous at the time of PPV (76% vs 6%; P = 0.001; McNemar test). The difference in sensitivity between the 2 techniques was primarily associated with false-negative culture results for undiluted samples (2/3 of cases), mainly for coagulase-negative staphylococci. CONCLUSIONS: The microbiological results obtained combining PCR and culture techniques were similar for diluted vitreous and undiluted vitreous analysis. When eubacterial PCR is available, sampling diluted vitreous, an easier procedure, may replace sampling undiluted vitreous.

Serotype distribution and antibiotic resistance of Streptococcus pneumoniae strains isolated from adults in France: evolution between 2001 and 2003.

Antibiotic-resistant Streptococcus pneumoniae (Sp) are described around the world. The present national surveillance study report analyzes more than 6000 Sp strains, isolated from adults across France in 2001 and 2003, from blood cultures (3086 in 2001 and 3164 in 2003), cerebrospinal fluid (respectively, 238 and 240), or middle ear fluid (respectively, 110 and 100). The proportion of isolates with reduced susceptibility to penicillin fell significantly between 2001 and 2003 from 46.5% to 43.9%. The proportion of high-level resistant strains to penicillin minimal inhibitory concentrations (MIC > 1 mg/L), amoxicillin, and cefotaxime (MIC > 2 mg/L) slightly decreased but remained low: 10.6%, 1.2%, and 0.2% in 2003. Resistance to other antibiotics (erythromycin, cotrimoxazole, tetracycline, and chloramphenicol) also decreased. Decrease in prevalence of penicillin-resistant Sp varied according to specimen source. The proportion of penicillin nonsusceptible pneumococci decreased in blood cultures and middle ear fluids between 2001 and 2003 but increased in cerebrospinal fluid (43.4% and 46.5%, respectively). Serotypes covered by the heptavalent vaccine accounted for 42.4% of all isolates recovered in 2001 and 46.1% in 2003. Prevalence of antibiotic-resistant Sp decreased in 2003 in France.

Impact of previous sepsis on the accuracy of procalcitonin for the early diagnosis of blood stream infection in critically ill patients.

BACKGROUND: Blood stream infections (BSI) are life-threatening infections in intensive care units (ICU), and prognosis is highly dependent on early detection. Procalcitonin levels have been shown to accurately and quickly distinguish between BSI and noninfectious inflammatory states in critically ill patients. It is, however, unknown to what extent a recent history of sepsis (namely, secondary sepsis) can affect diagnosis of BSI using PCT. METHODS: review of the medical records of every patient with BSI in whom PCT dosage at the onset of sepsis was available between 1st September, 2006 and 31st July, 2007. RESULTS: 179 episodes of either primary (n = 117) or secondary (n = 62) sepsis were included. Procalcitonin levels were found to be markedly lower in patients with secondary sepsis than in those without (6.4 [9.5] vs. 55.6 [99.0] ng/mL, respectively; p < 0.001), whereas the SOFA score was similar in the two groups. Although patients in the former group were more likely to have received steroids and effective antibiotic therapy prior to the BSI episode, and despite a higher proportion of candidemia in this group, a low PCT value was found to be independently associated with secondary sepsis (Odd Ratio = 0.33, 95% Confidence Interval: 0.16-0.70; p = 0.004). Additional patients with suspected but unconfirmed sepsis were used as controls (n = 23). Thus, diagnostic accuracy of PCT as assessed by the area under the receiver-operating characteristic curves (AUROCC) measurement was decreased in the patients with secondary sepsis compared to those without (AUROCC = 0.805, 95% CI: 0.699-0.879, vs. 0.934, 95% CI: 0.881-0.970, respectively; p < 0.050). CONCLUSION: In a critically ill patient with BSI, PCT elevation and diagnosis accuracy could be lower if sepsis is secondary than in those with a first episode of infection.

Microbiologic identification of bleb-related delayed-onset endophthalmitis caused by moraxella species.

PURPOSE: To report the clinical presentation and outcome of delayed-onset endophthalmitis caused by Moraxella species and to evaluate the eubacterial polymerase chain reaction (PCR) in aqueous humor samples for the microbiologic diagnosis. PATIENTS AND METHODS: Seven patients with bleb-related delayed onset-endophthalmitis caused by Moraxella were included in a prospective multicenter study (FRIENDS group, 2004 to 2005). Eubacterial PCR followed by direct sequencing and conventional cultures were carried out on aqueous humor samples taken before the first intravitreal antibiotic injection and on vitreous samples taken during pars plana vitrectomy. RESULTS: All cases were postoperative (5 after filtering surgery and 2 inadvertent filtering blebs). The mean delay of onset of endophthalmitis was 41.3 months+/-30.4 (SD) (range, 2.4 to 84.8) after surgery. Initial visual acuity was limited to light perception for 3 patients, hand motions for 2 patients, count fingers for 1 patient, and 20/125 for 1 patient. Functional recovery was variable with final visual acuity ranging from no light perception to 20/25. The eubacterial PCR carried out on aqueous humor provided microbiologic identification in all cases, whereas the cultures were negative in 6 of 7 cases. The eubacterial PCR performed on vitreous samples of 3 vitrectomized patients, after 2 intravitreal injections of antibiotics, identified Moraxella in 2 patients, whereas cultures were negative in all cases. CONCLUSIONS: Delayed-onset endophthalmitis caused by Moraxella occurs predominantly after a bleb-related infection. PCR is a more sensitive technique for the microbiologic diagnosis in this context than conventional culture.

Eubacterial PCR for bacterial detection and identification in 100 acute postcataract surgery endophthalmitis.

PURPOSE: To evaluate eubacterial PCR compared with conventional cultures for detection and identification of bacterial agents in ocular samples from patients with acute postcataract endophthalmitis. METHODS: Broad-range eubacterial PCR amplification was used, followed by direct DNA sequencing in ocular samples (aqueous humor, vitreous samples from tap or vitrectomy) from 100 consecutive patients presenting with acute postcataract endophthalmitis. Bacterial cultures were performed on the same ocular samples by using traditional methods (brain-heart infusion broth). RESULTS: At the time of admission, the detection rate was not significantly different between cultures and PCR (38.2% for cultures versus 34.6% for PCR in aqueous humor samples; 54% versus 57% in vitreous from a vitreous tap). In contrast, in the vitreous obtained from vitrectomy, after intravitreous injection of antibiotics, PCR detected bacteria in 70% of the cases, compared with 9% in cultures. By combining PCR and cultures, bacterial identification was obtained in 47% of aqueous humor samples at admission, in 68% of vitreous samples from a vitreous tap at admission, and in 72% of vitreous samples from pars plana vitrectomy. Gram-positive bacteria predominated (94.3%). The concordance between cultures and PCR was 100%. The contamination rate was 2%. CONCLUSIONS: Cultures and eubacterial PCR are complementary techniques for bacterial identification in eyes with acute postcataract endophthalmitis. PCR technique was needed for identification of the involved microbial pathogen in 25% of all the cases. Eubacterial PCR is more effective than cultures in detecting bacteria in vitreous samples from patients with previous intravitreous administration of antibiotics.

Antimicrobial resistance data on 16,756 Streptococcus pneumoniae isolates in 1999: A Pan-Regional Multicenter Surveillance Study in France.

The rising prevalence of antibiotic-resistant Streptococcus pneumoniae is a phenomenon observed to different degrees around the world. The present national surveillance study report analyzes a total of 16,756 strains of S. pneumoniae collected across France in 1999. The overall prevalence of S. pneumoniae with decreased susceptibility to penicillin was 44%, to amoxicillin 26%, and to cefotaxime 17%. The proportion of high-level resistant strains to penicillin (MIC > 1 mg/L), amoxicillin and cefotaxime (MIC > 2 mg/L) remained low: 12.3%, 1.8%, and 0.4% respectively. Prevalence of resistance to other antibiotics was high: 53% to erythromycin, 41.7% to cotrimoxazole, 31.8% to tetracycline, and 24.6% to chloramphenicol. Prevalence of penicillin-resistant S. pneumoniae varied according to subject age and specimen source. It was higher in children (52.7%) than in adults (39.8%) and higher in strains isolated from middle ear fluid (63.6%) than from blood cultures (41.8%) in children. S. pneumoniae resistant to other antibiotics were more common in children than in adults, although figures showed geographical variations. Comparison with a previous study realized in 1997 in the same regions confirms a rising trend in the prevalence of resistant bacteria. Therefore, we conclude that prevalence of antibiotic-resistant S. pneumoniae in 1999 continued to rise in France, although strains with high-level resistance to penicillin remained stable.

Survey of Enterobacteriaceae producing extended-spectrum beta-lactamases in a Slovak hospital: dominance of SHV-2a and characterization of TEM-132.

Eighty-five extended-spectrum beta-lactamase-producing Enterobacteriaceae from a Slovak hospital have been studied. SHV-2a was predominant, but other variants have been detected, namely, SHV-5, SHV-12, TEM-12, TEM-15, and TEM-132, which differed from TEM-1 by amino acid substitutions R164H, E240K, and I173V and had kinetic properties similar to those of TEM-28.