Compassionate use of amphotericin B lipid complex (Abelcet) in life-threatening fungal infections: report of 30 courses.

OBJECTIVE: To report a single-center experience of compassionate use of amphotericin B lipid complex (ABLC) in patients with proven or suspected fungal infection who were or would have been unable to tolerate conventional amphotericin B. METHODS: Twenty-eight patients receiving 30 courses of ABLC for 22 proven invasive mycosis episodes (11 aspergillosis, seven candidosis, four miscellaneous) and eight suspected episodes are described. Seven patients were given ABLC first-line therapy because of conditions precluding the use of amphotericin B deoxycholate (Am B). Twenty-one patients, initially given Am B, were shifted to ABLC because of failure in four, nephrotoxicity of AM B alone or in combination with another drug in 15, and acute side effects in two. The initial dose of ABLC was 5 mg/kg per day; this could be lowered to 3 mg/kg per day or transiently interrupted in cases of impairment of renal function. RESULTS: A mean cumulative dose of 6107 mg (660--16 050) was given over a mean duration of 22 days (4--49). Clinical response rate was 63% (14/22), with mycologic eradication in 37% (9/17) in proven infections. For proven aspergillosis, corresponding rates were 54% (6/11) and 20% (2/10), and in proven candidosis 71% (5/7) and 60% (3/5), respectively. Twenty-one courses were complicated by one or more side effects: fever and chills (11), impairment of renal function requiring a transient reduction of drug dosage (14), hypotension (1). However, for the whole group, creatinine clearance before and after 2, 4 and 6 weeks of treatment remained quite stable. CONCLUSIONS: ABLC, with its low toxicity, enabled us to treat patients who were or would have been unable to tolerate an efficacious dose of Am B. No conclusions about efficacy can be drawn from this small-size, compassionate study. Well-designed studies to compare efficacy and safety of conventional amphotericin B and the various lipidic formulations should be implemented.

Detection of rifampicin and isoniazid resistances of Mycobacterium tuberculosis strains by particle counting immunoassay (PACIA).

The particle agglutinated counting immunoassay (PACIA) was used to determine the susceptibility of Mycobacterium tuberculosis strains to the two major antimycobacterial drugs, isoniazid and rifampicin. On evaluating 12 M. tuberculosis strains with different sensitivities, our results were in complete accordance with those obtained using the well-known BACTEC system. The PACIA technique is automated and quite inexpensive. Interpretation of the test may be achieved in as little as five days.

A fatal case of Mycoplasma hominis meningoencephalitis in a full-term newborn.

We report the case of a 20-day-old full-term baby, born to a mother who had had an uncomplicated pregnancy and delivery, who died 13 days after the onset of meningitis. Mycoplasma hominis was the sole agent repeatedly recovered from cerebrospinal fluid and from postmortem brain tissue.

[Infectious endocarditis: old myths and current concepts]. / L'endocardite infectieuse: mythes anciens et concepts actuels.

Updating of several main themes concerning the infectious endocarditis with the aim to denounce various old myths and to precise different actual concepts. The authors consider principally the echocardiographic revolution and the new diagnostic criteria, the bacteriologic pitfalls and the preventive strategies.

[Cardiovascular diseases: toward an optimal use of clinical biological laboratories]. / Maladies cardiovasculaires: pour un recours optimal au laboratoire de biologie clinique.

Cardiovascular diseases are a frequent cause of morbidity and mortality in our country. The early detection of risk factors by laboratory tests and the subsequent preventive treatment may have a substantial beneficial effect on public health. However, since these tests are performed on large populations, they must be chosen with caution, in order to optimise their cost/ effectiveness ratio. Savings obtained by the judicious use of the clinical lab could allow, already in 1996, the reimbursement of some new informative tests, like the plasma homocysteine and the LDL-cholesterol, and later, of the lipoprotein (a), all tests which are presently at the charge of the patient.

Evaluation of the Gen-Probe amplified Mycobacterium tuberculosis direct test for the routine diagnosis of pulmonary tuberculosis.

A total of 624 respiratory specimens from 543 patients (418 Belgian, 110 Rwandan, and 15 Colombian patients) were tested for the presence of Mycobacterium tuberculosis by the Mycobacterium Tuberculosis Direct Test (MTDT, Gen-Probe). Compared to culture, the MTDT on 497 samples of sputum or broncho-alveolar lavage from Belgium had a sensitivity, specificity and positive and negative predictive value of 86.4%, 96.0%, 50.0% and 99.3% respectively. The pooled results for Rwanda (112 specimens) and Colombia (15 specimens) were 97.8%, 65.7%, 88.2%, 92% respectively. After resolution of discrepant results by taking into account the clinical data, the results for the Belgian patients were 86.9%, 96.2%, 52.6%, 99.3% respectively, and for the Rwandan-Colombian patients 98.1%, 100%, 100% and 92% respectively. Results could be improved by testing more than one specimen from each patient and the inclusion of an internal control to detect inhibitors of the reaction. Culture remains necessary for drug susceptibility tests and the isolation and identification of non-tuberculous mycobacteria.

[Pharyngo-tonsillitis: Current clinical, bacteriological, serological and therapeutic aspects]. / Les pharyngo-amygdalites: actualisations clinique, bactériologique, sérologique et thérapeutique.

The authors present the pharyngo-tonsillitis in four fields: clinical, bacteriology, serology and treatment. They insist on the danger of the beta-hemolytic Strep A, the failures of the ASLO detection and stress the execution of the rapid antigenic test at the office. They suggest the limitation of the administration of antibiotics and the prescription of a penicillin which is much better than macrolides or cephalosporins of second or third generation.

Evaluation of Rapid ATB Staph for 5-hour antimicrobial susceptibility testing of Staphylococcus aureus. Groupement pour le Dépistage, L'Etude et la Prévention des Infections Hospitalières-Groep ter Opsporing, Studie en Preventie van Infecties in de Ziekenhuizen.

The accuracy of Rapid ATB Staph (bioMérieux, La Balme-Les Grottes, France) for detection of oxacillin resistance and for detection susceptibility to 11 other antimicrobial agents in 553 and 519 Staphylococcus aureus isolates, respectively, was evaluated by comparing results with those produced by oxacillin agar screen and agar dilution methods, respectively. Further characterization of isolates with discrepant results for oxacillin testing was done by PCR detection of the nuc and mecA genes. By oxacillin agar screening, there were 307 oxacillin-resistant and 246 oxacillin-susceptible isolates. Rapid ATB results were obtained in 5 h for 515 (93.2%) of the isolates tested. Rapid ATB showed 97.0% sensitivity for detection of oxacillin resistance, confirmed by the presence of the mecA gene. After repeat testing of isolates flagged by the ATB software as possible errors, sensitivity increased to 99% for oxacillin-resistant isolates. Essential agreement with agar dilution testing for susceptibility to amoxicillin-clavulanic acid, gentamicin, erythromycin, clindamycin, and ciprofloxacin, as estimated by Youden's J statistic, was > 0.90. Subpopulations of isolates with significantly increased MICs of amikacin, rifampin, and minocycline, indicating borderline susceptibility, were detected by Rapid ATB and categorized as resistant. Rapid ATB Staph showed adequate accuracy for detection within 5 h of the oxacillin- and multiple-drug-resistant S. aureus isolates currently prevalent in Belgium.

Candida albicans septic thrombosis of the right atrium is associated with a central venous catheter.

Right atrial thrombus formation is a rare complication of central venous catheterization in adults. Infection of this thrombus is exceptional. A case of a right atrial thrombus associated with Candida albicans infection is described. Surgical thrombectomy, withdrawal of the catheter, and long-term antiinfectious therapy seem the only appropriate treatment. The literature on this unusual condition is reviewed.

Rapid identification of Mycobacterium xenopi from bacterial colonies or "Bactec" culture by the polymerase chain reaction and a luminescent sandwich hybridization assay.

Oligonucleotide primers were used in the polymerase chain reaction (PCR) to amplify a specific 584-bp DNA fragment, located in the 16S RNA gene of Mycobacterium xenopi. This set of primers, X222 and X224, was able to discriminate between the pathogen and other mycobacterial species as well as non-mycobacterial strains; it detected down to 3 fg of M. xenopi DNA, i.e. about one genome equivalent. These oligonucleotide primers proved suitable for the routine identification of M. xenopi cultures, starting from one single colony on solid medium or from a liquid culture in Middelbrook 12B "Bactec" medium. In addition, a luminescent hybridization assay was designed for use on PCR-amplified DNA. This system, which, for capture, relied on a matrix-bound oligonucleotide (M30) specific for the genus Mycobacterium and, for detection, on a biotinylated xenopi-specific X221 probe, proved fully specific, highly sensitive and rapid for the evaluation of M. xenopi Bactec cultures at low growth index.

Rapid simple and nested polymerase chain reaction for the diagnosis of Pneumocystis carinii pneumonia.

We have developed a rapid and easy extraction procedure for polymerase chain reaction (PCR) protocols. Using this simplified step, we evaluated the sensitivity and the specificity of a simple PCR using the primers of Wakefield et al, and of a nested PCR, using new internal primers selected by us, in a total of 89 bronochoalveolar lavage (BAL) fluid samples from 43 immunosuppressed patients. In 13 patients, Pneumocystis carinii pneumonia (PCP) was diagnosed by immunofluorescent antibody (IFA) staining performed on BAL cells cytospun on microscope slides. In seven of these patients we attempted to estimate the post-treatment persistence of P. carinii in BAL, by PCR. After a rapid 2-h extraction procedure, simple and nested PCR were positive in all cases of PCP. SImple and nested PCR both had a 100% sensitivity and a 98 and 84% specificity respectively, compared to IFA. After completion of treatment, BAL liquids from asymptomatic patients were no longer positive by both PCR techniques, whereas the BAL fluid of a patient who was still symptomatic was positive by simple and nested PCR. In follow-up BAL fluids of patients with proven PCP, persistence of P. carinii was detected for a longer period by nested PCR than by simple PCR. Simple PCR is a very rapid and sensitive assay for the diagnosis of PCP in BAL fluid and gives clear-cut results in the case of doubtful IFA staining results. Nested PCR seems to improve the sensitivity of the detection of P. carinii in BAL fluid, but the clinical relevance of a positive result remains to be investigated..

Evaluation of gas-liquid chromatography (GLC) for rapid detection of Clostridium difficile in fecal specimens.

Clostridium difficile intestinal infection is a major nosocomial hazard in patients receiving antimicrobial therapy. Rationale for rapid diagnosis include lifesaving antimicrobial therapy in patients with severe colitis and early isolation measures for transmission control. We have therefore analysed the sensitivity, specificity and predictive value of GLC identification of isocaproic acid in diarrheic stools from adult hospitalized patients in comparison with selective fecal culture on Cycloserine Cefoxitin Fructose Agar. During the study period, the prevalence of positive culture for C. difficile was 38/595 fecal specimens (6.4%). Compared with culture, GLC had a sensitivity of 24/38 (63%) and a specificity of 524/557 (94%). The predictive value of a positive GLC was 24/57 (42%) and of a negative GLC was 524/538 (97%). Measurement of the isocaproic acid peak height did not allow determination of a cutt-off value improving the test accuracy. The sensitivity of detection of isocaproic acid in stools by GLC is too low to be used as screening test for C. difficile infection. However, in a low prevalence population, a positive GLC test increased the pre-test probability of infection sevenfold.

Usefulness of gram staining of blood collected from total parenteral nutrition catheter for rapid diagnosis of catheter-related sepsis.

The accuracy of Gram staining of blood drawn from catheters used to administer total parenteral nutrition was compared with paired quantitative blood cultures for the diagnosis of catheter-related sepsis. Gram staining was positive in 11 of 18 episodes of catheter-related sepsis documented by quantitative culture (sensitivity, 61%) but in none of the 5 episodes of fever unrelated to catheter infection. Thus, this procedure enabled the rapid presumptive diagnosis and guidance of antimicrobial therapy for total parenteral nutrition catheter sepsis, with a positive predictive value of 100% and a negative predictive value of 42%.

Rapid biochemical screening for Salmonella, Shigella, Yersinia, and Aeromonas isolates from stool specimens.

Four screens for the rapid (4 to 6 h) biochemical detection of pathogens from enteric isolation media are described. The Salmonella screen consisted of Kligler iron agar (KIA), motility-indole-urea-tryptophan-deamination semisolid medium (MIU-TDA), and the o-nitrophenyl-beta-D-galactopyranoside (ONPG) test; the Shigella screen consisted of KIA, MIU-TDA, the ONPG test, and the lysine decarboxylation-indole test; the Yersinia screen consisted of a rhamnose broth; the Aeromonas screen consisted of a xylose agar plate. When tested on 2,102 fresh isolates and 71 stock strains, the screens correctly detected 212 enteric pathogens (sensitivity, 100%), with a specificity of 98.1%.

Prevotella bivia as an unusual cause of endocarditis.

A case of monomicrobial endocarditis due to Prevotella bivia in a 60-year-old man without previous cardiac lesions is reported. The extremely indolent course with multiple systemic emboli as the only clinical manifestation occurring at least seven months before diagnosis and the persistently negative blood cultures were remarkable features of this case. The incidence, clinical characteristics, treatment and outcome of published cases of infective endocarditis due to anaerobic bacteria are briefly reviewed.

Human milk banking: influence of storage processes and of bacterial contamination on some milk constituents.

This paper reviews the effects of storage and bacterial content contaminating human milk on some milk constituents. Moreover, it reviews the inhibitory effect of refrigeration and freezing on bacterial growth. Our results suggest that the type and length of storage have an effect on some milk constituents, that this effect is modulated by the bacterial contamination of the milk and that refrigeration has a significant inhibitory effect on bacterial growth which is not observed after freezing. This stresses the importance of collecting noncontaminated milk and justifies the choice of refrigeration at 0-4 degrees C for storage up to 8 days.

Pseudomonas aeruginosa and Enterobacteriaceae bacteremia after biliary endoscopy: an outbreak investigation using DNA macrorestriction analysis.

PURPOSE: An outbreak of gram-negative bacteremia in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) was investigated to determine the sources of infection and to control transmission. PATIENTS, METHODS, AND RESULTS: The incidence of post-ERCP bacteremia increased from 1.6% (60 of 3,696) procedures to 3.6% (53 of 1,454) procedures (relative risk 2.3, p < 0.0001) after endoscopes were processed in a new automated disinfector. Bacteremia involved nine species of Pseudomonas and Enterobacteriaceae, which were also isolated from processed endoscopes. Seven epidemic strains with highly related genomic macrorestriction profiles each infected 2 or more patients, accounting for 29 (55%) episodes of post-ERCP bacteremia. Strains recovered from endoscopes and from the disinfector were associated with 22 (42%) and 5 (9%) bacteremic episodes respectively. Effective endoscope disinfection was achieved by cleansing and disinfection of a blind channel not processed in the disinfector, additional isopropanol-air flush of all channels, and auto-disinfection of the disinfector. In the following period, the incidence of post-ERCP bacteremia returned to the pre-epidemic rate (1.7%, p = 0.0001). CONCLUSION: Bacterial genome fingerprinting by macrorestriction analysis enabled delineation of a multi-strain outbreak of post-ERCP bacteremia. Cross-contamination, and to a lesser extent, common-source contamination, appeared related to inadequate disinfection of endoscopes processed in an automated disinfector.

Nosocomial colonization and infection with multiresistant Acinetobacter baumannii: outbreak delineation using DNA macrorestriction analysis and PCR-fingerprinting.

The prevalence of nosocomial acinetobacter colonization and infection in a university hospital was reviewed and multiresistant Acinetobacter baumannii infections in an intensive care unit (ICU) were investigated using epidemiological typing and a case-control study. Acinetobacter colonization at various body sites was found in 3.2 to 10.8 per 1000 patients. Acinetobacter infection accounted for 0.3% of endemic nosocomial infections in critically ill patients and for 1% of nosocomial bacteraemia hospitalwide. Over a three-week period, four ventilated patients developed colonization, followed by pneumonia in two patients, with A. baumannii resistant to multiple antimicrobials. Cultures of samples from respiratory equipment and ICU surfaces (n = 27) as well as from hands of personnel (n = 14) failed to yield A. baumannii, except for one sample of respiratory tubing. Antibiogram, biotype, chromosomal DNA macrorestriction profiles and polymerase chain reaction (PCR) mediated fingerprints of A. baumannii isolates (n = 31) indicated that this outbreak was caused by two strains, one of which later spread to another hospital where it caused a second outbreak. Both strains were clearly discriminated from control strains from cases of sporadic infection. Risk factors for cross-colonization that were identified by a case-control comparison were neurosurgery, mechanical ventilation and treatment with broad-spectrum antibiotics. Transmission was controlled by implementing contact isolation precautions and routine sterilization of ventilator tubing. Wider use of sensitive genotypic methods like DNA macrorestriction analysis and PCR-mediated fingerprinting for typing nosocomial pathogens should improve the detection of micro-epidemics amenable to early control.

Detection of mycobacterial antigens present in short-term culture media using particle counting immunoassay.

Particle counting immunoassay (PACIA) was compared with the BACTEC system for detecting mycobacterial growth after short-term culture and was used to identify M. tuberculosis. The latex particles were coated with polyclonal anti-BCG or with specific 2A1-2 monoclonal antibodies. Bottles containing nonradioactive Middlebrook 7H9 liquid medium and BACTEC 12B vials were inoculated with equal amounts of mycobacteria from four reference strains (M. tuberculosis, M. kansasii, M. avium, and M. xenopi). Using anti-BCG, PACIA detected mycobacterial antigens 3 to 6 days before the BACTEC system. M. tuberculosis was differentiated from the other mycobacteria using 2A1-2. Seventeen clinical samples were also studied. In the same 10, the two techniques detected mycobacteria, PACIA with anti-BCG after 9 days and BACTEC 1 to 5 days later. For 9 of the 10 samples, PACIA with 2A1-2 detected M. tuberculosis after 20 days, a result confirmed with the AccuProbe system. M. xenopi was biochemically identified in Specimen 10. Nonmycobacterial diseases were diagnosed in the 7 remaining unreactive specimens. We conclude that PACIA detects mycobacterial growth earlier than BACTEC and that M. tuberculosis can be distinguished from other mycobacteria in PACIA performed with specific monoclonal antibodies.