Genetic heterogeneity and predominance of blaCTX-M -15 in cefotaxime-resistant Enterobacteriaceae isolates colonizing hospitalized children in Tunisia.

Extended-spectrum ß-lactamase (ESBL)-producing Enterobacteriaceae have emerged as important nosocomial pathogens. Community infections by these organisms have been also reported and were associated with previous intestinal colonization. We aimed to characterize cefotaxime-resistant Enterobacteriaceae (CTX-R-En) isolated from hospitalized children in a Tunisian paediatric ward. Seventy CTX-R-En isolates were collected from 227 rectal swabs from hospitalized children in a paediatric ward. Antimicrobial susceptibility testing was determined according to the EUCAST guidelines. Isolates were characterized by polymerase chain reaction (PCR, genes encoding: ESBLs, pAmpC, carbapenemases, plasmid-mediated quinolone resistance, virulence factors in Escherichia coli and Klebsiella pneumoniae isolates, occurrence of classes 1 and 2 integrons, phylogenetic groups of E. coli isolates, ERIC-PCR and PCR-based replicon typing) and conjugal transfer experiments. In total, 65 out of 227 (28·6%) hospitalized children were colonized with CTX-M-R-En, and 70 isolates were identified. Isolates were 59 ESBL-, 7 plasmidic-AmpC (pAmpC)-, 3 ESBL+pAmpC-, and one ESBL+carbapenemase producers. The following bla genes were identified: blaCTX-M-15 (n = 54), blaCTX-M-1 (n = 5), blaCTX-M-9 (n = 2), blaCTX-M-13 (n = 1) and blaCTX-M-14 (n = 1), blaCMY-2 (n = 5), blaCMY-4 (n = 4), blaACC-1 (n = 1) and blaOXA-48 (n = 1). Our results showed that hospitalized children were colonized with various CTX-R-En-producing several beta-lactamase enzymes.

Central venous saturation is not an alternative to mixed venous saturation during cardiopulmonary bypass in coronary artery surgery patients.

BACKGROUND: To evaluate the correlation and agreement between central venous saturation (ScvO(2)) and mixed venous saturation (SvO(2)) during cardiopulmonary bypass. METHODS: Twenty-two consecutive patients scheduled for coronary artery surgery were prospectively included. Paired measurements of ScvO(2) and SvO(2) were performed 5 minutes after aortic cross-clamping, after each cardioplegia dose and after de-clamping of the aortic cross-clamp. ScvO(2) and SvO(2) were measured, respectively, by a fibreoptic catheter in the superior vena cava and on blood samples from the venous return line of the extracorporeal circuit, using a blood gas analyser RESULTS: Ninety-five paired measurements of venous saturation were obtained. Correlation between the measurements was associated with an r = 0.55. The mean bias was 2.2 [Limits of agreement: -13.6%, +18%]. Changes in oxygen saturation over time showed an r = 0.4 and a mean bias of 0.2 [Limits of agreement: -17.9%, +18.3%]. Multivariate analysis identified the oxygen consumption index as the only factor explaining this variability. CONCLUSIONS: Although mean biases between the measurements were low, limits of agreement were too large to provide a clinically acceptable estimation of SvO(2) by ScvO(2) in these conditions. Variations in regional oxygen consumption seem to be the main factor worsening the relationship.

Anticardiolipin Autoantibodies as Useful Biomarkers for the Prediction of Mortality in Septic Patients.

Background: The detection of antiphospholipid antibodies (aPL) is of interest because of their importance in the pathogenesis of arterial or venous thrombosis. They could be a "second hit" of an inflammatory event such as infection. The aim of our study was to assess the performance of antiphospholipid antibody biomarker to predict in-hospital mortality in intensive care unit (ICU) septic patients. Methods: We conducted a prospective single-center observational study including consecutive critically ill septic adults admitted to the intensive care unit. Clinical and laboratory data including enzyme-linked immunosorbent assay for antiphospholipid antibodies (anticardiolipin (aCL), antiphosphatidylserine (aPS)) were obtained. Blood samples were collected on days 1, 3, 5, 8, and 10 of hospitalization. The primary study endpoint was ICU mortality defined as death before ICU discharge. Secondary end points included correlation between SOFA score and biological parameters. Results: A total of 53 patients were enrolled. 18.8% of patients were aPL positive. In-hospital mortality rate was 60%. Multivariate analysis showed that age and aCL at days 3 and 5 along with SOFA at day 3 were independent outcome predictors. A significant positive correlation existed between SOFA at days 3, 5, and 8 and antiphospholipid antibody concentrations. Conclusions: Our data showed that antiphospholipid was useful biomarkers for the prediction of mortality in critically ill septic patients. We found a positive correlation between SOFA score and antiphospholipid antibodies.

Nosocomial dissemination of extended-spectrum ß-lactamase VEB-1a-producing Providencia stuartii isolates in a Tunisian hospital.

A collection of 20 multidrug-resistant Providencia stuartii isolates recovered from 2005 to 2009 at the Military Hospital of Tunis, Tunisia, was analysed. They all expressed the extended-spectrum ß-lactamase (ESBL) VEB-1a. The bla (VEB-1a) gene was plasmid-located and it was associated with complex genetic structures, including Re elements. Pulsed-field gel electrophoresis (PFGE) revealed a clonal relationship between all of these isolates. This study identified a nosocomial dissemination of an ESBL-producing P. stuartii clone in a Tunisian hospital over a long period of time.

[Procalcitonin in invasive candidosis]. / Procalcitonine et candidoses invasives en milieu de réanimation.

The use of reliable and specific diagnosis tools in patients of intensive care unit constitutes the best way to follow up these patients and to take charge of severe infections. It is in the context that the measuring of procalcitonin should be considered in order to prove its role in invasive candidosis. This prospective study included 52 patients from an intensive care unit. Blood samples for serum procalcitonin were drawn on days 1, 3, 5. Our results showed that on the one hand, procalcitonin levels have significantly increased in cases of confirmed and probable candidosis. On the other hand, this parameter has a certain prognosis value. In conclusion, an increase in procalcitonin level does not only imply a bacterial infection but it should also evoke a case of invasive candidosis especially in intensive care units.

Suprascapular block associated with supraclavicular block: An alternative to isolated interscalene block for analgesia in shoulder instability surgery?

BACKGROUND: Interscalene brachial plexus block (ISB) is the gold standard for postoperative pain management in shoulder surgery. However, this technique has side effects and potentially serious complications. The aim of this study was to compare the combinations of ultrasound-guided suprascapular (SSB) associated with supraclavicular nerve block (SCB) and ultrasound-guided ISB for postoperative analgesia after shoulder instability surgery. METHODS: Sixty ASA physical status I-II patients scheduled to undergo shoulder instability surgery were included. Two groups: (i) the SSB+SCB group (n=30) in which the patients received a combination of US-guided SSB (15mL of bupivacaine 0.25%) and US-guided SCB (15mL of bupivacaine 0.25%) and (ii) the ISB group (n=30) in which the patients received US-guided ISB with 30mL of bupivacaine 0.25%. General anesthesia was administered to all patients. During the first 24h, the variables assessed were time to administer the anesthesia, duration of the analgesia, onset and duration of motor and sensory blockade, opioid consumption, cardiovascular stability, complications, and patient satisfaction. RESULTS: Anesthesia induction took more time for the SSB+SCB group than for the ISB group. However, the onset time of motor and sensory blockade was similar in the two groups. Statistical analysis of the visual analog postoperative pain scoring at H0, H6, H12, and H24 showed nonsignificant differences between the groups. Analgesia, the first request for morphine, and total morphine consumption during the first 24h was similar in both groups. No complication was recorded in the SSB+SCB group. However, phrenic nerve block occurred in all patients in the ISB group. CONCLUSION: US-guided SCB combined with US-guided SSB was as effective as ISB for postoperative analgesia after shoulder instability surgery without decreasing potential side effects. TRIAL REGISTRATION: NCT identifier: NCT02397330.

Effect of warming bupivacaine 0.5% on ultrasound-guided axillary plexus block. Randomized prospective double-blind study.

OBJECTIVE: To evaluate the effect of warming bupivacaine 0.5% on ultrasound-guided axillary brachial plexus block. STUDY DESIGN: Prospective, randomized, double-blind. PATIENTS AND METHODS: Eighty patients undergoing elective or emergency surgery beyond the distal third of the upper limb were divided into two groups of 40 patients: the warm group received 15mL bupivacaine 0.5% heated to 37°C; the cold group received 15mL 0.5% bupivacaine stored for at least 24hours in the lower compartment of a refrigerator at 13-15°C. Onset and duration of sensory and motor blocks were evaluated every 5minutes for 40minutes. Postoperative pain was evaluated at 1, 3, 6, 12 and 24hours. Effective analgesia time was recorded as the interval between anesthetic injection and the first analgesia requirement (VAS>30mm). RESULTS: Time to onset of sensory and motor block was significantly shorter in the warm group, and mean duration of sensory and motor block and of postoperative analgesia significantly longer. CONCLUSION: Warming bupivacaine 0.5% to 37°C accelerated onset of sensory and motor block and extended action duration.

Decongestive effects of levosimendan in cardiogenic shock induced by postpartum cardiomyopathy.

BACKGROUND: Catecholamines and/or levosimendan have been proposed for haemodynamic restoration during cardiogenic shock (CS). In CS induced by post-partum cardiomyopathy (PPCM), levosimendan might be particularly favourable. The aim of this study was to evaluate the haemodynamic and echocardiographic effects of levosimendan in patients with CS, in particular in patients with PPCM-induced CS. METHODS: Twenty-eight patients with refractory CS were retrospectively included in the study. Among them, a cohort of 8 women with PPCM-induced CS was included. All patients were treated with levosimendan (loading dose followed by a continuous infusion for 24 h) and were invasively monitored, including a pulmonary artery catheter, for 48hours. Echocardiographic measurements were performed at baseline and during follow-up. RESULTS: Significant improvements in haemodynamic parameters were observed 48 h after starting levosimendan. The cardiac index increased (+1.2±0.6L/min, P<0.001) and filling pressures decreased (pulmonary artery occlusion pressure, PAOP: -11.2±4.3mmHg, P<0.001; right-atrial pressure, RAP: -6.1±4.9mmHg, P<0.001). The left ventricular ejection fraction was significantly higher at 48 h compared to baseline (38% [34-46%] versus 27% [22-30%], P<0.001). Despite similar characteristics at baseline, in the subgroup of patients with PPCM, more profound decongestive effects at 48hours were observed: PAOP (13±2 versus 17±4mmHg, P=0.007) and RAP (12±4 versus 17±4mmHg, P=0.006) were significantly lower in the PPCM subgroup compared to the non-PPCM subgroup. CONCLUSIONS: Haemodynamics and left-ventricular ejection fraction rapidly improved after treatment with levosimendan. In patients with PPCM-induced CS, a more profound reduction of congestion was observed.

Circulating cardiac troponin T in myocardial contusion.

STUDY OBJECTIVE: Myocardial contusion may induce life-threatening complications, but its diagnosis is difficult. Circulating cardiac troponin T is considered a highly sensitive and specific marker of myocardial cell injury. We investigate the value of cardiac troponin T measurement in the diagnosis of myocardial contusion. DESIGN: Prospective study. SETTING: Level 1 trauma center. METHODS: We prospectively measured circulating cardiac troponin T and performed echocardiography and continuous Holter monitoring in patients who had suffered blunt trauma. Myocardial contusion was diagnosed in patients who fulfilled one of the following criteria: (1) an abnormal echocardiography compatible with myocardial contusion; (2) severe cardiac rhythm abnormalities; (3) severe cardiac conduction abnormalities; and (4) hemopericardium. MEASUREMENTS AND RESULTS: One hundred twenty-eight patients were included and myocardial contusion was diagnosed in 29 patients. Patients with myocardial contusion had more severe trauma, experienced more frequently associated thoracic lesions, and had a lower left ventricular ejection fraction area (48 +/- 15 vs 61 +/- 10%; p < 0.001). Elevated circulating cardiac troponin T concentrations were significantly more frequent in patients with a myocardial contusion (31 vs 9%; p < 0.007). An elevated circulating cardiac troponin T concentration (> or = 0.5 microgram/L) was more accurate than MB fraction of creatine kinase (CK) (CK-MB) and CK-MB/CK ratio in the diagnosis of myocardial contusion, as shown by an area under the receiver operating characteristic (ROC) curve (AROC), which was significantly different from 0.50 (AROC = 0.69; 95% confidence interval, 0.56 to 0.80). However, this improvement was not clinically acceptable (sensitivity, 0.31; specificity, 0.91). CONCLUSIONS: Circulating cardiac troponin T measurement had a slightly greater diagnostic value than usual biological parameters (CK-MB, CK-MB/CK) in myocardial contusion. Nevertheless, it was concluded that an elevated circulating cardiac troponin T concentration has no important clinical value in the diagnosis of myocardial contusion.

[Tuberculosis of the upper digestive and respiratory tract]. / Tuberculose des voies aéro-digestives supérieures (V.A.D.S.).

Based on seventeen cases of upper digestive and respiratory tract tuberculosis, the authors review the different localizations of the disease. The mean age of the patients is 34 years old. The diagnostic is based on bacteriological and especially histological examination. The prognostic of the affection is excellent if tuberculosis chemotherapy is used for a minimum of 9 months.

[Beware of yeast septicemia in intensive care medicine]. / Alerte aux septicémies à levures en réanimation polyvalente.

A retrospective study of 24 cases of systemic candidosis observed in a polyvalent intensive care unit over a 6.5 yr period (1987-1993) led to some constatations: an increasingly high incidence of this type of septicaemia (up to 27.5% of all septicaemias), large responsibility of skin saprophytes Candida ( > 62% vs 21% from intestinal Candida albicans), frequent diagnostic difficulties, and a fatal outcome in 7/24 patients (mainly from severe causal illness). In order to improve the prognosis, a more systematic and often empirical resort to fungicidal agents could be justified whenever patients with very severe surgical or medical conditions develop a protracted fever of unclear origin.

First characterisation of plasmid-mediated quinolone resistance-qnrS1 co-expressed bla CTX-M-15 and bla DHA-1 genes in clinical strain of Morganella morganii recovered from a Tunisian Intensive Care Unit.

PURPOSE: Aim of this study was to show the emergence of the qnr genes among fluoroquinolone-resistant, AMPC and ESBL (extended-spectrum-beta-lactamase) co-producing Morganella morganii isolate. MATERIALS AND METHODS: A multi resistant Morganella morganii SM12012 isolate was recovered from pus from a patient hospitalized in the intensive care unit at the Military hospital, Tunisia. Antibiotic susceptibility was tested with the agar disk diffusion method according to Clinical and Laboratory Standards Institute guidelines. ESBLs were detected using a standard double-disk synergy test. The characterization of beta-lactamases and associated resistance genes were performed by isoelectric focusing, polymerase chain reaction and nucleotide sequencing. RESULTS: The antimicrobial susceptibility testing showed the high resistance to penicillins, cephalosporins (MICs: 64-512 µg/ml) and fluoroquinolones (MICs: 32-512 µg/ml). But M. morganii SM12012 isolate remained susceptible to carbapenems (MICs: 4-<0.25 µg/ml). The double-disk synergy test confirmed the phenotype of extended-spectrum ß-lactamases (ESBLs). Three identical ß-lactamases with pI values of 6.5, 7.8 and superior to 8.6 were detected after isoelectric focusing analysis. These ß-lactamases genes can be successfully transferred by the conjugative plasmid. Molecular analysis demonstrated the co-production of bla (DHA-1), bla (CTX-M-15) and qnrS1 genes on the same plasmid. The detection of an associated chromosomal quinolone resistance revealed the presence of a parC mutation at codon 80 (Ser80-lle80). CONCLUSION: This is the first report in Tunisia of nosocomial infection due to the production of CTX-M-15 and DHA-1 ß-lactamases in M. morganii isolate with the association of quinolone plasmid resistance. The incidence of these strains invites continuous monitoring of such multidrug-resistant strains and the further study of their epidemiologic evolution.