Mupirocin/chlorexidine to prevent methicillin-resistant Staphylococcus aureus infections: post hoc analysis of a placebo-controlled, randomized trial using mupirocin/chlorhexidine and polymyxin/tobramycin for the prevention of acquired infections in intubated patients.

PURPOSE: The reduction in acquired infections (AI) due to methicillin-resistant Staphylococcus aureus (MRSA) with the mupirocin/chlorhexidine (M/C) decontamination regimen has not been well studied in intubated patients. We performed post hoc analysis of a prior trial to assess the impact of M/C on MRSA AI and colonization. METHODS: We conducted a multicenter, placebo-controlled, randomized, double-blind study with the primary aim to reduce all-cause AI. The two regimens used [topical polymyxin and tobramycin (P/T), nasal mupirocin with chlorhexidine body wash (M/C), or corresponding placebos for each regimen] were administered according to a 2 × 2 factorial design. Participants were intubated patients in the intensive care units of three French university hospitals. The patients enrolled in the study (n = 515) received either active P/T (n = 130), active M/C (n = 130), both active regimens (n = 129), or placebos only (n = 126) for the period of intubation and an additional 24 h. The incidence and incidence rates (per 1,000 study days) of MRSA AI were assessed. Due to the absence of a statistically significant interaction between the two regimens, analysis was performed at the margins by comparing all patient receiving M/C (n = 259) to all patients not receiving M/C (n = 256), and all patients receiving P/T (n = 259) to all patients not receiving P/T (n = 256). RESULTS: Incidence [odds ratio (OR) 0.39, 95 % confidence interval (CI) (0.16-0.96), P = 0.04] and incidence rates [incidence rate ratio (IRR) 0.41, 95 % CI 0.17-0.97, P = 0.05] of MRSA AI were significantly lower with the use of M/C. We also observed an increase in the incidence (OR 2.50, 95 % CI 1.01-6.15, P = 0.05) and the incidence rate (IRR 2.90, 95 % CI 1.20-8.03, P = 0.03) of MRSA AI with the use of P/T. CONCLUSION: Among our study cohort of intubated patients, the use of M/C significantly reduced MRSA AI.

[Soft tissue infection associated with bacteremia caused by Shewanella putrefaciens]. / Dermohypodermite et bactériémie àShewanella putrefaciens.

Shewanella putrefaciens is rarely involved in human infectious disease. We report here a case of soft tissue infection with bacteremia on a patient with risk factors (liver cirrhosis, diabetes mellitus).

[Epidemiology of healthcare-associated infections due to MRSA in Brest University Hospital from 2004 to 2007. Impact of hydroalcoholic gel and antibiotics consumptions]. / Épidémiologie des infections nosocomiales à SARM au CHU de Brest du 1(er) janvier 2004 au 31 décembre 2007. Impact des consommations de produits hydroalcooliques et d'antibiotiques.

UNLABELLED: The fight against healthcare-associated infections is based on preventive measures of multidrug resistant bacteria diffusion. Hand hygiene is the simplest and the most effective preventive measure to reduce cross-transmission of infectious agents. Hydroalcoholic solutions for hand hygiene was recently introduced in the University Hospital of Brest (France). The aims of the study were: to describe the epidemiology of healthcare-associated infections due to methicillin-resistant Staphylococcus aureus (MRSA); to determine the annual consumptions of antistaphylococcal antibiotics; and to discuss the relation between consumption of antiseptic products or antibiotics and the epidemiology of MRSA. METHODS: A retrospective epidemiological and pharmaco-epidemiological study was realized from January 2004 to December 2007 in the University Hospital of Brest (France). It allowed to bring to light the cases of healthcare-associated infections due to MRSA and to quantify the consumptions of hang hygiene products and antistaphylococcal antibiotics. RESULTS: this retrospective study showed a decrease of healthcare-associated infections due to MRSA and an increase of the consumption of hydroalcoholic solutions. Antistaphylococcal resistance rates also decreased in a context of fall of the global antibiotics consumption in the hospital.

[Acute exacerbation of chronic obstructive pulmonary disease and antibiotics: analysis of comparative trials]. / Antibiothérapie des exacerbations de bronchopneumopathie chronique obstructive: analyse critique des essais cliniques.

OBJECTIVE: The authors had for aim to assess the role of antibiotics in acute exacerbations of chronic obstructive pulmonary disease (COPD). METHODS: Comparative antibiotic trials were collected through systematic search on Medline data base--well-designed studies were selected. RESULTS: Eight equivalence studies were selected. No clear difference between antibiotics was demonstrated. The shortest treatment was as effective as the longest. CONCLUSION: No antibiotic has demonstrated its superiority. A new generation of antibiotic comparative trials for exacerbation of COPD is clearly needed.

[Pasteurella multocida meningitis following neurosurgery]. / Méningite à Pasteurella multocida au décours d'une intervention neurochirurgicale.

Pasteurella multocida is a rare cause of meningitis. We report a case of P. multocida meningitis following a recent neurosurgery procedure and review the 32 cases previously described.

High incidence of neurologic complications following rapid correction of severe hyponatremia in polydipsic patients.

BACKGROUND: Patients with self-induced water intoxication usually tolerate a large, rapid increase in plasma sodium without developing osmotically induced central pontine myelinolysis. However, we have previously reported a case of clinically suspected pontine myelinolysis in a patient with self-induced water intoxication. The purpose of our study was to investigate if a subgroup of these patients may also be vulnerable to neurologic complications of hyponatremia therapy. METHOD: Over a 10-year period, we identified retrospectively 12 polydipsic patients having a total of 24 episodes of symptomatic hyponatremia with plasma sodium < or = 115 mmol/L. The mode of treatment, the kinetics of correction, and the neurologic outcome were recorded. The presence of alcoholism was noted. RESULTS: Seven patients recovered uneventfully from 19 episodes of symptomatic hyponatremia. Five patients had delayed neurologic complications. Late therapy and/or respiratory arrest might have been associated with the complications for 2 patients. The other 3 patients experienced clinical features of central pontine myelinolysis leading to death in 1. Patients with neurologic complications had a higher maximal 24-hour increase in plasma sodium concentration (21.8 +/- 3.9 vs. 15.5 +/- 5.1 mmol/L, p < .02), and a higher incidence of both overcorrection to hypernatremia and chronic alcoholism, often associated with poor nutrition. All 5 patients became water intoxicated at home, and 2 patients with pontine dysfunction had subacute rather than acute hyponatremia. CONCLUSION: A large rapid increase in plasma sodium may also be detrimental in patients with self-induced water intoxication when they are alcoholic, malnourished, and have nonacute hyponatremia.

Folic acid deficiency in intensive care patients: comparison between two regimens of supplementation.

Serum folic acid (SFA) and red blood cell folic acid (RbcFA) levels were determined in 40 patients on the day of admission to our intensive care unit (ICU, D0). 65% of the patients had low SFA (< 3,4 ng/ml) and 27.5% had low RbcFA (< 275 ng/ml)L. Twenty-four hours later (Day 1:D1), both SFA and RbcFA had decreased significantly (respectively 0.49 ng/ml and 21 ng/ml, p < 0.01) in the 40 patients; the magnitude of RbcFA decrease was greater in patients with sepsis than in those without sepsis (p < 0.02). SFA and RbcFA levels were significantly lower in patients with sepsis on D0 and D1. Forty-two other patients with documented hypofolatemia were then randomly allocated to two regimens of FA supplementation. Patients on regimen A had an intravenous injection of 0.5 mg folinic acid daily for ten days whereas patients on regimen B received a single 5 mg intravenous injection of FA on day 1. Both regimens increased significantly SFA and RbcFA levels. But regimen A should be recommended because 1) RbcFA levels were significantly higher than with regimen B (p < 0.05) and 2) the mean increase was higher, particularly in patients with initial sepsis (p < 0.01).

Pneumocystis carinii pneumonia in patients with hematologic malignancies: a descriptive study.

Objectives. A retrospective multicentric study was conducted over a five-year period to evaluate the clinical and laboratory characteristics and outcome of patients with proven Pneumocystis carinii pneumonia (PCP) complicating hematologic malignancies.Results. The study included 60 HIV-negative patients with 18 non-Hodgkin's malignant lymphoma (30%), 13 chronic lymphocytic leukaemia (21.7%), 10 acute leukemia (16.6%), 5 multiple myeloma (8.3%), 4 Waldenström's diseases (6.6%), 4 chronic myeloid leukemia (6.6%), 3 myelodysplasia (5%), 2 Hodgkin's diseases (3.3%) and 1 thrombopenia. Bronchoalveolar lavage was diagnostic in all patients. Forty-nine patients received cytotoxic drugs (81.7%), 25 (41.7%) a long-term corticotherapy and 15 (25%) underwent bone marrow transplantation. Twenty-seven patients (45%) required admission in the intensive care unit, 35 (58.3%) received an adjunctive corticotherapy and 18 mechanical ventilation (30%). Twenty patients (33.3%) died of PCP. A previous long-term corticotherapy (p=0.04), high respiratory (p=0.05) and pulse rates (p=0.02), elevated C reactive protein (p=0.01) and mechanical ventilation (OR=13.37; IC: 1.9-50) were associated with a poor prognosis. Adjunctive corticotherapy did not modify the prognosis.Conclusions. These results suggest that PCP can occur during the course of various hematologic malignancies, not only lymphoproliferative disorders. Prognosis remains poor. The diagnosis should be advocated more frequently and earlier to improve the prognosis.

Non-invasive continuous positive airway pressure in acute hypoxaemic respiratory failure--experience of an emergency department.

Non-invasive continuous positive airway pressure (CPAP) seems to decrease the need for intubation in patients with severe cardiogenic pulmonary oedema (CPO) in the intensive care unit. The goals of our study were to delineate indications for CPAP in the emergency department, and to confirm its usefulness in such a setting. We retrospectively assess the evolution of all patients ventilated under CPAP for an acute hypoxaemic respiratory failure over a 1-year period (n = 64 patients). Hypercarbia and respiratory acidosis were present in most patients with CPO (PaCO2 = 54.4+/-22.3 mmHg; pH = 7.27+/-0.13), according to respiratory exhaustion, although initial PaCO2 was low in the pneumonia group. There was a significant improvement of arterial blood gases after 1 hour of ventilation in the CPO group (PaO2 = 254.1+/-121.0 mmHg; PaCO2 = 44.0+/-12.6 mmHg; pH = 7.34+/-0.08; p < 0.0001 for both parameters). In the pneumonia group, oxygenation was also improved but with the persistence of a significant shunt (PaO2 = 157.6+/-84.4 mmHg). Fifty-four patients (84%) were considered as successfully ventilated under CPAP, with no need for intubation and a favourable evolution, mainly in the CPO group. No side effects were reported. In conclusion, CPAP is a useful and easy-to-use ventilatory device in the emergency department. It is now one of our first line treatments during prehospital and emergency care of patients with CPO.

[Attempt at preventive treatment of esophagitis caused by intubation during intensive care]. / Tentative de traitement préventif des oesophagites sur sonde en réanimation.

A randomized prospective trial was designed to evaluate the preventive treatment of esophagitis in 31 intensive care patients who had a nasogastric feeding tube for at least 10 days. Fourteen patients (group B) received no preventive treatment while 17 patients (group A) received 300 mg of cimetidine every 6 h intravenously and 11 g of colloidal aluminium phosphate every 4 h per os. All patients were fed a standard diet through their nasogastric tube at a constant rate of 30 Kcal/kg/day. Endoscopic controls at day 1 and 10 showed that the number of initial and final esophagitis was not different in groups B and A: 7 and 8 at day 1, 11 and 10 at day 10, respectively. The inefficiency of this preventive treatment suggested that acid gastroesophageal reflux is not a major factor in the occurrence of nasogastric feeding tube-induced esophagitis. However as esophagitis is associated with a more severe Knaus index and a greater number of gastric stress ulcer risk factors, it is suggested that decreased defense of the mucosa may be a key factor in the occurrence of this type of esophagitis.

[A sociomedical geriatric assessment in the emergency units: an alternative to the hospitalization of aged patients?]. / L'accueil gérontologique médicosocial aux urgences: une alternative à l'hospitalisation des personnes âgées en médecine?

BACKGROUND: Elderly patients admitted to the emergency unit are usually hospitalized in medical units. Could a gerontologic evaluation in the emergency room lead to another solution than hospitalization? METHODS: Since January 1993, a sociomedical geriatric reception has been operating in the emergency unit of the university hospital in Brest, France, every day from 10 AM. to 6 PM. Patients older than 75 years, dependent or at risk of dependence are examined by a geriatrician. The medical situation is evaluated. The nutrition status, the cognitive functions, the thymic functions, the gait, and the functional abilities are systematically studied. In the same time the social evaluation is realised by a social worker. RESULTS: From January 1993 to December 1996, 1,514 patients have been cared for by the social medical team. Once the assessment of each patient was made only 49% of them actually had to be hospitalized in a medical department. The outcome of 100 patients discharged between January 1994 and June 1994 was evaluated one year after their discharge at home, 11 patients were rehospitalized. The reason for rehospitalization were different from the reasons for the first hospitalization. CONCLUSION: A gerontologic assessment in the emergency room permits to avoid hospitalization in 50% of the cases. One year after discharge at home only 11% of the patients were rehospitalized.

[Estrogen-progestogen agents and megaloblastic anemia]. / Oestro-progestatifs et anémie mégaloblastique.

TwO cases of megaloblastic anaemia, of which one was very severe, occurring in women who had been taking oestrogen-progestogen oral contraception over a long period of time, are reported. The authors take the opportunity, after having reviewed the literature, of pointing out the role of oestro-progestogen products in bringing about vitamin deficiencies. They discuss how and where oestrogen-progestogen products work on folic metabolism and emphasize that there is an associated factor which starts off the deficiencies.

[Spontaneous positive end-expiratory pressure ventilation in elderly patients with cardiogenic pulmonary edema. Assessment in an emergency admissions unit]. / Ventilation spontanée en pression expiratoire positive au cours de l'oedème pulmonaire cardiogénique de la personne âgée. Etude dans un service d'accueil et d'urgence.

OBJECTIVES: Intubation and ventilatory assistance are often required in patients presenting severe hypoxemic respiratory distress, but may be contraindicated in elderly subjects due to an underlying condition. The aim of this study was to assess the feasibility, acceptability and contribution of early assistance with spontaneous positive end-expiratory pressure ventilation for elderly subjects admitted to an emergency unit for acute respiratory distress due to cardiogenic pulmonary edema. PATIENTS AND METHODS: In our emergency admission unit, all patients with life-threatening hypoxemic respiratory distress are initially assisted with noninvasive spontaneous positive end-expiratory pressure ventilation using a standardized commercial device. We retrospectively analyzed the the files of all patients aged over 70 years who were treated with this standard protocol for cardiogenic pulmonary edema from April 1996 through September 1997. RESULTS: During the study period, 36 patients aged over 70 years required ventilatory assistance according to the standard protocol. Intubation was not reasonable in most of the patients (n = 30). After 1 hour of ventilation, none of the patients developed clinical signs of life-threatening distress. Blood gases demonstrated improved oxygenation (AEPO2 = +184.9 +/- 105.4 mmHg; p < 0.000001). Thirty-two patients were considered to be cured (88.9%) and were discharged; the cardiovascular condition was fatal in 4 patients (11.1%). CONCLUSION: The rapid improvement in clinical signs and blood gases as well as the final outcome suggests that early assistance with spontaneous positive end-expiratory pressure ventilation is warranted at admission for elderly patients with respiratory distress due to cardiogenic pulmonary edema. Compared with a control group of hospitalized patients cared for during the preceding year and who were not treated with the standard protocol, we also demonstrated a clear improvement in mortality (11% versus 20%).

[Prescription of beta-lactams for community-acquired broncho-pulmonary infections in adults. Observations in the hospital environment]. / Prescription des bêta-lactamines pour infections broncho-pulmonaires communautaires de l'adulte. Observatoire en milieu hospitalier.

OBJECTIVE: Analyze beta-lactam prescription patterns used in hospitals for the treatment of community-acquired lower respiratory tract infections in adults. PATIENTS AND METHODS: A prospective study was carried out over 4 months (October 1997 to January 1998) in 54 medical units caring for lung disease, internal medicine/infectious disease, geriatric and general medicine patients in 27 hospitals representative of the public facilities in France. Data were collected on the medical unit, the patients, and the antibiotic prescriptions, including discharge prescriptions. The cost analysis of antibiotic therapy took into account all antibiotics given to the patients during their hospital stay. RESULTS: One thousand eighteen patients were included in the study: 266 were treated for acute bronchitis, 405 for bronchitis infection with underlying chronic respiratory disease, and 347 for pneumonia. Noteworthy findings included: low percentage of protocols within the medical units (25.3%), an unexpected frequency of hospitalization for acute bronchitis generally among elderly women, and prolonged intravenous antibiotic therapy and hospitalization (5 to 6 days and 9 to 12.5 days respectively). CONCLUSION: This study confirms the need to reinforce measures aimed at optimizing antibiotic prescriptions in hospitals.

[Mycoplasma pneumoniae infections. A multicenter retrospective study of 182 cases]. / Les aspects des infections à Mycoplasma pneumoniae. Etude multicentrique rétrospective de 182 cas.

The spectrum of 182 hospital Mycoplasma pneumoniae infections, collected over a five-year period, is reviewed. The diagnosis was based on complement fixation test. Mycoplasma infection was encountered mainly in young people, mean age 29 years. Eighty-four per cent presented with an atypical pneumonia, 33 per cent had extrapulmonary manifestations mainly neurological and cutaneous. Acute respiratory failure occurred in 32 cases. Only 5 patients died. Macrolides or tetracyclines remain the most effective antibiotics but spontaneous recovery is usual.

[2 unusual manifestations of LAV-HTLV virus infection: BCGitis and pulmonary chickenpox]. / Deux manifestations inhabituelles d'une infection par le virus LAV-HTLV III: BCGite et varicelle pulmonaire.

A patient with AIDS developed local complications of BCG vaccination and disseminated chickenpox with severe pneumonia. This cas suggests that AIDS patients should not receive BCG vaccination and that adults with severe chickenpox should be investigated for LAV/HTLV III virus carriage.

[Use of helium-oxygen gas mixtures in acute obstructive respiratory insufficiencies]. / Utilisation des mélanges gazeux hélium-oxygène au cours des insuffisances respiratoires aiguës obstructives.

Therapeutic use of helium has been described since 1930. Its main action is to reduce bronchial resistances and consequently overall respiratory work. Helium is substituted for nitrogen. The effects of inhaling a helium-oxygen mixture result exclusively from the physicochemical properties of helium: very low density, high kinetic viscosity. With the advent of selective bronchodilators, use of helium was rapidly abandoned until recently with new interest for the treatment of severe acute asthma. We review the literature on the physical properties of helium-oxygen mixtures and propose an analysis of their therapeutic use in severe acute asthma as well as other indications such as acute episodes of obstructive bronchopneumonia and obstruction of the upper airways. Due to the non-invasive nature of this technique, its easy use with spontaneous ventilation and the large body of theoretical data emphasizing its adaptation for therapeutic use, helium-oxygen gas mixtures offer an important therapeutic option for treating severe diseases with poor prognosis. A multicentric national study is under way to validate its use early by emergency ambulatory units for the treatment of severe acute asthma.

Implication of antibiotic referents in complex bone and joint infections.

UNLABELLED: One of the main objectives of antibiotic referents in French hospitals is to promote the nationwide antibiotic stewardship program. National guidelines for complex bone and joint infection management (CBJI) issued in 2009, and expert and associated hospital centres were chosen. Our aim was to determine the role of antibiotic referents in CBJI treatment modalities, in 2012. METHOD: A questionnaire was proposed to participants at the seventh national meeting of antibiotic referent in June 2012. RESULTS: Ninety-seven questionnaires were completed. Antibiotic referents were mainly infectious diseases doctors working in public hospitals with more than 300 hundreds beds. Twenty-eight units dedicated to CBJI were reported, as well as 35 multidisciplinary team meetings, 57% of which including physicians from both private and public hospitals. The 2009 national recommendations were the reference for 81% of responders, while referring to expert and associated centres was reported by 80%. Patient transfer to a reference center was rare, for both geographic reason and divergent medical and surgical habits. Most antibiotic referents suggested a 6-week course of antibiotic therapy and 12 months of follow-up. Twenty-two percent of the responders participated in morbidity and mortality audits. CONCLUSION: The 2009 national guidelines were rapidly taken into account. Their implementation led to more homogeneous clinical practices as reported by antibiotic referents. Reference centres are used for advice but patient transfer to these centres is still rare.