CSF lactate for accurate diagnosis of community-acquired bacterial meningitis.

CSF lactate measurement is recommended when nosocomial meningitis is suspected, but its value in community-acquired bacterial meningitis is controversial. We evaluated the diagnostic performance of lactate and other CSF parameters in a prospective cohort of adult patients with acute meningitis. Diagnostic accuracy of lactate and other CSF parameters in patients with microbiologically documented episodes was assessed by receiver operating characteristic (ROC) curves. The cut-offs with the best diagnostic performance were determined. Forty-five of 61 patients (74%) had a documented bacterial (n = 18; S. pneumoniae, 11; N. meningitidis, 5; other, 2) or viral (n = 27 enterovirus, 21; VZV, 3; other, 3) etiology. CSF parameters were significantly different in bacterial vs. viral meningitis, respectively (p < 0.001 for all comparisons): white cell count (median 1333 vs. 143/mm(3)), proteins (median 4115 vs. 829 mg/l), CSF/blood glucose ratio (median 0.1 vs. 0.52), lactate (median 13 vs. 2.3 mmol/l). ROC curve analysis showed that CSF lactate had the highest accuracy for discriminating bacterial from viral meningitis, with a cutoff set at 3.5 mmol/l providing 100% sensitivity, specificity, PPV, NPV, and efficiency. CSF lactate had the best accuracy for discriminating bacterial from viral meningitis and should be included in the initial diagnostic workup of this condition.

[Loco-regional complications of pharyngitis: the example of Lemierre's syndrome]. / Complications locorégionales des pharyngites: 1'exemple du syndrome de Lemierre.

Pharyngitis is a common cause of consultation in ambulatory medicine. Although it is benign in most cases, serious complications may happen and must be recognized quickly. Lemierre's syndrome is one of them. It consists in the association of thrombosis of the internal jugular vein and septic emboli that generally involve the lungs and is classically associated with Fusobacterium necrophorum. It is usually found in young and healthy adults and has an estimated mortality of 5%. Diagnosis relies essentially on the characteristic presentation of the disease. Therapy consists of surgical drainage of purulent collections and necrotic tissues associated with a prolonged course of antibiotics. Some authors also recommend a anticoagulation.

[Microbiological diagnosis of Clostridium difficile infection]. / Diagnostic microbiologique des infections à Clostridium difficile.

The clinical microbiology laboratory plays an essential role in the management of Clostri- dium difficile infections, showing an increase in frequency and severity. Many tests (culture, EIA, PCR), detecting bacteria or their antigens, toxin genes or free toxins, allow the microbio- logist to provide the clinician and the infection control specialist with a reliable diagnosis as- sistance, which meet essential criteria for ra- pidity, sensitivity and specificity. This review presents the diagnostic algorithms currently used.

[Headache and transient aphasia in a 35-year-old female patient]. / Kopfschmerzen und passagere Aphasie bei einer 35-jährigen Patientin.

We describe the case of a 35-year-old female patient who suffered from fulminant tick-borne encephalitis and subsequently died. Remarkable about this case was that the woman was not living in an endemic area and that the disease occurred outside the usual season. Furthermore, this indicates that an increase in transmission of tick-borne encephalitis can be expected outside the classical endemic areas in higher altitudes, possibly as a consequence of climate changes.

[Tularemia, an emerging disease in Switzerland]. / La tularémie, une maladie émergente en Suisse.

Tularemia is an infection caused by Francisella tularensis. This zoonose is transmitted to human through contact with infected animals or by vectors such as ticks. It has been a rare disease in Switzerland until recently, but its incidence is increasing. The clinical manifestations of tularemia are diverse and the ulcero-glandular disease is the most common form. It presents with an ulcerative lesion at the site of inoculation and regional lymphadenopathy which can be massive. Diagnosis is based on culture, PCR or serology with antibody titer rise approximately 2 weeks after the onset of illness. Antibiotics with clinical efficacy include doxycycline, fluoroquinolones and aminoglycosides.

[Pet-associated infections]. / Infections transmises par les animaux domestiques.

Pet-related infections in humans are diverse, rather infrequent considering the high number of pets in households and often unrecognized. This article briefly covers a couple of them, caused by bacteria (salmonellosis and campylobacteriosis, cat-scratch disease, fish tank granuloma, psittacosis), fungi (dermatophytosis), viruses (lymphocytic choriomeningitis) and parasites (toxoplasmosis, toxocariasis, cutaneous larva migrans, echinococcosis) and describes their epidemiology and clinical presentation. Widening of public tastes in this area opens doors for emerging diseases (e.g. Cowpox virus with rats).

[Occupational exposures with risk of transmission of HIV, HBC and HCV in health care workers]. / Accidents avec risque de transmission, du VIH, du virus de l'hépatite B et du virus de l'hépatite C dans le secteur médical.

Health care workers are often victims of occupational injuries by contaminated sharps or projection of contaminated fluids to mucous membranes and are therefore at risk for transmission of HIV, HBV and HCV. Every technical and organisation-related measure useful to prevent injuries should be implemented and personal protection equipment must be made available to workers. Promotion of hepatitis B immunization is a key issue. Immediate evaluation of injured employee is necessary to assess the risk related to exposure and the indication for post-exposure prophylaxis (anti-retroviral therapy for HIV, immunoglobulins and vaccination for hepatitis B). When a health care worker has been exposed to one of the blood-born viruses, thorough information and follow-up should be offered by a specialist.

[Blood culture negative endocarditis: a diagnostic challenge]. / Endocardites a hémocultures négatives: un défi diagnostique.

Blood culture negative endocarditis (BCNE) account for about 5% of all cases of endocarditis. Diagnosis and initiation of antimicrobial therapy may be delayed, with a negative impact on clinical outcome. The most common cause of BCNE is antimicrobial drug therapy before blood sampling. Other common causes include slow growing and non cultivable organisms. Identification of the etiologic agent is critical in the management of BCNE and molecular tools such as broad range 16SrRNA PCR technique followed by direct automated sequencing and microorganism-specific PCR are promising. Some authors have proposed to include these techniques among major Duke's criteria for the diagnosis of BCNE.

[Positive blood cultures during a 2 years period at Hôspital cantonal de Fribourg]. / Revue des hémocuttures positives sur deux ans a l'Hôpital cantonal de Fribourg.

Several authors, mainly from the United States, have reported on the microbiology and interpretation of positive blood cultures. We conducted a retrospective study over a 2 years period to address this issue in a medium-size swiss hospital: two hundred and thirty-two episodes of positive blood culture were recorded, with 403 microorganisms; Escherichia coli (22%), Staphylococcus aureus (21%) and coagulase-negative staphylococci (110%) were the most frequent isolates. The latter were considered as contaminants in 38% of cases. Half the episodes were nosocomial, 23% originated from the urinary tract and 18% were linked to a vascular catheter. Attributable mortality of bacteremia/fungemia was 9%, significantly higher for fungi (36%) than for bacteria (8%; p 0.009).

Effect of sputum induction by hypertonic saline on specimen quality.

Microbiologic work-up of expectorated material is routinely used to search for the etiology of pulmonary infections, but sputum is often contaminated by saliva. Inhalation of hypertonic saline induces bronchial secretions and theoretically may improve specimen quality. We compared in a laboratory-blinded, randomized study the quality of sputum obtained either with induction by saline or without induction in patients with respiratory tract infection and a history of productive cough. The quality of sputum was considered good if the polymorphonuclear neutrophils (PMNs)/squamous epithelial cells (SECs) ratio was > or = 2 or the Q (quality) score was > or = +1 on Gram stain. Forty-nine and 50 patients were able to expectorate in the induced and spontaneous sputum groups, respectively. PMNs/SECs ratio was > or = 2 in 65% and 74% of the patients in the induced and spontaneous sputum groups (p = 0.47); for the Q score, a value > or = +1 was found in 55% and 66% of the patients of each group (p = 0.37). In conclusion, sputum induction by hypertonic saline inhalation does not improve specimen quality as judged by the PMNs/SECs ratio on Gram stain.

Clinical utility of cardiac valve Gram stain and culture in patients undergoing native valve replacement.

OBJECTIVES: To determine if routine cardiac valve culture is useful in diagnosing clinically unsuspected infective endocarditis in patients undergoing native valve replacement, to see if false-positive culture results have a deleterious effect on patient care, and to determine if microbiology and histopathology can be used to differentiate partially treated and untreated infective endocarditis from valve contamination. DESIGN: Case series. SETTING: Tertiary-care teaching hospital with 1125 beds. PATIENTS: Forty-eight patients with culture-positive cardiac valves after native valve replacement. RESULTS: A single unsuspected case of endocarditis was disclosed by microbiology over a 5-year period. Histopathology in this case was also positive, however, and the diagnosis should have been suspected clinically. Eighty-three percent of positive cultures were the result of contamination over an 18-month period; results were disregarded appropriately by clinicians. Clinical context or histopathology was required to categorize microorganisms correctly as pathogens or contaminants; only the presence of organisms on Gram stain had a good predictive value for endocarditis. CONCLUSION: Routine valve cultures in patients undergoing native valve replacement are not warranted. Although false-positive culture results had no deleterious effects on patient care in this study, misinterpretation of such results could lead to overtreatment. Microbiology results alone are not sufficient to distinguish endocarditis from contamination.

Treatment of Infections Associated with Implanted Medical Devices.

The development of an infection in the vicinity of an implanted medical device is a dramatic event in many fields of surgery, especially cardiovascular, orthopedic and neurosurgery. The diagnosis of these infections is usually difficult and their treatment is always complex and represents a challenge for both surgeons and infectious diseases specialists. As foreign materials are used with increased frequency in modern medicine, this problem will probably remain a major one in the future despite the improvement of techniques and the use of new antibiotics. For patients, infection of a prosthetic device often means the loss of its function and. is sometimes associated with a high mortality.

Investigation of classical epidemiological links between patients harbouring identical, non-predominant meticillin-resistant Staphylococcus aureus genotypes and lessons for epidemiological tracking.

According to molecular epidemiology theory, two isolates belong to the same chain of transmission if they are similar according to a highly discriminatory molecular typing method. This has been demonstrated in outbreaks, but is rarely studied in endemic situations. Person-to-person transmission cannot be established when isolates of meticillin-resistant Staphylococcus aureus (MRSA) belong to endemically predominant genotypes. By contrast, isolates of infrequent genotypes might be more suitable for epidemiological tracking. The objective of the present study was to determine, in newly identified patients harbouring non-predominant MRSA genotypes, whether putative epidemiological links inferred from molecular typing could replace classical epidemiology in the context of a regional surveillance programme. MRSA genotypes were defined using double-locus sequence typing (DLST) combining clfB and spa genes. A total of 1,268 non-repetitive MRSA isolates recovered between 2005 and 2006 in Western Switzerland were typed: 897 isolates (71%) belonged to four predominant genotypes, 231 (18%) to 55 non-predominant genotypes, and 140 (11%) were unique. Obvious epidemiological links were found in only 106/231 (46%) patients carrying isolates with non-predominant genotypes suggesting that molecular surveillance identified twice as many clusters as those that may have been suspected with classical epidemiological links. However, not all of these molecular clusters represented person-to-person transmission. Thus, molecular typing cannot replace classical epidemiology but is complementary. A prospective surveillance of MRSA genotypes could help to target epidemiological tracking in order to recognise new risk factors in hospital and community settings, or emergence of new epidemic clones.

[Effect and tolerance of ofloxacin in bronchopulmonary infections in comparison with amoxicillin]. / Wirksamkeit und Verträglichkeit von Ofloxacin bei bronchopulmonalen Infektionen im Vergleich zu Amoxicillin.

Ofloxacin and amoxicillin in the treatment of 121 bronchopulmonary infections were compared in a randomized, open clinical trial. 64% of the infections were pneumonias. S. pneumoniae, H. influenzae and B. catarrhalis accounted for 76% of the etiologic agents. The clinical and bacteriological responses were positive in more than 90% of the patients and comparable in both groups. None of the isolated agents was resistant to ofloxacin, whereas 21% were amoxicillin-resistant. Ofloxacin was used without randomization in the treatment of 26 atypical pneumonias and opportunistic infections, all of which were cured or improved. Occurrence of side-effects was rarely observed in either treatment group.

[Treatment of osteomyelitis with oral bactericidal antibiotics-- description of 9 cases]. / Die Behandlung der Osteomyelitis mit peroralen bakteriziden Antibiotika--Beschreibung von 9 Fällen.

The efficacy of oral bactericidal antibiotics in the treatment of osteomyelitis is analyzed retrospectively by a review of 9 cases histories. The first patient was treated in 1982. Clinical and laboratory controls were reviewed up to 1.1.1995. In 6 patients S. aureus was isolated, while in 3 patients the organism could not be cultured but gram + cocci were almost likely. 5 cases of osteomyelitis were acute, 4 were chronic and in one case there was an infection of an artificial knee prothesis. The isolated S. aureus were sensitive to the antibiotics prescribed. 8 patients received a combination of flucloxacillin (2-4 g/day) and rifampicin (600 mg/day); one patient was treated with the combination amoxicillin/clavulanic acid (1500/425 mg/day) followed by ofloxacin (400 mg/day) and finally co-trimoxazole (320/1600 mg/day). 3 patients received all antibiotics orally; in 6 patients oral administration followed a short intravenous course of the antibiotic combination. The duration of treatment varied between 6 and 23 weeks. Follow-up extended over 9 months (n = 1), 14 months (n = 3), 4-7 years (n = 3), and 10-12 years (n = 2). In 8 cases the osteomyelitis was cured (89%). In our view, a combination of bactericidal oral antibiotics with good penetration into bone tissue can be prescribed in selected cases of osteomyelitis to shorten or even avoid the standard intravenous therapy of acute or chronic diseases.

Bile-esculin test for presumptive identification of enterococci and streptococci: effects of bile concentration, inoculation technique, and incubation time.

The bile-esculin test is used to differentiate enterococci and group D streptococci from non-group D viridans group streptococci. The effects on test performance of the concentration of bile salts, inoculum, and duration of incubation were examined with 110 strains of enterococci, 30 strains of Streptococcus bovis, and 110 strains of non-group D viridans group streptococci. Optimal sensitivity (> 99%) and specificity (97%) of the bile-esculin test can be obtained with a bile concentration of 40%, a standardized inoculum of 10(6) CFU, and incubation for 24 h.