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.

[Prosthetic hip infection due to Listeria monocytogenes: review of the literature and case report]. / Infection prothétique de hanche à Listeria monocytogenes.

With the ageing of the population, articular prosthetic replacements are becoming more and more frequent. One of the most feared complications is prosthetic infection, mostly due to bacteria of the cutaneous flora. Listeria monocytogenes is rarely the cause. This paper describes the management of a hip prosthetic infection due to Listeria monocytogenes. The patient was cured with antimicrobial therapy and a two-stage exchange. This case report creates an opportunity to review the literature in the aim of determining the risk factors and the optimal care.

Nosocomial influenza in south-western Swiss hospitals during two seasonal epidemics: an observational study.

BACKGROUND: In Switzerland each year, influenza leads to between 112,000 and 275,000 medical consultations. Data on nosocomial influenza infection are limited. AIM: To describe nosocomial cases of seasonal influenza in south-western Switzerland. METHODS: This study was conducted during two seasonal influenza epidemics from 2016 to 2018 in 27 acute care public hospitals in south-western Switzerland. During these two time-periods, every patient hospitalized for >72 h who was positively screened by reverse transcription-polymerase chain reaction or antigen detection for influenza was included in the survey. Characteristics of patients included age, sex, and comorbidities. Included patients were followed up until discharge or death. Complications and administration of antineuraminidases and/or antibiotics were registered. FINDINGS: The median influenza vaccine coverage of healthcare workers was 40%. In all, 836 patients were included (98% with type A influenza virus in 2016-2017; 77% with type B virus in 2017-2018). Most patients (81%) had an unknown vaccine status. Overall, the incidence of nosocomial influenza was 0.5 per 100 admissions (0.35 per 1000 patient-days). The most frequent comorbidities were diabetes (20%), chronic respiratory diseases (19%), and malnutrition (17%). Fever (77%) and cough (66%) were the most frequent symptoms. Seventy-one percent of patients received antineuraminidases, 28% received antibiotics. Infectious complications such as pneumonia were reported in 9%. Overall, the all-cause mortality was 6%. CONCLUSION: The occurrence of nosocomial influenza underlines the importance of vaccinating patients and healthcare workers, rapidly recognizing community- or hospital-acquired cases, and applying adequate additional measures to prevent dissemination, including the timely administration of antineuraminidases to avoid antibiotic use (and misuse).

[Infection of a total knee prosthesis with Brucella spp]. / Infection d'une prothèse totale du genou par "Brucella spp".

Brucellosis, an "anthropophitic" disease of worldwide distribution can involve several organs and tissues but the osteoarticular disease is the most common complication. It can occur as sacroiliitis, bursitis, tenosynovitis or osteomyelitis. Prosthetic joint infection is a serious complication of total joint arthroplasty, with coagulase negative staphylococci and Staphylococcus aureus accounting for 50% of cases. Treatment of prosthetic infections remains complex. Prosthetic infections caused by Brucella spp are rarely described in the literature. We report a patient with a prosthetic joint infection due to Brucella spp, documented by a polymerase chain reaction. The patient has been cured after two-stage exchange of the prosthesis and long-term antimicrobial therapy.

[Tick-borne encephalitis in the North part of the canton de Vaud]. / Méningo-encéphalite verno-estivate dans le Nord vaudois.

Tick-borne encephalitis (TBE) is described in Switzerland since 1969. More than 200 cases are reported every year to the Federal office of public health (FOPH) and new sites of endemic disease have been documented recently, in particular in the North part of the canton de Vaud. The aim of this article is to review the clinical pictures of 11 patients hospitalised in Yverdon-les-Bains with a diagnosis of TBE between 2003 and August 2007. The occurrence of 5 new cases exposed in the North part of the canton de Vaud over these last 18 months confirms the presence of endemic foci in this area and should prompt the vaccination against the MEVE which is recommended by the FOPH in endemic zones. The sequels of MEVE being observed mainly in the elderly, vaccination should be afforded also to this group of patients.

Piperacillin-tazobactam monotherapy in high-risk febrile and neutropenic cancer patients.

Combination therapy with a beta-lactam plus an aminoglycoside has been the standard approach for treating febrile neutropenia for many years. More recently, beta-lactam monotherapy has also been shown to be a reliable and safe approach. In the present study, 763 eligible patients with fever and neutropenia received piperacillin-tazobactam monotherapy. On day 3, according to the study protocol, 165 patients with persistent fever who fulfilled the study entry criteria were randomised to receive vancomycin or a placebo. The success rate was 51% in the intention-to-treat analysis and 62% in the per-protocol analysis. The overall mortality rate was 8% (58/763), with only 18 (2.4%) deaths attributed to the initial or subsequent infection. Randomisation had no influence on the study endpoints. The adverse event rate was evaluated only in the patient population not included in the randomised part of the study. Among these patients, adverse events probably or definitely related to piperacillin-tazobactam therapy were uncommon, confirming the favourable safety profile of piperacillin-tazobactam. It was concluded that piperacillin-tazobactam could be considered as monotherapy for patients with high-risk febrile neutropenia.

[Evidence of new foci of tick-borne encephalitis in the French speaking part of Switzerland]. / Evidence de nouveaux foyers d'endémie de méningo-encéphalite verno-estivale en Suisse romande.

The incidence of tick-borne encephalitis (TBE) has more than doubled in Switzerland in recent years. In the French part of Switzerland several patients seem to have acquired the infection outside of known endemic foci. Thirty patients with TBE living or having acquired the infection in the French speaking part of Switzerland between 2000 and 2005 were identified. For one patient it wasn't possible to obtain precise information about the place of acquisition of the infection and 16 patients were infected in known endemic foci. Among the 13 remaining patients, 6 were infected on the southern shores of the lake of Neuchâtel and 7 in the plaine of Orbe. We conclude that there are new foci of TBE in the northern regions of the canton of Vaud. Vaccination should be proposed to the population at risk of these regions. In addition it is important that persons with outdoor activities in this regions respect the preventive

Vancomycin versus placebo for treating persistent fever in patients with neutropenic cancer receiving piperacillin-tazobactam monotherapy.

This prospective, double-blind trial assessed whether the addition of a glycopeptide would be able to reduce the time to defervescence in neutropenic patients with cancer who had persistent fever 48-60 h after the initiation of empirical piperacillin-tazobactam monotherapy. Of 763 eligible patients, 165 with persistent fever were randomized to receive piperacillin-tazobactam therapy plus either vancomycin therapy or placebo. Defervescence was observed in 82 (95%) of 86 patients in the vancomycin group and in 73 (92%) of 79 patients in the placebo group (P=.52). The distributions of the time to defervescence were not statistically significant between the 2 groups (estimated hazard ratio, 1.03; 95% confidence interval, 0.75-1.43; P=.75). The number of additional episodes of gram-positive bacteremia and the percentage of patients for whom amphotericin B was empirically added to their therapy regimen were also similar in both groups. This study failed to demonstrate that the empirical addition of vancomycin therapy to the treatment regimen is of benefit to persistently febrile neutropenic patients with cancer.

Antibiotic therapy for gram-negative bacteremia.

Although antibiotic therapy is the mainstay of therapy for gram-negative bacillary bacteremia, the amelioration of the underlying conditions, the correction of predisposing factors, the drainage of abscesses, the removal of infected foreign bodies, and adequate supportive care are also of paramount importance for curing the infection and should not be neglected. Beginning in the late 1960s, most of the clinical work on gram-negative infections has focused on the evaluation of new antibiotics. Numerous studies have shown that early, appropriate antibiotic treatment of gram-negative bacteremia significantly improved patients' outcomes and prevented the development of septic shock. Prescribing standard doses of antibiotics does not necessarily mean that therapeutic levels will be reached in all patients, and relapses of infections or breakthrough bacteremias can occur in patients with subinhibitory serum levels of antibiotics. The monitoring of serum concentrations of antibiotic is therefore recommended in critically ill septic patients. Whereas initial studies on the antibiotic treatment of gram-negative bacteremia were carried out in nonneutropenic patients, more recent clinical investigations have been performed almost exclusively in cancer patients with neutropenia. Studies conducted in the 1970s and 1980s among these patients have shown the following: (1) early empirical therapy reduced the mortality of gram-negative bacteremia; (2) therapy with a combination of two antibiotics, be it an extended spectrum penicillin plus an aminoglycoside or a third-generation cephalosporin, has significantly improved patients' outcomes; and (3) triple-drug combinations (i.e., a penicillin plus a cephalosporin plus an aminoglycoside) are not superior to combinations of beta-lactams and aminoglycosides. For the treatment of gram-negative bacteremia, clinicians today have a choice between well-established antibiotic combinations and broad-spectrum single-agent therapy with third-generation cephalosporins or carbapenem antibiotics. Although recent studies suggested that monotherapy could be as effective as combination therapy for the empirical treatment of fever in the neutropenic host, no definitive study has so far unquestionably demonstrated the equivalence of these treatments in patients with gram-negative bacteremias, especially those caused by P. aeruginosa, or in patients with adverse prognostic conditions, such as persistent and profound granulocytopenia. This literature should however be reviewed with great caution. Indeed, only a minority of studies have included a sufficient number of patients to confidently assess the impact of therapy on patients' outcomes. Obviously, small studies can have a significant risk of type II errors, that is, making false-negative conclusions.(ABSTRACT TRUNCATED AT 400 WORDS)

Empiric antibiotic monotherapy with carbapenems in febrile neutropenia: a review.

Early empiric antibiotic therapy can significantly decrease the risk of mortality and infectious morbidity in patients with hematologic malignancies. Broad-spectrum antibiotics, usually a combination regimen of a beta-lactam and an aminoglycoside, have traditionally been employed against the wide variety of organisms that cause febrile episodes. However, since the 1970's, there has been a shift in epidemiology from Gram-negative to Gram-positive infections, against which traditional combination regimens have only limited efficacy. The carbapenems offer a suitable monotherapeutic alternative as they have a very broad spectrum of antibacterial activity, and equivalent efficacy and safety compared with combination regimes. Trials using imipenem/cilastatin have shown equal efficacy to ceftazidime but neurologic and gastrointestinal toxicity were observed at high doses (1 g 6-hourly). In the largest study to date, meropenem (1 g 8-hourly) provided effective, well tolerated monotherapy for patients with febrile neuropenia, equivalent to a regimen of ceftazidime plus amikacin. It is concluded that meropenem appears to be a realistic option for initial monotherapy in febrile neutropenic patients, providing therapy that is equivalent to a standard regimen of ceftazidime and amikacin.

[Treatment with oral antibiotics of febrile neutropenia in onco-haematology. The experience of the EORTC antimicrobial group]. / Traitement antibiotique oral des neutropénies fébriles en onco-hématologie. L'expérience du groupe antimicrobien de l'EORTC.

THE CONTEXT: Up until the nineties, the intravenous administration of a broad spectrum antibiotic was the classical treatment of any patient presenting with febrile neutropenia. Since then, in patients considered at low risk and with expected of neutropenia less than 7-10 days, oral antibiotherapy has become an attractive option. TWO LARGE STUDIES: A study by the antimicrobial group of the EORTC (European organisation for research and treatment of cancer) and a North American study have compared the efficacy of an oral combination of ciprofloxacine and amoxicillin/clavulanic acid with that of an intravenous antibiotherapy in low-risk patients presenting febrile neutropenia. In both studies, the success rate was the same in the group of patients treated with oral antibiotics and those treated with intravenous antibiotics. RESERVATIONS: These two studies were conducted in hospitalised patients. No conclusions can be drawn with regard to out-patient treatment. Out-patient management would only be possible after appropriate selection of patients at low risk.

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.

[Focus on beta-lactam antibiotics]. / Le point sur les antibiotiques beta-lactames.

The beta-lactams are mainly active on the bacterial cell wall. Although it was long claimed that their clinical efficacy was due to the bactericidal effect observed in vitro, it is now demonstrated that this effect cannot be the sole explanation for the therapeutic successes noted with these antibiotics in clinical situations. Several effects other than bactericidal are observed at subinhibitory concentrations and allow a better understanding of the activity of the beta-lactams. These are, among others, inhibition of bacterial growth, the post-antibiotic effect, the morphological effect, loss of virulent factors and decrease of adherence. --Following recent developments in the field of the beta-lactams, the new antibiotics exhibit a major broadening of their microbiological spectrum that in some cases allows simplification of antibiotic therapy: in some clinical situations monotherapy can be used instead of a combination. Some antibiotics have very good pharmacokinetic properties, allowing once-a-day dosage and outpatient treatment. --Finally, adverse drug effects such as neutropenia, hitherto considered infrequent, have been recognized more often. Explanation of their physiopathological mechanisms could favour the development of less toxic antibiotics.

[Cardiac contusions in nonpenetrating chest injuries]. / Les contusions cardiaques lors de traumatismes thoraciques non pénétrants.

Cardiac contusion is frequently seen after blunt chest trauma; it is often missed, and can cause serious complications. The incidence, features and outcome of cardiac contusion are described.

The use of aminoglycosides in neutropenic patients.

Aminoglycoside antibiotics are widely used for the empirical treatment of febrile neutropenic patients. They are administered in combination with beta-lactam antibiotics and sometimes with glycopeptide antibiotics. This review sets out to determine which patient populations are most likely to benefit from the administration of aminoglycoside antibiotics. In addition, the efficacy and safety of aminoglycoside antibiotics administered in a single daily dose are discussed in the light of a recent trial.

[Treatment of severe infections: should one always administer an aminoglycoside?]. / Traitement des infections sévères: faut-il toujours administrer un aminoglycoside?

Until recently, aminoglycoside antibiotics were the cornerstone for the treatment of severe infections. The rationale for using combination therapy containing beta-lactams and aminoglycosides was not only to broaden the antimicrobial spectrum but also to achieve enhanced bacterial killing by synergism and to prevent the emergence of antibiotic resistance. However, with the advent of new potent broad-spectrum and highly bactericidal antibiotics, the necessity of combining beta-lactams with aminoglycosides should be reassessed. This review questions the use of aminoglycosides in three severe infections frequently observed in intensive care units, nosocomial pneumonia, nosocomial sepsis and severe diffuse peritonitis. A review of the literature suggests that the addition of an aminoglycoside to a broad-spectrum beta-lactam does not improve the outcome in nosocomial pneumonia and severe diffuse peritonitis. However, the lack of large prospective studies in severe sepsis or septic shock makes it impossible to draw any conclusion about the addition of an aminoglycoside, and the administration of these agents must be decided on an individual basis.

Polyclonal intravenous immune globulin for prevention and treatment of infections in critically ill patients.

Infections remain the leading cause of death among patients admitted to intensive care units (ICU). Infections due to Gram-negative bacteria are both frequent and difficult to treat. The poor outcome of such infections has been attributed to the endotoxin. The high mortality rate related to Gram-negative sepsis has prompted the testing of new, adjunctive therapies to prevent and treat infections in critically ill patients. Immunotherapy or immunoprophylaxis have long been investigated in this context. Passive immunotherapy consists of the administration of immune plasma or serum, or standard or hyperimmune purified immune globulins. Several clinical studies using such preparations to treat critically ill patients are reviewed in this article. While two studies using hyperimmune plasma or serum appeared to be successful, two studies using hyperimmune globulin failed to show a beneficial effect in the treatment or the prevention of Gram-negative septic shock. Regarding the infusion of standard intravenous immune globulin (IVIG) two studies have demonstrated a substantial benefit in the prevention of severe infections; the reduction of nosocomial pneumonia recorded in both trials and the shortness of stay in ICU may also afford savings in hospital costs. The cost effectiveness of such prophylactic administration of IVIG is worthy of further investigation.