Kinetics of SARS-CoV-2-Neutralising Antibodies of Residents of Long-Term Care Facilities

INTRODUCTION

Elderly residents of nursing homes (NHs) and long-term care units (LTCUs) have been shown to have a high risk of mortality and morbidity in cases of SARS-CoV-2 infection. The objective of this study was to examine the kinetics of neutralizing antibodies (NAbs) directed against the SARS-CoV-2 virus in residents of the NH and LTCU units of our University Hospital who were identified with positive serology after the first epidemic outbreak.

MATERIALS AND METHODS

The participants included were sampled every three months for qualitative serological testing, as well as quantitative testing by neutralization tests using retroviral particles containing the S glycoprotein of SARS-CoV-2. Vaccination using the Comirnaty (Pfizer BNT162b2) vaccine begun before the last serological follow-up.

RESULTS

The median NAb titer in June 2020 was 80 [40; 60] versus 40 [40; 160] three months later, showing a statistically significant decline (p < 0.007), but remained stable between the three- and six-month timepoints (p = 0.867). By nine months after vaccination, we observed a significant difference between vaccinated residents known to have positive serology before vaccination (SERO+, Vacc+) and those vaccinated without having previously shown COVID-19 seroconversion (SERO-, Vacc+), the latter group showing similar titers to the SERO+, Vacc- participants (p=0.166). The median antibody titer in SERO+, Vacc+ patients increased 15-fold following vaccination.

DISCUSSION

Humoral immunity against SARS-CoV-2 appears to be persistent in elderly institutionalized patients, with a good post-vaccination response by residents who had already shown seroconversion but a notably diminished response by those who were seronegative before vaccination. To evaluate immunity in its entirety and elaborate a sound vaccination strategy, the cellular immune response via T cells specific to SARS-CoV-2 merits analysis, as this response is susceptible to being affected by immunosenescence.

The value of post-operative antibiotic therapy after laparoscopic appendectomy for complicated acute appendicitis: a prospective, randomized, double-blinded, placebo-controlled phase III study (ABAP study)

BACKGROUND

Approximately 30% of appendectomies are for complicated acute appendicitis (CAA). With laparoscopy, the main post-operative complication is deep abscesses (12% of cases of CAA, versus 4% for open surgery). A recent cohort study compared short and long courses of postoperative antibiotic therapy in patients with CAA. There was no significant intergroup difference in the post-operative complication rate (12% of organ/space surgical site infection (SSI)). Moreover, antibiotic therapy is increasingly less indicated for other situations (non-complicated appendicitis, post-operative course of cholecystitis, perianal abscess), calling into question whether post-operative antibiotic therapy is required after laparoscopic appendectomy for CAA.

METHODS/DESIGN

This study is a prospective, multicenter, parallel-group, randomized (1:1), double-blinded, placebo-controlled, phase III non-inferiority study with blind evaluation of the primary efficacy criterion. The primary objective is to evaluate the impact of the absence of post-operative antibiotic therapy on the organ/space surgical site infection (SSI) rate in patients presenting with CAA (other than in cases of generalized peritonitis). Patients in the experimental group will receive at least one dose of preoperative and perioperative antibiotic therapy (2 g ceftriaxone by intravenous injection every 24 h up to the operation) and metronidazole (500 mg by intravenous injection every 8 h up to the operation) and, in the post-operative period, a placebo for ceftriaxone (2 g/24 h in one intravenous injection) and a placebo for metronidazole (1500 mg/24 h in three intravenous injections, for 3 days). In the control group, patients will receive at least one dose of preoperative and perioperative antibiotic therapy (2 g ceftriaxone by intravenous injection every 24 h up to the operation) and metronidazole (500 mg by intravenous injection every 8 h up to the operation) and, in the post-operative period, antibiotic therapy (ceftriaxone 2 g/24 h and metronidazole 1500 mg/24 h for 3 days). In the event of allergy to ceftriaxone, it will be replaced by levofloxacin (500 mg/24 h in one intravenous injection, for 3 days). The expected organ space SSI rate is 12% in the population of patients with CAA operated on by laparoscopy. With a non-inferiority margin of 5%, a two-sided alpha risk of 5%, a beta risk of 20%, and a loss-to-follow-up rate of 10%, the calculated sample size is 1476 included patients, i.e., 738 per group. Due to three interim analyses at 10%, 25%, and 50% of the planned sample size, the total sample size increases to 1494 patients (747 per arm).

TRIAL REGISTRATION

Ethical authorization by the Comité de Protection des Personnes and the Agence Nationale de Sécurité du Médicament: ID-RCB 2017-00334-59. Registered on ClinicalTrials.gov (NCT03688295) on 28 September 2018.

Daptomycin versus Vancomycin as Post-Operative Empirical Antibiotic Treatment for Prosthetic Joint Infections: A Case-Control Study

Purpose: To compare safety and efficacy of Vancomycin (Van) versus Daptomycin (Dap) as post-operative empirical antibiotic treatment (PEAT) in patients with periprosthetic joint infections (PJIs).

Methods: Medical charts of patients treated empirically with Van or Dap in the post-operative period of total hip/knee prosthesis septic revision until the results of intra-operative culture were reviewed. Cefotaxime, cefepime or aztreonam were used in combination with Dap or Van.

Results: Twenty Dap patients were matched with 20 other Van patients according to the age and type of prosthesis. The ASA score and the distribution of the pathogens was similar in the two groups especially regarding the number of methicillin-resistant staphylococci. The mean duration of the PEAT was 6.07 ± 0.85 days. A total of 17 episodes of adverse events (AE) in 10 patients (25%) were recorded during the PEAT which led to discontinue the treatment in 5 patients, all of them treated with Van (P=0.02). At the end of a mean post-treatment follow-up of 618 +/- 219 days, 36 patients remained in remission of infection; 2 patients failed in each group.

Conclusions: Our observations suggest that PEAT with Van for septic revision of PJIs is associated with a higher discontinuation rate due to AE but with a similar outcome than it is with Dap.

[Ecology and fluoroquinolon resistance profiles in febrile urinary tract infections (FUTI) after prostate needle biopsy: A retrospective study in 466 biopsies]

OBJECTIVE

The biopsies of prostate are the reference examination to assert the diagnosis of prostate cancer. Even if the urinary infectious complications are rare thanks to the systematic oral antibiotic prophylaxis, they may still be serious. The SPILF (Society of Infectious Pathology and French language) published in 2014, an important increase of the resistances in fluoroquinolones for Escherichia coli (3 to 25%), whereas this is the most bacterium frequently found in the urinary infections (70-80%). The objectives of this study were to estimate the indicence of the febrile urinary tract infections after prostate needle biopsy and to define the ecology and the profile of E. coli's resistance.

METHODS

A total of 466 transrectal ultrasound-guided needle prostate biopsy were included in the study from 2012 to 2015. All the patients were taken care according to the recommendations of the AFU (Ouzzane et al., 2011). We estimated, for all the inclusive patients, if they had presented a clinic sign of urinary infection like fever or burning which suggestive of an urinary infection, and having a urines and blood culture, in the next 30 days the realization of the medical exam.

RESULTS

Among 466 realized biopsies, seven patients developed a febril urinary tract infection (1.5%) [prostatitis (n=6), orchitis (n=1)]. Five infections to E. coli were identified; two were resistant for fluoroquinolones (40%). No germ was able to be identified for two patients.

CONCLUSION

The infectious complications post-biopsy of prostate are rare (1.5%). E. coli is the germ most frequently identified with 40% of resistance with fluoroquinolones.

LEVEL OF EVIDENCE

4.

Factors associated with delayed screening of contacts of tuberculosis cases in the Somme, France

AIM

To analyze the factors associated with the time to initiating tuberculosis contact investigations in the Somme department, France.

METHODS

All reported tuberculosis cases and all their contacts screened between 2007 and 2011 were retrospectively included. Univariate and multivariate analyses were conducted to determine the factors associated with a "system delay"≤1 month and a "contact delay"≤0 days.

RESULTS

The mean time between the mandatory notification of a case of tuberculosis and the date set for the contact's screening (system delay) was 35.3 days and the average time between that date and when the contact was actually screened (contact delay) was 12.5 days. In multivariate analysis, a smear-positive sputum sample (OR: 3.68; 95% CI: 1.63-8.30) and a diagnosis at the university hospital (OR: 2.61; 95% CI: 1.14-5.96) were significantly associated with a system delay≤1 month. A smear-positive sputum sample (OR: 1.35; 95% CI: 1.08-1.69), male gender (OR: 1.21; 95% CI: 1.01-1.49), being born in a foreign country (OR: 1.31; 95% CI: 1.02-1.69), being a family member (OR: 1.37; 95% CI: 1.05-1.77), or being another type of close contact of the case (OR: 2.47; 95% CI: 1.81-3.36) were significantly associated with a contact delay≤0 days.

CONCLUSION

System and contact delays were longer than recommended, and the factors associated with the lengthening of these delays need to be taken into account.

Adult patients hospitalized for measles in France, in the 21st century

BACKGROUND

An epidemic of measles broke out in France in 2008. We designed a retrospective study focusing on adults hospitalized for measles in 2010/2011.

METHODS

A case was any patient aged more than 15 years, hospitalized (September 2010 to September 2011) with a typical rash or a biological diagnosis. Data was collected with standardized questionnaires in participating hospitals.

RESULTS

Four hundred and sixty cases were reported: sex-ratio (M/F) = 0.93, median age 26 years (σ = 8.8). Twenty-nine cases were severe (6.5%), 27 of which hospitalized in an ICU. Three hundred and twelve (68%) cases had elevated serum transaminases (EST), 155 (34%) cases had pneumonia, 34 (7%) cases had elevated serum creatinine (ESC), four (0.9%) cases had elevated serum amylase and lipase (ESAL), and three (0.7%) cases had neurological symptoms. One hundred and four (23%) patients presented simultaneously with EST and pneumonia. One patient presenting with severe pneumonia died (0.2%). One hundred and ten (24%) patients received antibiotics during a median seven days.

CONCLUSION

Measles can present as various syndromes in adults and be responsible for a high burden during outbreaks. The immediate outcome is favorable in most patients. Long-term outcome needs further investigations to identify possible late complications.

Prevention of healthcare-associated infections in general practice: current practice and drivers for change in a French study

PURPOSE

The fight against Healthcare-associated infections is a public health priority and a major challenge for the safety and quality of care. The objective was to assess hygiene in general practitioners' (GPs') office and identify barriers to and drivers for better practice.

MATERIALS AND METHODS

We performed a cross-sectional study in which a questionnaire was sent to a randomly selected, representative sample of 800 GPs. We used a self-administered questionnaire. The first part assessed current practice and the second part focused on barriers and motivating factors for better practice. We performed a descriptive statistical analysis of the responses to closed questions and a qualitative analysis of the responses to open-ended questions.

RESULTS

Only a third of the GPs were aware of the current guidelines. Disposable equipment was used by 31% of the GPs. For the remainder, only 38% complied with the recommended procedures for sterilisation or disinfection. Seventy-two percent of the GPs washed their hands between consultations in the office. A significant minority of physicians disregarded the guidelines by never wearing gloves to perform sutures (11%), treat wounds (10%), fit intrauterine devices (18%) or perform injections (18%). The main barriers to good practice were the high cost of modifications and lack of time/space. Two third of the GPs did not intend to change their practices. The drivers for change were pressure from patients (4.8 on a scale of 1 to 7), inspection by the health authorities (4.8) and the fear of legal action (4.4).

CONCLUSIONS

Our results show that there are significant differences between current practice and laid-down professional guidelines. Policies for improvement of hygiene must take into account barriers and motivating factors.

High rate of early virological failure with the once-daily tenofovir/lamivudine/nevirapine combination in naive HIV-1-infected patients

BACKGROUND

The combination of one non-nucleoside reverse transcriptase inhibitor (NNRTI) with two nucleoside reverse transcriptase inhibitors is a validated first-line antiretroviral (ARV) therapy. The once-daily combination of lamivudine, tenofovirDF and nevirapine has not been evaluated in a clinical trial.

METHODS

Randomized, open-label, multicentre, non-inferiority trial comparing lamivudine, tenofovirDF and nevirapine once daily (Group 2) with zidovudine/lamivudine and nevirapine twice daily (Group 1), in naive HIV-1-infected patients with a CD4 count <350/mm(3). We planned to enroll 250 patients.

RESULTS

As of May 2006, 71 patients had been enrolled (35 in Group 1 and 36 in Group 2) and an unplanned interim analysis was done. The groups were comparable at baseline: median CD4 count was 195 and 191/mm(3) and median plasma viral load was 4.9 log(10) and 5.01 log(10), respectively, in Groups 1 and 2. Eight early non-responses (22.2%) were observed, all in Group 2, while two later viral rebounds occurred. Resistance genotypes for the nine Group 2 failing patients showed the mutations M184V/I (n = 3), K65R (n = 6), one or more NNRTI resistance mutations in all cases. At baseline, the nine Group 2 patients who failed had higher median plasma viral load (5.4 log(10)) and lower median CD4 count (110/mm(3)) than the other Group 2 patients (4.7 log(10), P = 0.002 and 223/mm(3), P = 0.004). Nevirapine trough concentrations were not different between the two groups, nor between patients with full viral suppression or those who failed in Group 2. Due to slow recruitment, and those results, the steering committee decided to stop the trial at 12 months.

CONCLUSIONS

In ARV-naive HIV-1-infected patients, the once-daily lamivudine, tenofovirDF and nevirapine regimen resulted in a high rate of early virological failures. The reasons for the failures remain unclear.

[Bilharziasis caused by Schistosoma mansoni in a traveler returning from Guinea: failure of serodiagnostic testing]

The purpose of this report is to describe a case of febrile hypereosinophilic syndrome in a traveler three weeks after returning from a sightseeing trip to Guinea. Laboratory testing demonstrated an inflammatory response syndrome and hepatic cytolysis. Parasite serology led to suspicion of toxocariasis that was treated using albendazole. Follow-up tests at two months showed the presence of Schistosoma mansoni eggs in stools despite negative standard serodiagnostic testing (hemagglutination). Secondarily Western blot testing of serum samples at one, two and 14 months after returning from Guinea continued to show only protein bands specific to toxocariasis with no bands specific to bilhariziasis. These findings provide further evidence of the limitations of serological testing for detection of bilharziasis in travelers and the difficulty of diagnosis. Guinea is a high-risk tourist destination. Intestinal and urinary bilharziasis are endemic over three-fourths of country. Travelers planning even short stays in areas where bilharziasis is endemic should be advised on preventive measures.

Incidence of and risk factors for severe liver toxicity in HIV-infected patients on anti-tuberculosis treatment

OBJECTIVE

To assess the incidence and risk factors for severe liver toxicity in human immunodeficiency virus (HIV) infected patients on anti-tuberculosis treatment and the impact of patients' characteristics and concomitant medications instituted during the first week of antituberculosis treatment.

METHODS

HIV-infected patients referred to six French hospitals between 1 January 1992 and 31 December 2004, with confirmed or 'presumptive' tuberculosis (TB). Liver toxicity was studied during the first 2 months of TB treatment.

RESULTS

During the 12 years of the study period, 144 patients were enrolled. Severe liver toxicity developed in 15 (10.7%). The median time to development of liver toxicity was 14 days. In the univariate analysis, high baseline bilirubin levels (P = 0.004), CD4 cell counts between 50 and 100 cells/mm3 (P = 0.022) and the use of fluconazole (P = 0.0005) were associated with liver toxicity. In the multivariate analysis, independent risk factors were abnormal baseline alanine aminotransferase (ALT) (P = 0.028) and bilirubin levels (P = 0.033) and the use of fluconazole (P = 0.008).

CONCLUSION

Severe liver toxicity is frequent, and occurs early in the course of anti-tuberculosis treatment. ALT and bilirubin levels should be closely monitored during the first month of treatment, especially in patients with high baseline ALT or bilirubin levels. We suggest caution when prescribing fluconazole and anti-tuberculosis drugs concomitantly, although this needs to be confirmed and further investigated.

Community-acquired bacteraemic pneumococcal pneumonia in adults: effect of diminished penicillin susceptibility on clinical outcome

Pneumococcal pneumonia remains a common disease with a high mortality rate. Between 1995 and 2000, we prospectively analyzed 95 consecutive adult cases of community-acquired bacteraemic pneumococcal pneumonia treated in a single centre. The incidence of pneumococcal resistance to penicillin increased from 19 to 50% during the study period. Multivariate analysis showed that only age and recent hospitalization were independently associated with fatal outcome. The proportion of penicillin-resistant strains was slightly but not significantly higher among patients who died before the fourth hospital day than among those who died later. Patients who died before D4 were more likely to have a recent history of hospitalization, cancer and/or chemotherapy. It thus appears that infection by a resistant pneumococcal strain is not in itself a gravity factor in this setting, but that their acquisition is associated with pejorative clinical features.

[Evaluation of the efficacy of a multiresistant bacteria control programme in a teaching hospital, studying the evolution of methicillin-resistant Staphylococcus aureus incidence]

Methicillin-resistant Staphylococcus aureus (MRSA) constitute the most important multiresistant bacteria (MRB) recovered in French hospitals. Our objective was to measure these MRSA diffusion in our hospital to evaluate the MRB control programme which had been implemented in the beginning of 1999. This study was conducted in a teaching hospital containing 1800 beds, from February 1999 to January 2001. All MRSA isolated in clinical samples were included. Duplicates (same bacteria in the same patient) were excluded. The detection of methicillin-resistance was performed at 30 degrees C, by disk diffusion method. Incidence densities were determined with their 95% confidence interval (CI 95%). Their evolution by four-month period was evaluated with the chi-square test for trend. During the two-year period, 866 MRSA were isolated. The global incidence was 0,88 per 1000 patient-days (PD) (IC 95% = left open bracket 0,83-0,93 right open bracket ). For cases acquired in our hospital the incidence was 0,66 per 1000 PD, whereas it was 0,26 per 1000 PD for imported cases. Concerning the evolution of incidences, no significant trend was observed for global incidence. The incidence of acquired MRSA decreased during the first year, but increased thereafter. The incidence of imported MRSA increased with a significant trend (p < 10(-5)). The number of these imported MRSA isolated in our hospital was twice fold higher in 2000. This study emphasizes an important actual problem : the increase of patient colonization pressure at the time of admission in hospitals. This increase, which can be due in part to a community transmission, is responsible for a reduction of the efficacy of MRSA control programmes.

Iliac muscle abcess and staphylococcal metastatic infection in a diabetic patient

We report the case of a 44-year-old obese diabetic woman admitted for fever. Blood cultures grew Staphylococcus Aureus and antibiotherapy was started. Iliac abscess was diagnosed and surgical drainage done. Clinical evolution was marked by metastatic dissemination: sacroiliac osteolysis, right shoulder osteoarthritis, spondylitis of the third lumbar vertebra and pulmonary localizations. This case-report shows diagnosis and treatment difficulties of an iliac muscle abscess with metastatic localization in a diabetic patient.

[Atypical cutaneous leishmaniasis]

French Guyana is an endemic area for American cutaneous leishmaniasis. At the start, the initial red lesion may be mistaken for a whitlow. Twenty percent of developed forms exhibit a sporotrichosis pattern. The notion of travel to an endemic area is very important for diagnosis. We report the case of a young man from French Guyana presenting with a cutaneous lesion of the finger. After numerous surgical treatments for a "whitlow", the final diagnosis of leishmaniasis was difficult because of local-complications and cutaneous rearrangement. Erroneous initial orientation in a unit unaware of tropical diseases can forestall appropriate care of the patients. Epidemiological, clinical and therapeutic data on American tegument leishmaniasis are discussed.

Determinants of transfusion-associated bacterial contamination: results of the French BACTHEM Case-Control Study

BACKGROUND

Transfusion-associated bacterial contamination (TABC), probably the most frequent transfusion-transmitted infection, may induce serious adverse events. Systematic information and documentation on determinants are lacking.

STUDY DESIGN AND METHODS

The BACTHEM Study is a French matched case-control study assessing TABC determinants. Included were cases of TABC reported in France in a 2-year period, as determined from uniform definitions. Information on recipient-, blood component-, and donor-related potential determinants was collected on site. ORs were estimated by conditional logistic regression.

RESULTS

Of the 158 cases of suspected TABC reported, 41 that involved transfusion with 25 RBCs and 16 platelet concentrates were included. Gram-negative rods accounted for nearly half of the bacteria species involved and for all six deaths. In comparison with the risk of TABC for patients receiving RBCs for anemia, the risk was higher for patients receiving RBCs for pancytopenia (OR, 7.3; 95% CI, 1.3-41.0) and for those receiving platelets for thrombocytopenia (OR, 5.3; 95% CI, 1.2-24.1). Other potential determinants were platelet transfusion for pancytopenia (OR, 4.5; 95% CI, 0.5-40.0), immunosuppressive treatment (OR, 2.8; 95% CI, 0.7-10.6), shelf-life of more than 1 day for platelets or 8 days for RBCs (OR, 2.6; 95% CI, 0.7-9.6), and more than 20 previous donations by donors (OR, 1.9; 95% CI, 0.7-5.3).

CONCLUSION

This first comparative study revealed TABC determinants that suggest approaches for prevention.

[A prospective study on erysipelas and infectious cellulitis: how are they dealt within hospital?]

771 cases of erysipelas and 52 cases of infectious cellulitis were collected over 3 months in a prospective study carried out in French hospitals. The mean age was 62.7 +/- 19.3 years for the erysipelas patients and 69.7 +/- 16 years for the cellulitis patients. Sex-ratios were respectively 0.92 and 2.7. The infection was mainly localized in the lower limbs in both categories (90.9 p. 100 and 71 p. 100); the upper limbs and the face were more often involved in cellulitis than in erysipelas (13 p. 100 versus 5.2 p. 100 and 10 p. 100 versus 2.5 p. 100). Penicillin G was the initial antimicrobial treatment in 45 p. 100 of the erysipelas cases, whereas amoxicillin-clavulanic acid was used in 32.7 p. 100 of the cellulitis cases. Other antibiotics used were pristinamycin, antistaphylococcal penicillin, and amoxicillin. Combinations of antibiotics were used to treat 50 p. 100 of the cellulitis cases but only 11 p. 100 of the erysipelas cases. Anticoagulants were used in 67.4 p. 100 of the erysipelas cases and in 59.7 p. 100 of the cellulitis cases. Surgery was performed in 52 p. 100 of the cellulitis cases, and hyperbaric oxygen in 4.2 p. 100. The outcome was quite different for the 2 diseases: cure rate without complications reached 86.6 p. 100 for erysipelas, and only 48.1 p. 100 for cellulitis; death rates reached respectively 0.77 p. 100 and 5.7 p. 100, median length of hospitalization 8 days and 21 days, and median length of antibiotic treatment 15 days and 21 days.

[Dealing with bacterial hypodermal infection in general practice: an inquiry and a prospective study]

OBJECTIVE

The author had for aim to collect data on how general practitioners deal with bacterial hypodermal inflammation.

MATERIAL AND METHODS

An enquiry on practice and a prospective study were carried out over 3 months.

RESULTS

The mean number of cases reached 0.54 per physician over the 3-month period, for a total of 103 cases of bacterial hypodermal infection. The patients'mean age was slightly superior to 60 years, with a high female predominance and a preferential site of infection located in the lower limbs (89.6 p. 100 of the cases). 20 p. 100 of the patients were immediately sent to hospital, mainly because of the importance of local and/or general symptoms, and of the underlying conditions. In home care, antibiotic therapy was almost always oral and consisted in courses of group A penicillin or pristinamycin in over half of the cases, for a mean duration of 12.4 days for erysipelas, and 9.1 days for cases classified as "other type of bacterial hypodermal infection". An anticoagulant treatment was associated in close to 30 p. 100 of the cases, and anti-inflammatory or corticoids agents were prescribed in 17.9 p. 100 of the cases. The cure rate among home care patients reached 89.3 p. 100 and only 3 patients were hospitalized after the initial treatment; these 3 patients had all been given non-steroidal anti-inflammatory agents.

Evaluation of the contribution of isolation precautions in prevention and control of multi-resistant bacteria in a teaching hospital

From February 1999 to January 2000, a control programme to prevent the spread multi-resistant bacteria (MRB) was implemented in a French teaching hospital. This programme focused on methicillin-resistant Staphylococcus aureus (MRSA) and Enterobacteriaceae producing extended-spectrum beta-lactamases (ESBL), and was based on the application of barrier precautions (washing hands with antiseptic soaps, wearing disposable gloves and gowns, identifying MRB carriers). No changes in antibiotic policy occurred during the year. Our aim was to conduct an evaluation of this programme by measuring incidence rates. Concurrently, the effect of barrier precautions was estimated in an indirect way, by documenting the availability of barrier precautions in MRB carriers' rooms and by analysing the monthly correlation between the supply of such material and the theoretical cumulated length of MRB carriers' isolation in six randomized wards. All MRB isolated in hospitalized patients were recorded, and differentiated between acquisition in our hospital or from elsewhere. For the analysis of trends, the year was divided in three periods of four months. Over the year, the global MRB incidence was 1.26 per 1000 patient-days (PD) [95% confidence interval (95%CI)=1.16-1.36]. The MRSA incidence was 0.89 per 1000 PD (95%CI=0.81- 0.97) and the ESBL incidence was 0.38 per 1000 PD (95% CI=0.33-0.43). The MRB incidence decreased significantly in all types of specialties except for surgical wards. The incidence decreased by 17.9% for MRSA, 54.9% for ESBL and 34.8% for both MRB. Concurrently, the proportion of strains acquired in our hospital decreased for MRSA (P for trend > or = 0.05) and ESBL (P for trend > or = 0.01), whereas the incidence of imported strains increased slightly. The proportion of multiresistant strains in S. aureus (36.8%) and Enterobacter aerogenes (37.0%) remained similar throughout the year. Thus, the decrease of the incidence concerned both resistant and susceptible strains. The availability of antiseptic soaps increased significantly (P for trend > or = 0.01). The amount of antiseptic soap ordered and the theoretical lengths of isolation were correlated on a monthly basis (Spearman coefficient = 0.72; P > or = 0.02). These results shows the efficacy of such a programme of MRB containment in a large hospital, provided barrier nursing is instigated, together with the availability of such material as antiseptic soap, to allow implementation.

Determination of the endothelin receptor antagonist ABT-627 and related substances by high performance liquid chromatography

The determination of the endothelin (ET) antagonist receptor ABT-627 (I) and related substances is performed by HPLC. I is determined in bulk drug substance and drug formulation using isocratic conditions and an Inertsil ODS-2 column. The determination is stability indicating and detector response is linear from 24 to 118 microg ml(-1) (33-164% of assay level). Intermediate precision for the determination ranged from +/- 0.60 to +/- 1.9% RSD. The measurement is accurate, with quantitative recovery of I from the formulation placebo. Related substances in I and formulated I are determined using the same chromatographic conditions, with a gradient elution profile to elute impurities having varying relative polarities. The detector response for related substances determination is linear for I from 0.60 to 17.8 microg ml(-1) (0.05-1.5% of assay level) with the limit of detection and quantitation estimated at 0.01 and 0.05%, respectively. Comparable precision was obtained in drug substance and drug formulation (RSD values +/- 3.7 to +/- 12% and +/- 5.5 to 16.9%, respectively for impurities ranging from 0.05 to 0.30%). The quantitated impurities agreed well for the same lot of I when assayed as a bulk substance and after the formulation into a drug product.

Utility of blood cultures in community-acquired pneumonia requiring hospitalization: influence of antibiotic treatment before admission

It has been previously shown that antibiotics given before hospitalization significantly reduce the proportion of positive blood cultures in community-acquired pneumonia (CAP). The aim of this prospective study was to compare the utility and cost-benefits of blood cultures in patients, hospitalized for moderate CAP, who had or had not received antibiotic therapy prior to admission. During 1 year, 53 patients were included and separated into two groups: group 1 patients had not received antibiotic treatment prior to admission (n = 30), whereas group 2 patients had been treated with antibiotics (n = 23). Within the first 48 hours, a set of blood cultures was collected if the body temperature was higher than 38.5 degrees C or in the case of shaking chills. A total of 136 blood cultures was collected; 74 in group 1 and 62 in group 2. Bacteraemia was significantly more frequent in group 1 than in group 2, 5/30 patients vs. 0/23, respectively (P < 0.05). The cost of negative blood cultures was valued at 13,939.2 FF in group 1 and 13,164.8 FF in group 2, respectively 464.6 +/- 244.3 FF and 569.3 +/- 233.4 FF per patient (n.s.). Moreover, blood cultures were the method of diagnosis in only one of the five patients with bacteraemia and in no case did a positive blood-culture result influence the initial therapeutic regime. Thus, our results suggest a reduced clinical utility and cost-benefit of blood cultures in patients hospitalized for moderate CAP who have received an antibiotic treatment prior to admission.

[Direct cost of antibiotic therapy prescribed for nosocomial bacteremia. Prospective study during 6 months at a CHU (University Hospital Center)]

A six-month prospective study of costs associated with antimicrobial therapy in nosocomial bacteremia was conducted from November 1, 1995 to April 30, 1996 in a 1837-bed teaching hospital, with the help of the hospital pharmacists and hospital hygiene unit. Only the costs due to the antimicrobials themselves were taken into account. A total of 238 cases of nosocomial bacteremia occurred during the study period. The total direct cost of antimicrobial therapy was 444,931 French francs (FF), i.e., 6.8% of total expenditures for antimicrobials. Mean cost per case was 1869 FF, and was 2.6-fold higher in the 21 patients with bacteremia due to more than one organism (P = 0.03). CAses with an identifiable portal of entry contributed 75% of the total cost. Portals of entry associated with the highest cost included central venous lines (103,928 FF) and urinary tract infections (50,810 FF). Although 20% of nosocomial bacteremias due to coagulase-negative staphylococci did not lead to antimicrobial therapy, the remaining 80% contributed 40.8% of the total cost, followed by nosocomial bacteremias due to Escherichia coli with 19.7% of the total cost. Thirty-seven patients (15.5%) did not receive specific antimicrobial therapy, for the following reasons: death before treatment initiation, transfer to another hospital, antimicrobial therapy initiated earlier for another infection elsewhere in the body due to a different organism, or other form of treatment. The results of this study highlight the need for prevention.

Polymerization of composite resins: argon laser vs conventional light

The purpose of this in vitro study was to compare polymerization of composite resins, as indicated by microhardness, at increasing depths using an argon laser versus a conventional light. For this, a microfill (Silux Plus) and a hybrid (TPH) composite resin were used. Five specimens per group were prepared by injecting composite into a rectangular split Teflon mold 3 x 3 x 8 mm. Specimens were then polymerized by either a 40-second exposure to the conventional visible light (VL) or a 30-, 20-, or 10-second exposure to the argon laser (AL). Specimens were stored in a light-proof container for 24 hours at 37 degrees C, then Knoop hardness was determined. Four measurements were taken for each specimen at depths of 0, 1, 2, 3, and 4 mm from the exposed surface. No significant differences were found in surface hardness for either the microfill or hybrid composite regardless of light source or exposure time. For the microfill composite, at 1, 2, 3, and 4 mm depths, VL40 and AL30 exposures produced comparable hardness, which was significantly greater than that found for AL20 and AL10. At a depth of 4 mm, exposure to VL40 resulted in significantly greater hardness compared to AL20. With AL10 exposure, the composite was too soft to determine hardness. The hybrid composite had comparable hardness to a depth of 3 mm for VL40, AL30 and AL20.

[Outcome of cardiac valve ring abscesses after medical treatment: attempt to identify criteria of favorable prognosis]

OBJECTIVES

Identify factors predicting favorable outcome after medical management of valve ring abscesses in order to propose a surveillance schedule for conservative treatment.

METHODS

A multicentric study conducted from July 1989 to February 1996 included 28 patients (mean age 64 +/- 16 years, range 26-83) hospitalized for active endocarditis and valve ring abscesses diagnosed at transthoracic or transesophageal echography. Conservative medical therapy was given because of a decision of the medico-surgical team (n = 9), high surgical risk (n = 12), or patient refusal of surgery (n = 7). Outcome was favourable in 18 patients (Group I) and unfavorable in 10 (Group II) due to death (n = 9) or subsequent surgery (n = 1). Univariate and multivariate analysis were used to determine differences between the groups in terms of clinical and laboratory data.

RESULTS

Mean follow-up in Group I was 33 +/- 18 months and 15 +/- 10 months in Group II. Univariate analysis showed significant differences between Group I and II respectively for age (59 +/- 18 yr vs 72 +/- 10, p = 0.04), delay to apyrexia after antibiotics (4.3 +/- 2.8 vs 8.3 +/- 2.4 days, p < 0.0008), heart failure (5% vs 70%, p = 0.003), grade III or IV valvular regurgitation (5% vs 60%, p < 0.04), and mean surface area of the abscess (1.5 +/- 1.2 vs 5.4 +/- 6.4 cm2, p < 0.03). Independent factors at multivariate analysis were by decreasing order: lack of heart failure at admission, delay to apyrexia, abscess surface area, and age. Outcome was favorable (mean follow-up 33 +/- 10 months) in all patients with an abscess surface area < 1.5 cm2, no signs of heart failure, no grade III or IV valvular regurgitation, apyrexia after less than 8 days on antibiotics and no staphylococcus positive blood culture.

CONCLUSION

Medical management of valve ring abscesses may be indicated in selected patients in care units with rigorous surveillance facilities. Further studies are needed to precisely identify surveillance and treatment criteria.

[Convulsions associated with the administration of excessive dose of ceftazidime in patients with renal failure]

Central neurological diseases caused by beta-lactamins are usually associated with excessive dosages in patients with renal failure. Two case reports of convulsive encephalopathy in patients treated with ceftazidime, show the absolute necessity of adapted posology, in case of renal dysfunction. In one case, we could follow plasma levels of ceftazidime during hemodialysis, and calculated the pharmacokinetic parameters. We conclude that extra renal epuration is an efficient technique in case of acute ceftazidime intoxication.

[Neurologic side effects of fluoroquinolones. Apropos of 9 cases concerning pefloxacin]

Neurological side-effects were a limiting factor with older quinolones. Although they appear to be less frequent with the newer fluoroquinolones, we observed nine such cases at Amiens University Hospital over a four-year period. The patients were six women and three men, with a mean age of 61 years. They received a mean dose of 800 mg/day of pefloxacin. Four had septic shock, one left ventricular failure, and seven had signs of cholestasis (signs of liver failure were absent). Neurological manifestations occurred between 24 hours and seven days after starting treatment and disappeared within 24 to 48 hours of stopping the drug or reducing the dosage. They included myoclonia (3 cases), convulsions (2 cases, one with concomitant theophylline), delirium and agitation (2 cases, one in a patient on steroids) and confusion (3 cases). Plasma drug levels were determined in six patients and were above normal peak levels (10 micrograms/ml) in five. Pefloxacin was measured in the cerebrospinal fluid in two cases (8.7 and 15.0 micrograms/ml). Neurological manifestations during pefloxacin treatment are probably related to overdose (plasma levels were above normal in 5/6 cases), possibly being favoured by cholestasis (7/9 cases) and/or hemodynamic factors (5/9). Symptoms can resolve when the pefloxacin dosage is reduced.

Efficacy of teicoplanin for enterococcal infections: 63 cases and review

Sixty-three cases of monomicrobial enterococcal infections treated with teicoplanin in two open clinical studies in Europe from 1982 to 1989 are presented. Infections were documented as endocarditis (n = 18); septicemia (n = 8); and urinary tract (n = 29), skin/soft-tissue (n = 6), or bone/joint (n = 2) infections. A total of 63 enterococcal strains were isolated; all of 29 strains tested were susceptible to teicoplanin (geometric mean MIC, 0.16 micrograms/mL; range, 0.06-0.5 micrograms/mL). Forty-eight patients were treated with teicoplanin alone and 15 were treated with teicoplanin in combination with an aminoglycoside. The rate of clinical cure was 84.1%; 4.8% of patients clinically improved, 7.9% had clinical recurrence, and 3.2% did not respond to therapy. Bacteriologic eradication was observed in 87.2% of patients; persistence, in 3.2%; recurrence, in 3.2%; and reinfection, in 4.8%. One case was not evaluable bacteriologically. Of 18 patients with endocarditis, 15 were cured with a mean daily dose of 5.4 mg/kg--six with monotherapy and nine with combination therapy. All patients with urinary tract infections were treated with monotherapy, and 89.7% were cured (mean daily dose, 4.6 mg/kg). Lower rates of clinical cure and bacteriologic eradication were observed in septicemic patients without endocarditis (62.5%). This study demonstrated a good efficacy of teicoplanin for the treatment of enterococcal infections due to susceptible strains, but further clinical studies would be useful for establishing optimal dosage and the indications for combination therapy, especially for severe infections.

The clinical significance of antibiotic-associated pseudomembranous colitis in the 1990s

Antibiotic-associated pseudomembranous colitis is an uncommon but potentially serious adverse reaction, resulting in acute diarrhoea and characterised by colonic pseudomembranes. A direct relationship between the disease, recent antibiotic therapy and proliferation of Clostridium difficile in the colonic lumen was established in the late 1970s. It is thought that antibiotic therapy may alter the enteric flora, enabling C. difficile to proliferate and produce toxins with cytopathic (toxin B or cytotoxin) and hypersecretory (toxin A or enterotoxin) effects on the mucosa. Apart from clindamycin, the first antibiotic recognised to be clearly associated with pseudomembranous colitis, the antimicrobial agents most commonly responsible are cephalosporins and ampicillin (or amoxicillin). However, virtually all antibiotics except parenterally administered aminoglycosides can cause the disease. Vancomycin and metronidazole, 2 drugs used to treat antibiotic-associated pseudomembranous colitis, have also been reported to be responsible for the complication when used parenterally. Pseudomembranous colitis may develop after perioperative prophylactic antibiotic therapy with cephalosporins. Antibiotic-associated pseudomembranous colitis is most frequent in elderly and debilitated patients and in intensive care units. Nosocomial acquisition of C. difficile has been documented. Therefore it has been recommended that enteric isolation precautions should be taken with patients with this disease. The clinical symptoms include watery diarrhoea, abdominal cramping, and frequently fever, leucocytosis and hypoalbuminaemia. Toxic megacolon and acute peritonitis secondary to perforation of the colon are the most serious complications. The pseudomembranes are usually seen during endoscopic procedures, sigmoidoscopy or, if possible, colonoscopy; the most useful microbiological tests for confirmation of the diagnosis include cycloserine cefoxitin fructose agar (CCFA) stool cultures and stool toxin assays on tissues or by immunological techniques. However, cultures and toxin tests may be positive in patients without pseudomembranous colitis or C. difficile-associated diarrhoea. Mild cases may respond to discontinuation of the drug responsible, but therapy with an anticlostridial antibiotic is often necessary: a 10-day course of oral vancomycin, metronidazole or bacitracin should be given. Relapses are seen in 5 to 50% of patients treated. Antibiotic treatment should avoid sporulation leading to other relapses. 'Biotherapy' (lactobacilli, Saccharomyces) has also been proposed.

Pharmacokinetics of single-dose intravenous, oral, and intraperitoneal pefloxacin in patients on chronic ambulatory peritoneal dialysis

Comparison of plasma and dialysate concentrations of pefloxacin after intravenous, oral, or intraperitoneal administration shows excellent bidirectional diffusion of the quinolone through the peritoneal membrane, demonstrating that therapeutical concentrations can be achieved in the dialysate after intravenous or oral administration. In this study, the half-life of the drug was 18.8 +/- 1.4 h, i.e., apparently longer than that reported for normal controls or uremic patients on hemodialysis.

[10 fatal endocarditis: autopsy observations, causes of death]

Among 841 autopsies realized between january 1982 and september 1988, by the Pathological the department of Amiens University Hospital the ten patients dead of infectious endocarditis have been autopsied. Macroscopic and microscopic observations have two cases of acute endocarditis and eight of subacute endocarditis. For the two patients dead of acute endocarditis, autopsy affirms the cardiovascular etiology of death. For the eight cases of subacute endocarditis, necropsic findings differs from the germs. In the three cases where the germ is a Staphylococcus aureus, the diagnosis of endocarditis was made before death and the cardiovascular etiology of death was affirmed by autopsy. For the other germs (3 Streptococcus sp, 1 Salmonella typhimurium, and 1 germ unknown), the diagnosis of endocarditis was made by autopsy, but necropsy disclosed the cause of death in only two cases.

[Nosocomial infections caused by intravascular catheters]

In intensive care units nosocomial infections associated with intravascular catheters are an important cause of morbidity. Infection is essentially due to the implantation of cutaneous pathogens and to the contamination of infusion line components by manipulations. The risk of infection therefore mainly depends on the way the catheter is handled and on the duration of catheterization. The diagnosis of infection rests on clinical observation of the patient and on a semi-quantitative study of the catheter. Preventing such infections requires strict asepsis of the skin when the catheters is introduced and while it is maintained in situ and changes of infusions lines and of the catheter itself. These changes must be particularly frequent when the catheter is manipulated and when the patient is already infected prior to catheterization.

[Infections caused by central venous catheterization at intensive care units]

All different types of catheters can induce localized (subcutaneous) or systemic sepsis. Infection rates of 7 to 20% have been reported in the literature; catheter infection results from bacterial colonization of the skin, colonization of the line or may be secondary to blood born seeding. In a one year prospective study of 56 catheters in our unit, the rate of systemic infection was 5.3%, insertion site infection 3.6%, and contamination without infection 25%. No catheter with less than 10(2) colonies on a semi-quantitative culture method was infected. Prevention of catheter related sepsis needs strict aseptic protocols, and short duration of catheterization, antiseptic wrapping of the line; antimicrobial filtersets may further reduce the infection risk.

[Treatment of post-traumatic and post-neurosurgical bacterial meningitis with ceftriaxone alone or in combination with fosfomycin]

From 1984 to 1986, 13 patients (10 adults, 3 children) with bacterial meningitis following neurosurgery or traumatism were given ceftriaxone alone 6 times at a dose of 40 mg/kg one IV injection per day, or in association 7 times with fosfomycin at a dose of 200 mg/kg/day, 3 IV perfusions every 4 h. The bacteriological diagnosis was confirmed in 9 cases (3 Staphylococcus aureus, 4 Streptococcus pneumoniae, 1 Klebsiella, 1 Peptococcus). In vitro neither synergy nor antagonism were observed between the two antimicrobial agents. The acute infections episode resolved in all patients except on who died with a negative CSF culture. One superinfection meningitis with Achromobacter was seen. CSF concentrations of ceftriaxone were assayed and found to be comparable with those reported by most authors. Tolerance was excellent for all our patients.

[Clinical evaluation of timentin in intensive care]

16 patients admitted to a MICU were treated with timentin (ticarcillin + clavulanic acid) for bacterial infections: 11 cases of pulmonary infection, 3 cases of urinary tract infection, 2 septic shocks, 3 septicemias and 1 case of multifocal infection. The pathogens considered as a firmly established cause of infection were: 5 Acinetobacter, 12 Pseudomonas, 3 Serratia, 4 Klebsiella, 1 E. coli, 2 Proteus, 1 Providencia, 1 Staphylococcus aureus, 1 Staphylococcus epidermidis, 1 Streptococcus D and 1 Flavobacterium meningosepticum. The susceptibility of these pathogens to ticarcillin and timentin is reported. Timentin was prescribed alone in 9 cases and associated (with an aminoglycoside) in 7, in a daily dose of 9 to 18 g, for 6 to 45 days. 3 patients died. The value of timentin in infections due to multiresistant MICU pathogens is stressed.