Agreement of respiratory viruses' detection between nasopharyngeal swab and bronchoalveolar lavage in adults admitted for pneumonia: a retrospective study

OBJECTIVES

The COVID-19 pandemic has highlighted the high diagnostic accuracy of the nasopharyngeal swab (including in intensive care unit (ICU) patients). This study aimed to compare nasopharyngeal swab and bronchoalveolar lavage (BAL) results for non-SARS-CoV-2 viruses in patients with suspected pneumonia.

METHODS

A retrospective analysis was performed in one French academic hospital on consecutive adults from 2012 to 2018 and tested nasopharyngeal swab and BAL within 24 hours by using multiplex PCR. The agreement in pathogen detection between nasopharyngeal swab and BAL was evaluated.

RESULTS

Patients were primarily men (n = 178/276, 64.5%), with a median age of 60 years (IQR: 51-68 years). Of the 276 patients, 169 (61%) were admitted to the ICU for acute respiratory distress. We detected at least one respiratory virus in 34.4% of the nasopharyngeal swabs (n = 95/276) and 29.0% of BAL (n = 80/276). Two or more viruses were detected in 2.5% of the nasopharyngeal swabs (n = 7/276) and 2.2% of BAL (n = 6/276). Rhinovirus/enteroviruses were the most frequently detected viral group in 10.2% (n = 29/285) of the nasopharyngeal swabs and 9.5% (n = 27/285) of BAL, followed by influenza A, detected in 5.6% (n = 16/285) of the nasopharyngeal swabs and 4.9% (n = 14/285) of BAL. Overall agreement was 83.7% (n = 231/276 (95% CI [78.7%, 87.7%])) (i.e. same pathogen or pathogen combination was identified in the nasopharyngeal swab and BAL for 231 patients). Rhinovirus/enterovirus (n = 29/231) and respiratory syncytial virus (n = 13/231) had the lowest agreement of 62.1% (n = 18/29 (95% CI [42.4%-78.7%])) and 61.5% (n = 8/13 (95% CI [32.3%-84.9%])), respectively).

CONCLUSIONS

There was a good agreement between nasopharyngeal swabs and BAL in detecting respiratory viruses among adult patients with suspected pneumonia. However, these data still encourage BAL in the case of a negative nasopharyngeal swab.

Individual and collective impact of Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae in patients admitted to the ICU

KPC-producing Klebsiella pneumoniae (KPC-Kp) raises major concerns in the context of intensive care, owing to limited treatment options and the ability to cause outbreaks in this specific setting. The objectives of this review are to give an overview of the burden of KPC-Kp in ICU patients and to discuss methodological issues and limitations regarding the quality of data available. Robust and reliable assessment of the KPC-Kp impact in the ICU should take into consideration not only characteristics of the individuals, but also of the health systems including length of stay, costs and hospital organization issues. Estimates of mortality reported in the current literature are weakened by the poor quality of adjustment for age-specific risks, co-morbidities, and appropriateness of therapy. All these confounding factors should be taken into account in models, with consideration of control groups and competing risks that is currently lacking in the published literature. Since development of antibiotic resistance is an unstoppable phenomenon and economic and human resources are facing progressive limitations due to budget constraints, cost-saving strategies targeted to avoid ICU closure, temporary limitation of admissions or delayed hospital discharge are necessary. The early identification of KPC-Kp-colonized patients through active screening strategies is likely to be the cornerstone of such a cost-saving strategy. However, there are still many open issues concerning which of these strategies are the most effective. Owing to extreme heterogeneity and several methodological flaws in current publications, future studies investigating the long-term sequelae and economic impact of KPC-Kp in the ICU are urgently needed.

Prescribers' experience and opinions on antimicrobial stewardship programmes in hospitals: a French nationwide survey

OBJECTIVES

To assess prescribers' experiences and opinions regarding antimicrobial stewardship programme (ASP) activities.

METHODS

A cross-sectional paper-based survey was conducted among prescribers in 27 out of 35 randomly selected large hospitals in France.

RESULTS

All 27 investigated hospitals (20 non-university public, 4 university-affiliated and 3 private hospitals) had an ASP and an appointed antibiotic advisor (AA), with a median of 0.9 full-time equivalents per 1000 acute-care beds (IQR 0-1.4). Of the 1963 distributed questionnaires, 920 were completed (46.9%). Respondents were mainly attending physicians (658/918, 71.7%) and medical specialists (532/868, 61.3%). Prescribers identified two main ASP objectives: to limit the spread of resistance (710/913, 77.8%) and to improve patient care and prognosis (695/913, 76.1%). The presence of an AA constituted a core element of ASP (96.2% agreement between answers of ASP leader and respondents). Respondents acknowledged an AA's usefulness especially on therapeutic issues, i.e. choosing appropriate antibiotic (agreement 84.7%) or adapting treatment (89.6%), but less so on diagnostic issues (31.4%). Very few respondents reported unsolicited counselling and post-prescription controls. Three-quarters of prescribers identified local guidelines (692/918, 75.4%). Prescribers did not approve of measures counteracting their autonomy, i.e. automatic stop orders (agreement 23.4%) or pre-approval by AAs (28.8%). They agreed more with educational interventions (73.0%) and clinical staff meetings (70.0%).

CONCLUSIONS

Prescribers perceived ASP mainly through its 'on-demand' counselling activities. They preferred measures that did not challenge their clinical autonomy. High levels of antibiotic consumption in French hospitals bring into question the effectiveness of such an approach. However, limited ASP staffing and resources may preclude extended activities.

Factors associated with single-room assignment among patients admitted through the emergency department during influenza epidemics

INTRODUCTION

Every winter, emergency departments (EDs) face overcrowding with patients presenting influenza-like symptoms, and organisational issues such as single room assignment and droplet precautions to avoid hospital-acquired influenza. Our main objective was to assess the impact of PCR results and patient's severity on single room assignment.

METHODS

All patients admitted to Bichat-Claude Bernard Hospital through the ED and tested for influenza by PCR (GenXpert, Cepheid) or (FilmArray, BioMérieux) on a nasopharyngeal swab were retrospectively included during three influenza seasons (2015-2018.

RESULTS

Of 1,330 included patients, 278 (20.9%) had a positive PCR for influenza. The median time to obtain a PCR result was 19 hours, and 238 (18.3%) patients were assigned a single room. Among patients with positive and negative influenza PCR, 22.3% and 16.7% were assigned a single room (p = 0.03). The multivariable analysis was performed on the two first epidemic periods, excluding the third epidemic because of the concomitant use of influenza immune-chromatic test. Only level 1 of the Emergency severity index (ESI) (aOR, 1.9; 95% CI, 1.3-2.8; p < 0.01) was associated with single-room assignment. PCR result was not statistically associated with the decision of single room assignment (aOR, 1.4; 95%CI, 1.0-1.4; p = 0.07).

CONCLUSION

A PCR positive for influenza was not significantly associated with single-room assignment. Less than one quarter of influenza patients were adequately assigned a single room, likely due to the long turnaround time of PCR result and other conflicting indications for single room-assignment. Accelerating biological diagnosis could improve single-room assignment.

Bathroom contamination by antibiotic-resistant Enterobacterales (ESBLPE and CPE): an experimental study

BACKGROUND

Extended-spectrum β-lactamase-producing Enterobacterales (ESBLPE) and carbapenemase-producing Enterobacterales (CPE) cause serious infections. Their presence in urine may lead to environmental contamination potentially responsible for cross-transmission.

AIM

To evaluate the level of spraying and contamination after emptying urine in the toilet and rinsing in the sink, a common practice in the healthcare setting.

METHODS

For each test, the procedure was similar: seat raised, emptying urinal bottle into the toilet at the height of the bowl, rinsing in the sink and flushing. To study splash-drops, water and fluorescein were mixed in the urinal bottle. In each area, the splash-drops frequency and level were assessed with UV. To study contamination, three ESBLPE and one CPE were diluted in saline, 10⁶/mL. Contamination was assessed by sampling before, immediately after and 3 h after the test. The swabs were cultured and the colonies counted and identified.

FINDINGS

The areas at the highest risk of spraying were the toilet bowl contour (N = 36/36), the underside of the toilet seat (N = 34) and the inside of the sink (N = 34). Except for gloves (N = 14), there was low clothing contamination. The most frequently contaminated areas were inside the sink (40/48), where the highest levels of contamination were found (14/48).

CONCLUSION

Emptying the urinal bottles in the toilet followed by sink rinsing is associated with a significant risk of projection and contamination, depending on the area (highest risk at the sink), but the bacteria did not survive beyond 3 h. This practice, which carries a risk of cross-transmission, should be reviewed.

Awareness among French healthcare workers of the transmission of multidrug resistant organisms: a large cross-sectional survey

Background

Much effort has been made over the last two decades to educate and train healthcare professionals working on antimicrobial resistance in French hospitals. However, little has been done in France to assess perceptions, attitudes and knowledge regarding multidrug resistant organisms (MDROs) and, more globally, these have never been evaluated in a large-scale population of medical and non-medical healthcare workers (HCWs). Our aim was to explore awareness among HCWs by evaluating their knowledge of MDROs and the associated control measures, by comparing perceptions between professional categories and by studying the impact of training and health beliefs.

Methods

A multicentre cross-sectional study was conducted in 58 randomly selected French healthcare facilities with questionnaires including professional and demographic characteristics, and knowledge and perception of MDRO transmission and control. A knowledge score was calculated and used in a logistic regression analysis to identify factors associated with higher knowledge of MDROs, and the association between knowledge and perception.

Results

Between June 2014 and March 2016, 8716/11,753 (participation rate, 74%) questionnaires were completed. The mean knowledge score was 4.7/8 (SD: 1.3) and 3.6/8 (SD: 1.4) in medical and non-medical HCWs, respectively. Five variables were positively associated with higher knowledge: working in a university hospital (adjusted odds ratio, 1.41, 95% CI 1.16–1.70); age classes 26–35 years (1.43, 1.23–1.6) and 36–45 years (1.19, 1.01–1.40); medical professional status (3.7, 3.09–4.44), working in an intensive care unit (1.28, 1.06–1.55), and having been trained on control of antimicrobial resistance (1.31, 1.16–1.48). After adjustment for these variables, greater knowledge was significantly associated with four cognitive factors: perceived susceptibility, attitude toward hand hygiene, self-efficacy, and motivation.

Conclusions

We found a low level of MDRO awareness and knowledge of associated control measures among French HCWs. Training on hand hygiene and measures to control MDRO spread may be helpful in shaping beliefs and perceptions on MDRO control among other possible associated factors. Messages should be tailored to professional status and their perception. Other approaches should be designed, with more effective methods of training and cognitive interventions.

Trial registration

Clinical Trials.gov NCT02265471. Registered 16 October 2014 - Retrospectively registered.

Clinical management of respiratory syndrome in patients hospitalized for suspected Middle East respiratory syndrome coronavirus infection in the Paris area from 2013 to 2016

Background

Patients with suspected Middle East respiratory syndrome coronavirus (MERS-CoV) infection should be hospitalized in isolation wards to avoid transmission. This suspicion can also lead to medical confusion and inappropriate management of acute respiratory syndrome due to causes other than MERS-CoV.

Methods

We studied the characteristics and outcome of patients hospitalized for suspected MERS-CoV infection in the isolation wards of two referral infectious disease departments in the Paris area between January 2013 and December 2016.

Results

Of 93 adult patients (49 male (52.6%), median age 63.4 years) hospitalized, 82 out of 93 adult patients had returned from Saudi Arabia, and 74 of them were pilgrims (Hajj). Chest X-ray findings were abnormal in 72 (77%) patients. The 93 patients were negative for MERS-CoV RT-PCR, and 70 (75.2%) patients had documented infection, 47 (50.5%) viral, 22 (23.6%) bacterial and one Plasmodium falciparum malaria. Microbiological analysis identified Rhinovirus (27.9%), Influenza virus (26.8%), Legionella pneumophila (7.5%), Streptococcus pneumoniae (7.5%), and non-MERS-coronavirus (6.4%). Antibiotics were initiated in 81 (87%) cases, with two antibiotics in 63 patients (67.7%). The median duration of hospitalization and isolation was 3 days (1–33) and 24 h (8–92), respectively. Time of isolation decreased over time (P < 0.01). Two patients (2%) died.

Conclusion

The management of patients with possible MERS-CoV infection requires medical facilities with trained personnel, and rapid access to virological results. Empirical treatment with neuraminidase inhibitors and an association of antibiotics effective against S. pneumoniae and L. pneumophila are the cornerstones of the management of patients hospitalized for suspected MERS-CoV infection.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3223-5) contains supplementary material, which is available to authorized users.

Infection prevention and control measures and tools for the prevention of entry of carbapenem-resistant Enterobacteriaceae into healthcare settings: guidance from the European Centre for Disease Prevention and Control

Background

Infections with carbapenem-resistant Enterobacteriaceae (CRE) are increasingly being reported from patients in healthcare settings. They are associated with high patient morbidity, attributable mortality and hospital costs. Patients who are “at-risk” may be carriers of these multidrug-resistant Enterobacteriaceae (MDR-E).

The purpose of this guidance is to raise awareness and identify the “at-risk” patient when admitted to a healthcare setting and to outline effective infection prevention and control measures to halt the entry and spread of CRE.

Methods

The guidance was created by a group of experts who were functioning independently of their organisations, during two meetings hosted by the European Centre for Disease Prevention and Control. A list of epidemiological risk factors placing patients “at-risk” for carriage with CRE was created by the experts. The conclusions of a systematic review on the prevention of spread of CRE, with the addition of expert opinion, were used to construct lists of core and supplemental infection prevention and control measures to be implemented for “at-risk” patients upon admission to healthcare settings.

Results

Individuals with the following profile are “at-risk” for carriage of CRE: a) a history of an overnight stay in a healthcare setting in the last 12 months, b) dialysis-dependent or cancer chemotherapy in the last 12 months, c) known previous carriage of CRE in the last 12 months and d) epidemiological linkage to a known carrier of a CRE.

Core infection prevention and control measures that should be considered for all patients in healthcare settings were compiled. Preliminary supplemental measures to be implemented for “at-risk” patients on admission are: pre-emptive isolation, active screening for CRE, and contact precautions. Patients who are confirmed positive for CRE will need additional supplemental measures.

Conclusions

Strengthening the microbiological capacity, surveillance and reporting of new cases of CRE in healthcare settings and countries is necessary to monitor the epidemiological situation so that, if necessary, the implemented CRE prevention strategies can be refined in a timely manner. Creating a large communication network to exchange this information would be helpful to understand the extent of the CRE reservoir and to prevent infections in healthcare settings, by applying the principles outlined here.

This guidance document offers suggestions for best practices, but is in no way prescriptive for all healthcare settings and all countries. Successful implementation will result if there is local commitment and accountability. The options for intervention can be adopted or adapted to local needs, depending on the availability of financial and structural resources.

Electronic supplementary material

The online version of this article (10.1186/s13756-017-0259-z) contains supplementary material, which is available to authorized users.

Audit of carbapenem prescriptions comparing 2 assessment periods

OBJECTIVE

The emergence of extended-spectrum beta-lactamase (ESBL) producing Enterobacteriaceae has resulted in the increase of carbapenem prescriptions. The objective of our study was to determine the appropriateness of carbapenem prescriptions from initiation to reassessment of treatment, between 2009 and 2011.

PATIENTS AND METHOD

A questionnaire drafted by infectious diseases specialists (IDS) and microbiologists was used to collect clinical and microbiological data concerning carbapenem prescriptions in 2009 and 2011. An IDS then compared the results to assess carbapenem prescription compliance with our hospital's local recommendations.

RESULTS

Seventy-one prescriptions were included in 2009 and 32 in 2011. The carbapenem treatment had been most frequently probabilistic to treat nosocomial infections. The microbiological data revealed that the number of multidrug-resistant (MDR) infections had increased between 2009 and 2011, especially infections involving ESBL-producing Enterobacteriaceae. At treatment reassessment, in 2009 and 2011, 15 (21%) and 12 (38%) carbapenem prescriptions were appropriate and continued. Overall, when comparing the 2 periods, prescriptions complied with local guidelines from initiation to reassessment of treatment without any statistically significant difference (68% in 2009 and 75% in 2011).

CONCLUSION

Our study results showed that MDR infections had increased and especially infections due to ESBL-producing Enterobacteriaceae; this was consistent with epidemiological data. We also proved that most carbapenem prescriptions were compliant with recommendations. The increased mobile IDS interventions in medical and surgical departments helped reach this rate of compliance. Carbapenem stewardship may be promoted even in a difficult epidemiological context, especially with IDS interventions for the duration of treatment or at treatment reassessment.

Postoperative pneumonia following cardiac surgery in non-ventilated patients versus mechanically ventilated patients: is there any difference?

INTRODUCTION

No studies have compared ventilator-associated pneumonia (VAP) and non-VAP following cardiac surgery (CS). The aim of this study was to assess the incidence, clinical and microbiologic features, treatment characteristics and prognosis of postoperative pneumonia following CS with a special focus on non-VAP.

METHODS

This was a retrospective cohort study based on a prospectively collected database. We compared cases of non-VAP and VAP following CS observed between January 2005 and December 2012. Statistical analysis consisted of bivariate and multivariate analysis.

RESULTS

A total of 257 (3.5%) of 7,439 consecutive CS patients developed postoperative pneumonia, including 120 (47%) cases of non-VAP. Patients with VAP had more frequent history of congestive heart failure (31% vs. 17%, P = 0.006) and longer duration of cardiopulmonary bypass (105 vs 76 min, P < 0.0001), than patients with non-VAP. No significant differences were observed between the 2 groups in terms of the types of microorganisms isolated with high proportions of Enterobacteriaceae (35%), Pseudomonas aeruginosa (20.2%) and Haemophilus spp (20.2%), except for a lower proportion of Methicillin-susceptible S. aureus in the non-VAP group (3.2% vs 7.9%, P = 0.03). In the intensive care unit, patients with non-VAP had lower sequential organ failure assessment scores than patients with VAP (8 ± 3 versus 9 ± 3, P = 0.004). On multivariate analysis, in-hospital mortality was similar in both groups (32% in the non-VAP group and 42% in the VAP group, adjusted Odds Ratio (aOR): 1.4; 95% confidence intervals (CI): 0.7-2.5; P = 0.34) and appropriate empiric antibiotic therapy was associated with a reduction of in-hospital mortality (aOR: 0.4; 95% CI: 0.2-1; P = 0.05). Piperacillin/tazobactam or imipenem monotherapy constituted appropriate empiric therapy in the two groups, with values reaching 93% and 95% with no differences between VAP and non-VAP cases.

CONCLUSIONS

Intensive care patients with VAP are more severely ill than non-VAP patients following CS. Nevertheless, patients with non-VAP and VAP following CS have similar outcomes. This study suggests that the empiric antibiotic regimen in patients with pneumonia following CS should include at least a broad-spectrum antibiotic targeting non-fermenting Gram-negative bacilli, regardless of the type of pneumonia, and targeting S. aureus in VAP patients.

Staphylococcus aureus healthcare associated bacteraemia: An indicator of catheter related infections

PURPOSE

Surveillance of preventable healthcare associated infections and feedback of the results to clinicians is central in the efforts to improve performance. We assessed Staphylococcus aureus healthcare associated bloodstream infection (HA-BSI) as an indicator of healthcare quality.

PATIENTS AND METHOD

Between 2002 and 2012, we carried out a ten-year prospective bedside surveillance of S. aureus healthcare associated bacteraemia in a 940-bed university hospital using standard definitions.

RESULTS

Overall, 2784 HA-BSI were identified during the study period, among which 573 (18%) were due to S. aureus. Among these 573 S. aureus bacteraemias, 189 originated from intravascular catheters (32.8%) of which 84% (158/189) in patients outside intensive care units. The proportion of catheter related HA-BSI due to S. aureus was 56% (61/109) in PVC-related HA-BSI and 34% (103/301) in CVC-related HA-BSI. A sharp decrease of PVC-related HA-BSI from 20 to 7 per year was obtained during the same period.

CONCLUSION

In our experience, S. aureus HA-BSI is a simple and useful indicator of catheter associated infections, and therefore of healthcare quality, especially in units not covered by other type of surveillance.

Acquisition of carbapenemase-producing Enterobacteriaceae by healthy travellers to India, France, February 2012 to March 2013

Healthy travellers to countries where carbapenemases-producing Enterobacteriaceae (CPE) are endemic might be at risk for their acquisition, even without contact with the local healthcare system. Here, we report the acquisition of CPE (two OXA-181, one New Delhi metallo-beta-lactamase 1 (NDM-1)) in three healthy travellers returning from India. The duration of CPE intestinal carriage was less than one month. The results indicate that healthy travellers recently returning from India might be considered as at risk for CPE carriage.

Introduction of highly resistant bacteria into a hospital via patients repatriated or recently hospitalized in a foreign country

We describe the prevalence of carriage and variables associated with introduction of highly drug-resistant microorganisms (HDRMO) into a French hospital via patients repatriated or recently hospitalized in a foreign country. The prevalence of HDRMO was 11% (15/132), with nine carbapenamase-producing Enterobacteriaceae, nine carbapenem-resistant Acinetobacter baumannii and six glycopeptide-resistant enterococci. Half of the admitted patients (63/132, 48%) were colonized with extended spectrum beta-lactamase-producing Enterobacteriaceae (ESBLPE). Among the four episodes with secondary cases, three involved A. baumannii.

Personal decision-making criteria related to seasonal and pandemic A(H1N1) influenza-vaccination acceptance among French healthcare workers

BACKGROUND

Influenza-vaccination rates among healthcare workers (HCW) remain low worldwide, even during the 2009 A(H1N1) pandemic. In France, this vaccination is free but administered on a voluntary basis. We investigated the factors influencing HCW influenza vaccination.

METHODS

In June-July 2010, HCW from wards of five French hospitals completed a cross-sectional survey. A multifaceted campaign aimed at improving vaccination coverage in this hospital group was conducted before and during the 2009 pandemic. Using an anonymous self-administered questionnaire, we assessed the relationships between seasonal (SIV) and pandemic (PIV) influenza vaccinations, and sociodemographic and professional characteristics, previous and current vaccination statuses, and 33 statements investigating 10 sociocognitive domains. The sociocognitive domains describing HCWs' SIV and PIV profiles were analyzed using the classification-and-regression-tree method.

RESULTS

Of the HCWs responding to our survey, 1480 were paramedical and 401 were medical with 2009 vaccination rates of 30% and 58% for SIV and 21% and 71% for PIV, respectively (p<0.0001 for both SIV and PIV vaccinations). Older age, prior SIV, working in emergency departments or intensive care units, being a medical HCW and the hospital they worked in were associated with both vaccinations; while work shift was associated only with PIV. Sociocognitive domains associated with both vaccinations were self-perception of benefits and health motivation for all HCW. For medical HCW, being a role model was an additional domain associated with SIV and PIV.

CONCLUSIONS

Both vaccination rates remained low. Vaccination mainly depended on self-determined factors and for medical HCW, being a role model.

Long-term control of vancomycin-resistant Enterococcus faecium at the scale of a large multihospital institution: a seven-year experience

Binary file ES_Abstracts_Final_ECDC.txt matches

Long-term control of vancomycin-resistant Enterococcus faecium at the scale of a large multihospital institution: a seven-year experience

Repeated outbreaks of vancomycin-resistant Enterococcus faecium (VRE) occurred between 2004 and 2010 in Assistance Publique--Hôpitaux de Paris (AP-HP), a 23,000-bed multi-hospital institution. From August 2004 to December 2005, the French guidelines for preventing cross-transmission of multiresistant bacteria were applied. Because the number of VRE cases continued to increase, an institutional control programme was implemented from January 2006 onwards: it foresees stopping transfer of VRE and contact patients, separating VRE and contact patients in distinct cohorts, intervention of a central infection control team to support local teams, and quick application of measures as soon as first VRE cases are identified. Between August 2004 and December 2010, 45 VRE outbreaks occurred in 21 of the 38 AP-HP hospitals, comprising 533 cases. Time series analysis showed that the mean number of cases increased by 0.8 cases per month (95% confidence interval (CI): 0.3 to 1.3, p=0.001) before, and decreased by 0.7 cases per month after implementation of the programme (95% CI: -0.9 to -0.5, p<0.001), resulting in a significant trend change of -1.5 cases per month (95% CI: -2.1 to -0.9, p<0.001). The number of cases per outbreak was significantly lower after implementation of the programme. A sustained and coordinated strategy can control emerging bacteria at the level of a large regional multihospital institution.

[The vaccination of older adults: a challenge for the future!]

In developed countries, the population is getting older and the prevention of infectious diseases is therefore a major public health issue for elderly. Infectious diseases preventable by vaccination, including influenza, pneumococcal infection, pertussis, herpes zoster infections, and to a lesser extent, diphtheria and poliomyelitis, are direct or indirect causes of hospitalization. Few data are available on the proportion of vaccinated elderly, the impact of the under nutrition, or immunosenescence on the quality of the immune response to vaccination and the level of protection. The infectious diseases preventable by vaccination are considered in this article, and the epidemic risk related to infectious diseases in older adults living in community, the specific vaccine recommendations, the vaccines available in France, the vaccine coverage of elderly, factors interfering with vaccine response, and future prospects in this area.

Epidemiology of Pseudomonas aeruginosa and risk factors for carriage acquisition in an intensive care unit

Because of a high prevalence of Pseudomonas aeruginosa infections, we conducted an epidemiological study to assess the need for systematic surveillance, as well as the value of applying barrier precautions toP. aeruginosa carriers. From July 1997 to February 1998, we conducted a prospective cohort study in an 18-bed medical intensive care unit (ICU), which is part of the infectious diseases department in a 1200-bed tertiary-care teaching hospital. Rectal and oropharyngeal swabs were obtained on admission and twice weekly. Acquired strains were genotypically characterized by pulsed-field gel electrophoresis (PFGE). A risk factor analysis for carriage, colonization and infection was performed. Among 269 eligible patients, 116 (43%) were P. aeruginosa carriers, with 46 (17%) detected on admission and 70 (26%) who acquired carriage during their stay in ICU. Among these 70 patients, 29 became colonized (N=13) or developed infection (N=16). Conversely, in the 121 patients who remained free of carriage, no colonization or infection were detected. Genotyping analysis using PFGE was performed for 81/85 (95%) acquired strains in 67 patients. The same genotype I was observed for 58/81 (70%) of these strains issued from 47 patients, and a distinct genotype II affected two other patients (three strains). The last 20 strains were not genetically related. In a multivariate model, mechanical ventilation was associated with the acquisition of P. aeruginosa carriage. Antibiotics ineffective against P. aeruginosa significantly increased the risk of colonization or infection in ICU. Although several recent studies concluded that endogenous sources account for the majority of P. aeruginosa colonizations or infections, we conclude that epidemiology may vary according to the ICU, and that cross-colonization (i.e., exogenous source) may occur and warrant reinforced barrier precautions.

[The importance of detecting methicillin-resistant Staphylococcus aureus in an intensive care setting]

In recent years, the fight against nosocomial infections has constituted a major public health challenge. Measures aimed at preventing the spread of multiresistant bacteria (MRB) through carriage combine the more or less systematic detection of carriers and precautions concerning isolation. In the light of published data, elements for the evaluation of a cost-efficiency ratio for measures concerning detection and isolation in intensive care are presented. The high levels of methicillin-resistant Staphylococcus aureus (MRSA) observed in hospitals constitute the principal target. Although isolation precautions appear to be effective, the value of detecting MRSA remains a subject of debate. Such detection has several objectives: the identification of carriers, assistance in the implementation of isolation precautions, the eradication of carriage and the evaluation of strategy. These different objectives are discussed.

Delayed treatment contributes to mortality in ICU patients with severe active pulmonary tuberculosis and acute respiratory failure

OBJECTIVES

To clarify the patterns of pulmonary tuberculosis (TB) that should result in a high index of suspicion, to increase the chances of early therapy and to identify predictors of 30-day mortality.

PATIENTS AND METHODS

Retrospective, 7-year study in two medical intensive care units (ICUs). All patients admitted with pulmonary TB were enrolled. Clinical and laboratory data at admission and events within 48 h of admission were collected. Predictors of 30-day mortality were identified by univariate and multivariate analysis.

RESULTS

The study included 99 patients with a median age of 41 years. Immunodeficiency was present in 60 patients, including 38 with AIDS. Fifty-nine patients had pulmonary TB alone, 22 also had extrapulmonary TB and 18 had miliary. All 99 patients were admitted for acute respiratory failure, some also with shock (20), neurologic disorders (18) or acute renal failure (10). Mechanical ventilation was needed in 50 patients; 22 patients met criteria for acute respiratory distress syndrome (ARDS). The 30-day mortality rate was 26.2%. Four factors independently predicted mortality: a time from symptom onset to treatment of more than 1 month (OR, 3.49; CI, 1.20-10.20), the number of organ failures (OR, 3.15; CI, 1.76-5.76), a serum albumin level above 20 g/l (OR, 3.96; CI, 1.04-15.10), and a larger number of lobes involved on chest radiograph (OR, 1.83; CI, 1.12-2.98).

CONCLUSION

Delayed clinical suspicion and treatment of active pulmonary TB with respiratory failure may contribute to the persistently high mortality rates in ICU patients with these diseases.

Duration of colonization by methicillin-resistant Staphylococcus aureus after hospital discharge and risk factors for prolonged carriage

To investigate persistent carriage of methicillin-resistant Staphylococcus aureus (MRSA), we conducted a prospective 10-month study of MRSA carriage in previous carriers who were readmitted to our hospital. Four screening specimens, 2 from the skin and 2 from the nares, were obtained within 3 days after admission, in addition to diagnostic specimens requested by physicians. Of the 78 patients included in our study, 31 (40%) were persistent carriers of MRSA, with an estimated median time of 8.5 months to MRSA clearance. In the multivariate analysis, the only factor significantly associated with persistent carriage was the presence of a break in the skin at readmission (odds ratio, 4.34; P=.004); however, a trend was found for admission from a chronic-care institution (odds ratio, 3.65; P=.06). Our data confirm that prolonged carriage of MRSA can occur after hospital discharge, support routine screening for MRSA at readmission of previously MRSA-positive patients, and suggest that a particularly high index of suspicion for MRSA carriage should be maintained if these patients have a break in the skin.

[Evaluation of three testing strategies for detection of hepatitis C in a hospital medical consultation and in an HIV testing center]

AIMS

Testing for hepatitis C virus (HCV) is recommended. The purpose of this study was to evaluate the efficacy of HCV testing in a medical consultation without an appointment and in an HIV testing center based on three testing strategies: 1997 French Consensus Conference, "Lettre de la Direction Générale de la Santé" (January 1996), and extension to other risk factors.

PATIENTS AND METHODS

For 6 months a free blood test was offered to any patient with a risk factor according to the literature.

RESULTS

There were 1 736 new patients at the medical consultation and 1 616 at the testing center. The patients were younger at the testing center than at the medical consultation (31.1 vs 43.3 years; P<0.001). Acceptance of screening was better at the testing center (97.8% vs 75.2%; P<0.001). There were more patients exposed to one of the risk factors at the testing center (31.2% vs 13.9%; P<0.001). Tests were more efficient at the testing center: 30 HCV positive patients/1 616 (1.86%) vs 11/1 736 (0.63%, P<0.01). Tests based on the 1997 French Consensus Conference provided detection in 27/30 (90%) of HCV positive patients at the testing center but only 4/11 (36.3%) at the medical consultation (P<0.01).

CONCLUSION

Testing was effective in both places but was more efficient at the testing center. Efficacy of the testing strategies differs significantly according to the place of screening. At the testing center, screening can be restricted to patients with a history of intravenous drug use and blood transfusion. At the medical consultation, screening should be extended to other risk factors.

Incidence and risk factors of bacteriuria after transurethral resection of the prostate

INTRODUCTION

Postoperative bacteriuria is a frequent event after transurethral resection of the prostate, despite the use of prophylactic antibiotics. Certain risk factors have been clearly established (preoperative urinary catheter or bacteriuria, operating time), while others remain uncertain.

MATERIALS AND METHODS

We conducted a prospective study in five urology centers, including non-catheterized patients with sterile preoperative urine undergoing transurethral resection of the prostate for benign prostatic hyperplasia. All received antibiotic prophylaxis with cefamandole. The incidence of bacteriuria and its risk factors were investigated.

RESULTS

The postoperative bacteriuria rate was 26% (26/101), with 8% on removal of the catheter, 14% between the 7th and 10th postoperative days and 5% 1 month postoperatively. Factors associated with bacteriuria on univariate analysis were: operating time, disconnection of the closed urine drainage system and postoperative catheterization > or =3 days. Two variables were associated on multivariate analysis (logistic regression): operating time >52 min (odds ratio 9.0, 95% confidence interval 2.1-39.0) and disconnection of the closed urine drainage system (odds ratio 26.3, 95% confidence interval 6.1; 6.1-113).

CONCLUSIONS

The postoperative bacteriuria rate after transurethral resection of the prostate was high in this study, raising the question of the choice and/or duration of prophylactic antibiotics. Prevention of postoperative bacteriuria must be based on careful hemostasis, prevention of postoperative catheter disconnections, and limitation of the duration of postoperative catheterization.

An outbreak of imipenem-resistant Acinetobacter baumannii in critically ill surgical patients

OBJECTIVE

To describe an outbreak of imipenem-resistant Acinetobacter baumannii (IR-Ab) and the measures for its control, and to investigate risk factors for IR-Ab acquisition.

DESIGN

An observational and a case-control study.

SETTING

A surgical intensive care unit (ICU) in a university tertiary care hospital.

METHODS

After admission to the ICU of an IR-Ab-positive patient, patients were prospectively screened for IR-Ab carriage upon admission and then once a week. Environmental cleaning and barrier safety measures were used for IR-Ab carriers. A case-control study was performed to identify factors associated with IR-Ab acquisition. Cases were patients who acquired IR-Ab. Controls were patients who were hospitalized in the ICU at the same time as cases and were exposed to IR-Ab for a similar duration as cases. The following variables were investigated as potential risk factors: baseline characteristics, scores for severity of illness and therapeutic intervention, presence and duration of invasive procedures, and antimicrobial administration.

RESULTS

Beginning in May 1996, the outbreak involved 17 patients over 9 months, of whom 12 acquired IR-Ab (cases), 4 had IR-Ab isolates on admission to the ICU, and 1 could not be classified. Genotypic analysis identified two different IR-Ab isolates, responsible for three clusters. Ten of the 12 nosocomial cases developed infection. Control measures included reinforcement of barrier safety measures, limitation of the number of admissions, and thorough environmental cleaning. No new case was identified after January 1997. Eleven of the 12 cases could be compared to 19 controls. After adjustment for severity of illness, a high individual therapeutic intervention score appeared to be a risk factor for IR-Ab acquisition.

CONCLUSION

The outbreak ended after strict application of control measures. Our results suggest that high work load contributes to IR-Ab acquisition.

Nosocomial bacteremia in HIV patients: the role of peripheral venous catheters

A retrospective case-control study compared 40 human immunodeficiency virus (HV)-infected patients with 43 nosocomial bacteremias (NB) to 77 HIV-infected patients without NB. Presence of a peripheral venous catheter (PVC) was associated with occurrence of NB and was significantly more frequent in NB without an identified source. PVCs probably are an underestimated source of NB in HIV-infected patients.

Risk factors for surgical wound infections in patients undergoing head and neck oncologic surgery

Risk factors for surgical wound infection are difficult to establish in head and neck surgery. Flap reconstruction, which correlates with tumour size and surgical procedure, appears to be the main risk factor. Attempts should be made by the surgical staff to improve surgical procedures in terms of duration of surgery and choice of the procedure. The intraoperative choice between primary closure and flap reconstruction should be studied further. More subtle risk factors may appear in studies of large groups of patients and/or if a distinction is drawn between early and late SWI.

Microbiological evaluation of central venous catheter administration hubs

We compared, in three intensive care units, colonization of hubs with hub protection boxes or hubs with needleless closed connectors; 137 central venous catheters and 451 hubs were randomized in two groups with similar characteristics. Catheter and hub colonization were not different between the two groups. Among 30 colonized catheters, the same isolate was found in only two hubs; hub contamination rarely is responsible for catheter colonization in short-term catheters. Further studies are required to evaluate the benefit of protected hubs compared with unprotected hubs.

Control of a prolonged outbreak of extended-spectrum beta-lactamase-producing enterobacteriaceae in a university hospital

Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBLPE) were isolated from clinical specimens from 130 to 140 patients/year in 1989-1991 in our hospital. In February 1992, a control program was initiated: screening tests in 3 intensive care units (ICUs) and contact-isolation precautions in all units. The septic surgical unit served as an isolation ward for surgical patients from whom ESBLPE was isolated. In 1992, the incidence of ESBLPE acquisition failed to decrease, and most acquisitions occurred in 3 ICUs. Critical evaluation of implementation of isolation procedures in these ICUs prompted corrective measures for barrier precautions. The incidence of acquired cases subsequently decreased, and a second evaluation determined that these measures had been correctly applied. The incidence of acquired cases in the septic surgical unit was lower than those in the other units. Decreases were also found in the incidence of acquisition of other hand-transmitted multidrug-resistant organisms. Barrier precautions, screening tests for ICU patients, and grouping of cohorts after ICU discharge are effective in controlling the spread of multidrug-resistant microorganisms by cross-contamination. The outbreak was effectively controlled without restricting antimicrobial use.

Methicillin-resistant Staphylococcus aureus as a causative agent of postoperative intra-abdominal infection: relation to nasal colonization

In the surgical intensive care unit of a university hospital, we investigated the frequency of and the risk factors for acquisition of methicillin-resistant Staphylococcus aureus (MRSA) during postoperative intra-abdominal infection (pIAI). We conducted a prospective MRSA nasal screening and case evaluation for 17 months among 73 consecutive patients with having pIAI. MRSA pIAI was diagnosed when MRSA was obtained from culture of intraperitoneal fluids. The identity of nasal and peritoneal MRSA strains was assessed by genomic analysis. Twelve patients had MRSA pIAI, representing 21% of all MRSA infections acquired by the 73 patients. An organ system failure score of >/=1 and MRSA nasal carriage prior to pIAI were the independent risk factors for acquisition of MRSA pIAI. Patients with MRSA pIAI had a longer intensive care unit stay and more reoperations than did those free of MRSA pIAI. We conclude that MRSA may be a causative pathogen in pIAI and may be related to nasal colonization.

Cost of antimicrobial treatment for nosocomial infections based on a French prevalence survey

An estimate of the antibiotic cost of nosocomial infections (NI) was made in a university hospital group based on data collected in adult inpatients enrolled in the French national prevalence survey in 1996. Among the 6839 study patients, 636 (9.3%) presented with at least one NI, of these, data on antimicrobial treatment were available for 480. The overall daily antibiotic cost was estimated between FF 49,439 and 103,526, resulting in FF 103 to 216 per infected patient. The most expensive antibiotic treatment was prescribed in intensive care patients, for pneumonia for device-related NI, or for multi-resistant bacterial infections. Non-documented NI represented about 20% of the overall antibiotic cost. Beta-lactam antibiotics, especially third generation cephalosporins, and parenteral fluoroquinolones were the most expensive antimicrobial drugs. The cost of antibiotic treatment for NI represents a significant part of hospital expenditure that should be reduced by better control of highly expensive prescriptions.

Clinical and bacteriologic epidemiology of extended-spectrum beta-lactamase-producing strains of Klebsiella pneumoniae in a medical intensive care unit

The epidemiology of extended-spectrum beta-lactamase (ESBL)-producing strains of Klebsiella pneumoniae was studied over a 16-month period in a medical intensive care unit (ICU). A control program involving enhanced isolation procedures, surveillance cultures at admission and then at 1-week intervals, and selective digestive decontamination (SDD) was instituted. Phenotypic and genotypic markers (plasmid content and DNA macrorestriction polymorphism determined by pulsed-field gel electrophoresis) were used to compare 138 strains of ESBL-producing K. pneumoniae. The incidence of colonization and/or infection with ESBL producers was 11.9%. ESBL-producing K. pneumoniae strains were isolated from 64 of 65 patients. Fifty-five cases were considered acquired in the ICU, while nine cases were imported. Forty-five infections occurred in 32 patients; 20 infections involved the urinary tract. SDD failed to reduce the incidence of acquisition of ESBL-producing K. pneumoniae. Combined use of markers was necessary to achieve accurate differentiation of strains. A single epidemic clone (SHV-4 beta-lactamase-producing K. pneumoniae) was the cause of 85% of the ICU-acquired cases. Sporadic occurrence of SHV-5, TEM-3, SHV-2, and SHV-3 producers accounted only for a few cases.

[Control of multiple-resistant bacteria]

The number of multiply-resistant bacteria, especially methicillin-resistant Staphyloccoccus aureus, has reached an alarming level in France. This number reflects the inadequacy of efforts against nosocomial infections, and non-respect of hygiene rules by hospital staff. Two mechanisms lead to multiple resistance: the selection of multiply-resistant bacteria by antimicrobials; and, once resistance is acquired, bacterial dissemination by hand-mediated cross transmission. Controlling the spread of multiple resistance thus requires both judicious use of antimicrobials, and compliance with basic rules of hygiene, particularly handwashing. Although the hospital setting favors the emergence and spread of bacterial resistance, this is also increasing, albeit to a lesser extent, in the non-hospital environment. The same measures of careful antimicrobial use and good hygiene should be applied.

[Invasive pulmonary aspergillosis in AIDS]

Risk factor for invasive pulmonary aspergillosis in HIV-negative patients include neutropenia, corticosteroid therapy, and chemotherapy. Corresponding risk factors in HIV-positive patients have not yet been reported. A case-control study was conducted at the Bichat-Claude Bernard Teaching Hospital, Paris, France, between 1991 and 1996. Eight cases were identified. In three cases, the diagnosis was documented histologically. Of the remaining five patients, four had a de novo lung cavity with a positive bronchoscopy sample, and one had a pulmonary infiltrate with a positive bronchoscopy sample in the absence of any other potential pathogen. Each case was matched with three controls who were admitted during the same period and had CD4 counts lower than 50/mm3. Median age was 38.1 years in the cases and 38.4 years in the controls. Median CD4 counts were 12.5 +/- 19.2 in the cases versus 19.3 +/- 16.3 in the controls (P = 0.14). No case-control differences were found for AIDS duration, neutrophil counts at diagnosis or during the previous six months, history of corticosteroid therapy or chemotherapy, or number of previous opportunistic infections. Cases were more likely than controls to have a preexisting lung cavity (3/8 versus 0/24; P = 0.01) and had spent more time in the hospital during the previous year (7 +/- 4.5 versus 2.8 +/- 3.2 weeks; P = 0.02). These data do not support a role for neutropenia or immunosuppressive treatments as risk factors for invasive aspergillosis in AIDS. They suggest that AIDS patients with a lung cavity or frequent hospital stays are at increased risk for invasive aspergillosis.

Notification of tuberculosis in a university hospital

The aim of this study was to evaluate completeness of tuberculosis notification in Bichat Claude-Bernard University Hospital and to evaluate whether misclassification of atypical mycobacterial infection could have contributed to the inaccuracy of tuberculosis notification. Data from Microbiology Laboratory of the hospital and statutory notifications were compared. From 1 January 1994 to 31 December 1995, 299 tuberculosis cases were diagnosed in the Microbiology Laboratory and 316 cases were notified as tuberculosis. Notification rate for laboratory-documented tuberculosis was 57.5%, was significantly higher in cases with positive acid fast bacilli smear (75%) than without this feature (45%) and was similar in HIV-positive (59.4%) and HIV-negative (63.5%) patients. Among notified cases, diagnosis was established by laboratory proofs in only 54.4% and by clinical signs in 45.6%. Three cases with positive smear and culture growing atypical mycobacteria were wrongly notified. Notification of laboratory-documented tuberculosis was higher than that observed in a previous study in the same hospital, suggesting that the rise of tuberculosis incidence reported in our country could be partially artificial. Nevertheless, extent of notification remains insufficient and needs to be improved by combining microbiological data with current system of notification.

[Enterobacteria producing extended spectrum beta-lactamases]

Extended-spectrum beta-lactamases (ESBL) were first observed in 1983. Since then, the number and variety of ESBLs have increased rapidly, particularly in France, and their distribution is now worldwide. The number of ESBLs has now reached more than 30, some of them spreading largely in several countries, such as SHV-4 in France. Intensive care units were first involved. Patients from nursing homes may recirculate ESBLs into acute care units. ESBL clinical epidemiology does not differ from other enterobacteriaceae. Digestive tract is the main reservoir, hands are the route of transmission. Infection develops in about 50% of colonized patients, more than one-half being urinary tract infections. Risk factors for colonization or infection are length of exposure to an epidemic strain and frequency of health-care-worker contact. Strategies for containing spreading of ESBL-producing strains include use of barrier precautions for carriers. Judicious use of antimicrobial agents is also important, by decreasing antibiotic selective pressure.

[Mediastinitis after sternotomy. Mortality and hospital length of stay. Groupe parisien détude des sternotomies]

The morbidity of deep sternal wound infections after sternotomy was assessed by a case-controlled study. The 41 cases were identified by a prospective enquiry over 4 months in 10 centres of cardiac surgery in the Paris region. The cases were compared with 41 non-infected controls, paired by centre, age, gender, ASA anaesthetic risk, stage of cardiac failure and type of surgery. The criteria of pairing were respected in 96% of cases. The mortality was 12% in the study population and 5% in the controls. Thirty-two of the 41 cases required reoperation for the sternal wound infection, usually to insert Redon drains after debridement of the wound. The total duration of the hospital stay was 53 days in the study cases and 30 days in controls, a median prolongation of the hospital stay of 23 days. The authors conclude that deep wound infection after sternotomy is responsible for almost doubling the duration of hospital stay. The economic consequences alone justify active research into the prevention of this complication.

Pulmonary toxoplasmosis in patients infected with human immunodeficiency virus: a French National Survey

We reviewed all cases of pulmonary toxoplasmosis (PT) that were documented by detection of Toxoplasma gondii in bronchoalveolar lavage fluid specimens during a French nationwide review of extracerebral toxoplasmosis in patients infected with human immunodeficiency virus (HIV). Only 64 cases of proven PT were recorded during the 33-month survey. The patients were similar to other patients with AIDS in terms of age, sex, and risk factors for HIV infection. PT occurred mainly in patients with advanced immunodeficiency (mean [+/- SD] CD4+ lymphocyte count, 40 +/- 75/mm3). Clinical features of PT usually include fever, cough and dyspnea; the associated radiological findings were mainly diffuse interstitial infiltrates. Serological data were uninformative. The treatment for PT was the same as that for cerebral toxoplasmosis. A clinical response was observed for 47% of patients, 23% of whom relapsed. Twenty-four patients (37%) died of toxoplasmosis, and 17 (27%) died of other causes. The median survival time was 150 days. We conclude that PT is an infrequent but severe infection in HIV-patients in France.

Outbreak of multiply resistant enterobacteriaceae in an intensive care unit: epidemiology and risk factors for acquisition

A prospective study was initiated in an intensive care unit (ICU) where extended-spectrum beta-lactamase-producing enterobacteriaceae (ESBLPE) were endemic. From July 1990 to July 1991, patients hospitalized for > or = 5 days were screened for ESBLPE acquisition by means of weekly rectal sampling and clinical cultures. Baseline characteristics and various ICU procedures in 62 cases of ESBLPE were compared with those for 205 patients without ESBLPE, with use of Cox's model. Risk for acquiring ESBLPE (Klebsiella pneumoniae in most cases) increased during the ICU stay, from 4.2% in the first week to 24% in the fourth week. Baseline characteristics were not different between the two groups. Urinary catheterization (P = .04) and arterial catheterization (P = .03) were independent risk factors for acquiring ESBLPE and probably reflected frequency of health care manipulations. The first site of ESBLPE acquisition was the digestive tract in 58 of the 62 patients; 28 infections developed in 22 patients, and these followed or occurred simultaneously with rectal colonization in 18 of those 22. DNA macrorestriction analysis suggested that the same strain was responsible for most cases. In conclusion, ESBLPE acquisition depends on length of stay in the ICU and the use of invasive procedures. Colonization is a prerequisite for infection.

Early predictors of outcome for HIV patients with neurological failure

OBJECTIVE

To carry out a descriptive study of human immunodeficiency virus (HIV)-infected patients admitted to an intensive care unit (ICU) with neurological failure and to identify parameters that are predictive of death within 3 months.

DESIGN

Case series study.

POPULATION AND SETTING

A total of 84 consecutive HIV-infected patients admitted to an infectious disease ICU in a university hospital for neurological failure. A thorough clinical, laboratory, and brain computed tomography (CT) scan workup was done within 48 hours of admission.

MAIN RESULTS

The mean (+/- SD) CD4+ lymphocyte count was 0.067 (+/- 0.086) x 10(9)/L. Mechanical ventilation was necessary within 48 hours of admission in 67 cases (80%). The brain CT scan revealed abscesses in 51 patients (61%). The abscesses were attributed to probable toxoplasmosis in 47 patients. A total of 57 patients died, yielding a 3-month survival rate of 32%. By the log-rank test, the following factors were predictive of death within 3 months of admission to the ICU: Glasgow Coma Scale score less than 7 (P = .01), signs of brain stem involvement (P = .001), and need for mechanical ventilation in the 48 hours after admission (P = .02). In a Cox model, only Glasgow Coma Scale score less than 7 (P = .006) and clinical signs of brain stem involvement (P = .02) were predictive of death within 3 months of admission to the ICU.

CONCLUSIONS

Despite a thorough examination, no initial HIV-specific parameters were identified as predictive of death. The prognostic factors found simply reflected the severity of neurological involvement in the various etiologies.

Fulminant hepatitis with severe lactate acidosis in HIV-infected patients on didanosine therapy

We report two cases of fulminant hepatic failure in HIV-1-infected patients treated with didanosine (ddI). Clinical manifestations including vomiting, diarrhoea and dyspnoea were identical in both cases. Biological data mainly revealed hepatic failure and lactic acidosis. Histological examination of liver biopsies showed diffuse microvesicular steatosis. The outcome was fatal in both patients. The only comparable case previously reported (Lai et al., 1991) showed close similarities in the clinical, biological and histological manifestations with microvesicular steatosis. This prompted us to suspect that ddI might be responsible for fulminant hepatitis in all three AIDS patients. This toxic effect may be added to the list of potential adverse events occurring during ddI therapy.

Septic shock due to toxoplasmosis in patients infected with the human immunodeficiency virus

PURPOSE

To describe the presentation and clinical course of septic shock due to Toxoplasma gondii in patients infected with the human immunodeficiency virus (HIV).

PATIENTS AND METHODS

From April 1988 to February 1992, nine HIV-infected patients were admitted because of predominant septic shock (7 patients) or developed septic shock in the ICU (2 patients). The recent CD4+ cell count ranged from 2 to 84 x 10(6)/L.

RESULTS

The main clinical features were (1) a history of fever for longer than 15 days, with a recent increase to more than 39.5 degrees C; (2) a recent history of dyspnea (< 15 days, 8 cases; < 7 days, 3 cases); and (3) recent onset of thrombocytopenia (6 of 9 cases). All patients were in shock (hyperkinetic profile in 6 of 7; hypokinetic in 1 of 7), and 8 of 9 were in respiratory distress (ratio of PaO2 over fractional concentration of oxygen in the inspired gas of 117 +/- 23; range, 88 to 155). Chest roentgenograms revealed diffuse alveolar infiltrates in six of nine cases. The serum lactate dehydrogenase (LDH) activity was 6,510 +/- 5,080 IU/L (range, 1,010 to 15,450 IU/L). Serologic tests for T gondii were negative in two cases. Toxoplasma gondii was isolated from lung (9/9), bone marrow (5/7), or blood (2/2). One, 3, and 2 patients had brain, ocular, and myocardial involvement, respectively. No other microbial pathogens were isolated. Seven patients died, 5 less than 3 days after admission.

CONCLUSION

Disseminated toxoplasmosis can cause septic shock in HIV-infected patients. In two cases, the disease was probably a primary infection. The association of high fever, acute dyspnea, recent onset of thrombocytopenia, and a very high level of LDH activity is suggestive of disseminated toxoplasmosis.