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Background: Rodents are one of the most dangerous reservoirs and carriers of infectious diseases. Gradually, rats have become predominant in cities, sometimes staying in close vicinity to humans, pets, and other animals. Consequently, they tend to increase the transmission risk of pathogens., Case Description: Here, we report an original case of bacterial pneumonia in a street rat ( Rattus norvegicus ). The rat was found dead on a street in the chief town of Marseille (France) after being run over by a car. The necropsy of the corpse revealed generalized granulomatous pneumonia in almost all the pulmonary lobes. Lung lesions and predominantly multiple fibro-inflammatory areas are presumably the witness of an infectious etiology. Bacterial isolation was carried out from lung tissues. Colonies were identified by MALDI-TOF MS and confirmed by 16S rRNA sequencing. The following bacteria were identified: Staphylococcus cohnii , Bordetella bronchiseptica , Bordetella parapertussi, Corynebacterium glucuronolyticum , Pelistega suis and Rodentibacter rarus . Based on the histopathological diagnosis and the avoidance approach, the most likely etiological agent of pneumonia is therefore R. rarus , a little-known Pasteurellales bacterium that is closely related to Rodentibacter pneumotropicus., Conclusion: These data emphasize the severity of R. rarus infection in rodents. Thus, pointing out a potential risk for other animals (dogs, cats, and birds), as well as humans. The health monitoring program for rodents and rabbits pasteurellosis should now include R. rarus . Therefore, the pathological effect of the Rodentibacter species and/or strains needs to be better explored., Competing Interests: The authors declare that there is no conflict of interest.

Background: Ventilator-associated pneumonia (VAP) accounts for 25% of infections in intensive care units. Compared to a long duration (LD) of antibiotic therapy, a short duration (SD) has a comparable clinical efficacy with less antibiotic use and less multidrug-resistant (MDR) pathogen emergence, with the exception of documented VAP of non-fermenting Gram-negative bacilli (NF-GNB), including Pseudomonas aeruginosa (PA). These results have led the American Thoracic Society to recommend SD therapy for VAP, except for PA-VAP. Thus the beneficial effect of SD therapy in PA-VAP is still a matter of debate. We aimed to assess the non-inferiority of a short duration of antibiotics (8 days) versus prolonged antibiotic therapy (15 days) in PA-VAP., Methods/design: The impact of the duration of antibiotics on clinical events in patients with Pseudomonas aeruginosa ventilator-associated pneumonia (iDIAPASON) trial is a randomized, open-labeled non-inferiority controlled trial, conducted in 34 French intensive care units (ICUs), comparing two groups of patients with PA-VAP according to the duration (8 days or 15 days) of effective antibiotic therapy against PA. The primary outcome is a composite endpoint combining day 90 mortality and PA-VAP recurrence rate during hospitalization in the ICU. Furthermore, durations of mechanical ventilation and hospitalization, as well as number and types of extrapulmonary infections or acquisition of MDR pathogens during the hospitalization in the ICU will be recorded. Recurrence with predefined criteria (clinical suspicion of VAP associated with a positive quantitative culture of a respiratory sample) will be evaluated by two independent experts., Discussion: Demonstrating that an SD (8 days) versus LD (15 days) therapy strategy in PA-VAP treatment is safe and not associated with an increased mortality or recurrence rate could lead to a change in practices and guidelines in the management of antibiotic therapy of this frequent ICU complication. This strategy could lead to decreased antibiotic exposure during hospitalization in the ICU and in turn reduce the acquisition and the spread of MDR pathogens., Trial Registration: ClinicalTrials.gov: NCT02634411 . Registered on 19 November 2015.

Recommendations for the use of diagnostic testing in low respiratory infection in children older than 3 months were produced by the Groupe de Recherche sur les Avancées en Pneumo-Pédiatrie (GRAPP) under the auspices of the French Paediatric Pulmonology and Allergology Society (SP(2)A). The Haute Autorité de santé (HAS) methodology, based on formalized consensus, was used. A first panel of experts analyzed the English and French literature to provide a second panel of experts with recommendations to validate. Only the recommendations are presented here, but the full text is available on the SP(2)A website., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Respiratory infections are the most common complications in HIV patients, regardless of the degree of immunosuppression. Even though antiretroviral therapy has a protective effect on the risk of bacterial pneumonia, this still remains high (including those with CD(4)>500/mm(3)). The most frequently isolated bacteria are Streptococcus pneumoniae and Haemophilus influenzae. The clinical and radiological presentations of lower respiratory tract infections in HIV patients are quite variable. The clinical presentation is more severe and the radiological presentation is more atypical if the immunosuppression is severe. The first-line antibiotic therapy is an injectable third-generation cephalosporin (ceftriaxone or cefotaxime) or co-amoxiclav. Pneumococcal vaccination (as well as influenza vaccine) is recommended. Although rare, Nocardia spp. and Rhodococcus equi seem more common among AIDS patients., (Copyright © 2012 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

Unlabelled: After liver transplantation (LT), postoperative pulmonary complications (PPC) occur in approximately 35% to 50% of the recipients. Among these PPC, pneumonia is the most frequently encountered. Pulmonary dysfunction has also been widely reported among patients awaiting LT. The links between this dysfunction and PPC have not been clearly established. In this present cohort study, we evaluated the incidence and profile of post-LT pneumonia and identified potential preoperative risk factors., Methods: The postoperative clinical course of 212 liver transplant recipients between January 2008 and April 2010 was analyzed. These patients were treated in a single intensive care unit and received standardized postoperative care., Results: During the postoperative period, 47 (22%) patients developed pneumonia, of whom 20 (43%) developed respiratory failure requiring mechanical ventilation. Univariate analysis showed that several preoperative factors (age of recipient, model for end-stage liver disease score, indication for LT, platelet count, and restrictive lung pattern revealed by preoperative pulmonary function tests) and the transfusion (blood units and fresh frozen plasma units) during the operative period were associated with pneumonia. Using multivariate analysis by logistic regression, only a restrictive lung pattern (odds ratio=3.14; 95% confidence interval, 1.51-6.51; P=0.002) and the international normalized ratio measured prior LT (OR=4.95; 95% confidence interval, 1.86-8.59; P=0.0004) were independent predictors of pneumonia after LT., Conclusion: Pneumonia is common among patients undergoing LT and is a major cause of morbidity. A restrictive pattern on preoperative pulmonary testing and a higher international normalized ratio measured prior LT were associated with more risk of postoperative pneumonia.

Postoperative pneumonia (POP) is a life-threatening complication of lung resection (LR). Its risk factors, bacteriological profile and outcome are not well known. The aims of this study were to describe the outcome and causal bacteria and to identify risk factors for POP. We reviewed all cases admitted to intensive care after LR. Clinical parameters, operative and postoperative data were recorded. POP was suspected on the basis of fever, radiographic infiltrate, and either leucocytosis or purulent sputum. The diagnosis was confirmed by culture of a respiratory sample. Risk factors for POP were identified by univariate and multivariate analysis. We included 159 patients in this study. POP was diagnosed in 23 patients (14.4%) and was associated with a higher hospital mortality rate (30% versus 5%, P = 0.0007) and a longer hospital stay. Members of the Enterobacteriaceae and Pseudomonas species were the most frequently identified pathogens. Early respiratory acidosis (ERA; OR, 2.94; 95% CI, 1.1-8.1), blood transfusion (OR, 3.8; 95% CI, 1.1-13.1), bilobectomy (OR, 7.26; 95% CI, 1.2-43.1) and smoking history (OR, 1.84; 95% CI, 1.1-3) were identified as independent risk factors. ERA may be a risk factor for POP and could serve as a target for therapeutic interventions.

Early-onset hospital-acquired pneumonia (E-HAP) is one of the leading causes of sepsis and mortality after liver transplantation (LT). The appropriate antimicrobial therapy is crucially important for surviving sepsis in this context. The aim of this study was to analyze microbiological findings, associated factors, and optimal antibiotic regimens for E-HAP after LT. Patients demonstrating E-HAP in a single-center cohort of 148 LT recipients were prospectively detected. The diagnosis of pneumonia relied on a combination of supportive clinical findings and a positive culture of a lower respiratory tract sample. E-HAP was considered present if pneumonia occurred within 6 days of intensive care unit (ICU) admission after LT. Twenty-three patients (15.5%) developed E-HAP, which were caused by 36 pathogens (61.1% were gram-negative bacilli, and 33.3% were classified as hospital-acquired). For patients who developed E-HAP, the duration of mechanical ventilation and the ICU stay were significantly longer. Despite a trend toward higher mortality at any time in the E-HAP group, there was no significant difference in mortality between patients with E-HAP and patients without E-HAP. Lactatemia, vasopressor requirements, Simplified Acute Physiology Score II (SAPS II) score on ICU admission, and mechanical ventilation lasting more than 48 hours after LT were associated with E-HAP. Combinations of broad-spectrum β-lactams and aminoglycosides were active against more than 91% of the encountered pathogens. However, antibiotic de-escalation was possible in more than one-third of cases after identification of the pathogens. In conclusion, E-HAP after LT is a severe condition that appears to be influenced by physiological derangements induced by the surgery, such as lactatemia, vasopressor requirements, and mechanical ventilation requirements, as well as the postoperative SAPS II score. At the time of treatment initiation, an antimicrobial regimen usually proposed for late-onset pneumonia should be followed., (© 2010 AASLD.)

Unlabelled: We performed urinary antigen tests for pneumococcus and Legionella for patients with community-acquired pneumonia (CAP), to prescribe a documented antibiotic therapy. We report the efficiency of low-spectrum antibiotic treatment, illustrating the inappropriateness of bacteriological respiratory sampling., Patients and Methods: Patients with CAP were enrolled from three different units; the pneumonia severity index was used to assess the disease. Respiratory samples were also listed. Low-spectrum antibiotic therapy was amoxicillin for pneumococcal infection, and macrolides or non-anti-pneumococcal fluoroquinolone for legionellosis., Results: Six hundred and seventy-five CAP were diagnosed during the study period,, 150 with positive urinary antigen tests (23%), among which 108 pneumococcal infections (73%), 40 legionellosis (26%), and two mixed infections. The pneumonia severity index was 106+/-38. Amoxicillin was prescribed in 108 cases, fluoroquinolone in 24 cases, macrolide in 18 cases. The outcome was favourable for 138 patients (92%). Eighty three respiratory samples allowed identification of a bacterium for 58 patients (39%), among which 24 strains were not in the antibiotic spectrum: Haemophilus influenzae and Pseudmomonas aeruginosa in six cases, Staphylococcus aureus in five cases, Klebsiella pneumoniae in two cases, and another Gram negative bacillus in five cases. These strains were resistant in vitro to the prescribed treatment in 19/24 cases (79%). One out of 12 patients who died had a respiratory sample positive for Enterobacter spp strain resistant to the ongoing antibiotic treatment., Conclusion: The low-spectrum antibiotic therapy based on urinary antigen tests is efficient, and demonstrates respiratory tract colonisation with bacteriological strains usually considered as pathogenic.

Objective: This study was designed to determine if bronchoalveolar lavage (BAL) quantitative culture results can be used confidently for the diagnosis of bacterial ventilator-associated pneumonia (VAP) without taking dilution into account., Design: Prospective observational cohort study., Setting: A 12-bed medical ICU in a teaching hospital., Patients: A total of 241 BAL (three 50-mL aliquots) were performed in 127 patients presenting a suspicion of VAP., Interventions: All consecutive adults who were ventilated more than 48 h were included if VAP was clinically suspected. A dilution factor, k, was developed according to the formula: dilution factor k = concentration of urea in plasma/concentration of urea in lavage fluid recovered. Using this dilution factor, the quantitative bacterial counts were interpreted accordingly with a corrected positive threshold at 10(5) colony forming unit (CFU) mL(-1)., Measurements and Results: Eighty-nine BAL with at least one micro-organism > or = 10(4) CFU mL(-1) were identified (37%). In 176 BAL (73%), k ranged from 10 to 100. Median k was 24.4 (9.7-40.2) in VAP group and 24.6 (13.1-57.8) in patients without pneumonia (NS). Among the 25 BAL with micro-organism counts of 10(4) CFU mL(-1), 3 had a dilution factor lower than 10, resulting in corrected counts below the threshold of 10(5) CFU mL(-1). Two out of 15 patients with micro-organism counts of 10(3) CFU mL(-1) had corrected micro-organism counts of 10(5) CFU mL(-1). Finally, only five BAL (2.1%) were misclassified when the dilution correction factor was applied., Conclusions: Using urea as dilution factor, we showed that BAL dilution variations did not alter the interpretation of BAL quantitative bacterial culture when administrating three aliquots of 50 mL of saline.

Nocardiosis is an uncommon infection, which is exceptionally present as a postoperative event. A case of postoperative pulmonary and cerebro-meningeal infection caused by Nocardia otitidiscaviarum after a leg amputation in a diabetic patient is reported. Diagnosis has been delayed and the clinical, radiological and microbiological causes of this delay are assessed from a quality of care management point of view. Recommendations are proposed regarding physicians' role and optimized microbiological procedures for recognition of slowly growing nocardial strains.

Particular attention is given to lower respiratory tract infections because of their frequency and potential severity. These infections represent a major cause of death worldwide and pneumonia remains the first cause of death from infectious origin in France. Three nosological entities are usually described according to the anatomic localization of the infectious process: acute bronchitis, pneumonia, and bronchopneumonia (if the infection involves the bronchial tree and the lung parenchyma). If bronchial infection occurs within the context of a chronic respiratory tract disease, it is called acute decompensation of chronic lung disease (usually chronic obstructive pulmonary disease). The major diagnostic difficulties are to be able to confirm alveolar implication in the infectious process and to determine the pathogenic agent(s) responsible for the clinical pattern. This information is essential for subsequent care depends. Apart from clinical examination, essential in this context, only chest-X-rays can be of any help to confirm alveolar involvement in the disease process. On the contrary, the interest of systematic microbiological confirmation and its value according to various techniques and swab conditions may be questioned for the clinical diagnosis. Microbiological confirmation does not seem essential in every case. The feasibility and relevance of microbiological techniques must be determined before any decision is taken on documentation. The microbiological documentation value depends on its yield and sensitivity profile in identifying the pathogen.

Background: The diagnosis of ventilator-associated pneumonia relies on protected specimen brush (PSB), BAL, and plugged telescoping catheter (PTC) procedures. In the particular setting of nosocomial pneumonia (NP) occurring in non-mechanically ventilated patients, no consensus exists on their use. When mechanical ventilation (MV) becomes mandatory, postintubation tracheal aspiration (PITA) could be a simple, fast, and cheap diagnostic tool. Our aim was to compare the diagnostic accuracy of PITA to that of PSB, BAL, or PTC in patients requiring MV for suspected NP., Methods: Patients with a prior hospital stay of > or = 48 h who required MV for suspicion of NP were prospectively enrolled in the study. PITA was performed by sterile suction. Within 2 h, pulmonary samples were obtained by PSB, BAL, or blinded PTC, which are referred to hereafter as "reference methods" (RMs). The definite diagnosis of NP was made using a composite item of clinical, radiologic, and bacteriologic (ie, blood or pleural fluid cultures) patterns. The agreement between the quantitative microbiological results obtained with PITA and those of the RMs was assessed by the kappa-statistic. The sensitivity, specificity, and positive and negative likelihood ratios of PITA and RMs were calculated taking the definite diagnosis of NP as the reference., Results: There were 44 cases (63.8%) of confirmed NP. The kappa-statistic was 0.71. The sensitivity, specificity, and positive and negative likelihood ratios were 77%, 84%, 4.80, and 0.27, respectively, for PITA, and 75%, 88%, 6.25, and 0.28, respectively, for RMs., Conclusions: PITA may be a reliable alternative to RMs in the particular setting of NP in newly mechanically ventilated patients.

Study Objectives: To test whether routine quantitative cultures of endotracheal aspirates obtained before the onset of ventilator-associated pneumonia (VAP) could help to predict the causative microorganisms and to select early appropriate antimicrobial therapy before obtaining BAL culture results., Design: Prospective observational study., Setting: French medical ICU., Patients: A total of 299 patients received mechanical ventilation for at least 48 h., Interventions: Endotracheal aspiration (EA) was performed twice weekly in all mechanically ventilated patients. A diagnosis of VAP was made by BAL culture. Only the EA performed just before the suspicion of VAP (EA-pre) were evaluated. This strategy (ie, the EA-pre-based strategy) was compared with an antibiotic therapy that would have been prescribed if the recommendations of both the American Thoracic Society (ATS) and Trouillet et al (Am J Respir Crit Care Med 1998; 157:531-539) had been applied., Measurements and Results: VAP was diagnosed (by BAL culture) in 41 of the 75 patients in whom BAL was performed. Among the 41 BAL specimens that were positive for VAP, EA-pre had identified the same microorganisms (with the same antibiotic resistance patterns) in 34 cases (83%). In one case, EA-pre was not available at the time BAL was performed (a case of early-onset VAP), but the empiric antibiotic therapy was adequate. While EA-pre did not give the same results as the BAL culture, the antibiotic therapy based on the results of the EA-pre was adequate in four other cases. Finally, antibiotic therapy was delayed in only two cases. Antibiotic treatment was therefore adequate in 38 of the 40 assessable cases (95%). If the Trouillet-based strategy had been used, the antibiotic treatment would have been adequate in 34 of the 41 cases (83%; p = 0.15 [vs EA-pre strategy]). Based on the ATS classification, the antibiotic treatment would have been adequately prescribed in only 28 of the 41 cases (68%; p = 0.005 [vs EA-pre strategy])., Conclusions: Routine EA performed twice a week makes it possible to prescribe adequate antibiotic therapy (while waiting for BAL culture results) in 95% of the patients in whom a VAP is ultimately diagnosed by BAL culture.

Objective: To evaluate the potential ability of an algorithm based on the clinical pulmonary infection score (CPIS) to identify and treat patients with bacterial ventilator-associated pneumonia (VAP) compared to a strategy based on quantitative cultures of bronchoscopic specimens., Design: Retrospective cohort study., Setting: Thirty-one critical care units across France., Patients: Two hundred and one patients clinically suspected of having VAP who had been included in the "invasive strategy" group of the French multicenter randomized trial and for whose quantitative cultures bronchoscopic specimens were obtained. CPIS was determined retrospectively, based on data that had been collected for the initial study., Interventions: None., Measurements and Results: The clinical pulmonary infection score was determined on days 1 and 3, and compared in patients identified as having developed VAP or not, as defined by bronchoscopic specimen culture results. On day 3 138 of the 201 patients (69%) had a CPIS of more than 6 that would have required prolonged antimicrobial therapy based on the algorithm. In contrast, based on bronchoscopy, only 88 (44%) patients were considered to have VAP (kappa coefficient for concordance between the two strategies, 0.33). While the sensitivity of CPIS more than 6 on day 3 for identifying VAP was 89%, its specificity was only 47%, leading to potentially unnecessary treatment of 60 (53%) of the 113 patients without VAP as diagnosed by bronchoscopy., Conclusion: A strategy based on the CPIS to decide which patients with suspected VAP should receive prolonged administration of antibiotics would appear to over-prescribe these agents, as compared to a strategy based on bronchoscopy.

EPIDEMIOLOGICAL EVOLUTION: Until the mid-eighties, infectious complications (pneumonia, septicemia) observed in neutropenic patients were, in 70% of cases, of bacterial origin with Gram negative bacillae (Escherichia coli, Klebsiella sp, Pseudomonas aeruginosa) isolated 8 times out of 10. Among the Gram positive bacteria, Staphylococcus aureus predominated. The etiological profile of bacterial infections has since evolved with a predominance (60 to 70%) of Gram positive bacteria (coagulase-negative staphylococci, viridans streptococci) and a change in the epidemiology of the Gram positive bacteria notably with a lesser frequency of P. aeruginosa infections. THE GRAM POSITIVE BACTERIA: Coagulase-negative staphylococci are among the first germs responsible for nosocomial bacteremia (central venous catheters) and they are usually multiresistant. Viridans streptococci are a frequent cause of bacteremia; they are generally sensitive to antibiotics active on Gram positive bacteria, but the incidence of resistant strains is increasing. Enterococci are in majority responsible for colonisation in neutropenic patients and less frequently for infections; they raise the problem of resistance to antibiotics, notably to glycopeptides. Other Gram positive bacteria can be responsible for infections in neutropenic patients; it is crucial that they be identified because they require treatment with an appropriate antibiotic. GRAM NEGATIVE BACTERIA: Among the enterobacteria, Escherichia coli is predominantly isolated and raises the problem of the increasing incidence of resistance to fluoroquinolone. Pseudomonas aeruginosa, less frequently responsible today, remains associated with a far greater rate of mortality than that observed with the other microorganisms. Other Gram negative bacteria can be identified; they require an adapted antibiotherapy because they are often naturally multiresistant to antibiotics. THE ROLE OF THE LABORATORY: For the diagnosis of infections in neutropenic patients, the microbiology laboratory has a determinating role. The laboratory ensures the analysis of various biological examinations: blood cultures, methods permitting the diagnosis of an infection on a permanent catheter, copro-cultures (research for common enteropathogens, quantification in the case of digestive decontamination, screening for multiresistant bacteria), cytobacteriological examination of urine, samples of respiratory origin, cytobacteriological examination of cerebro-spinal fluid...).

Objectives: Prognosis factors of ventilator-associated pneumonia (VAP) have been largely investigated, while the data concerning postoperative pneumonia (POP) are scarce. The aim of this multicenter, prospective study was to evaluate the predictive factors of mortality due to POP and the impact of initial antibiotic therapy on outcome., Methods: Two hundred centers were included. Diagnosis of POP was assessed on clinical and laboratory criteria, chest X-ray changes and microbiological criteria, when possible. Outcomes of the patients were noted. An independent committee made a retrospective assessment of appropriateness of antimicrobial therapy., Results: The overall mortality among the 556 cases of POP was 23% (126 patients). Five parameters were independently associated with mortality: American Society of Anesthesiology (ASA) grade 3 or more ( p<0.001), age 64 years or more ( p<0.01), time to onset of pneumonia more than 3 days ( p<0.01), mottling ( p<0.05) and hypotension ( p<0.05). Among the 322 microbiologically confirmed cases of pneumonia, 92 received inappropriate antibiotic (AB) therapy (29%). No difference in mortality was observed between the patients receiving inappropriate and appropriate AB therapy (22.8 vs 16.9%). In this subgroup, three parameters remained independently associated with mortality: ASA grade 3 or higher ( p<0.001), time to onset of pneumonia more than 3 days ( p<0.05) and hypotension ( p<0.05). Inappropriate initial AB did not modify the model ( p=0.22)., Conclusions: Five independent predictive factors for mortality of POP were identified. Despite a trend toward decreased mortality with appropriate initial antimicrobial therapy, no difference was observed between the groups. Polymicrobial pneumonia or non-fermenting Gram-negative bacilli appeared to be a risk factor for inappropriate AB.

Objective: Protected specimen brush (PSB) and bronchoalveolar lavage (BAL) are proposed in combination to optimize antimicrobial treatment. Nevertheless, they are only validated for immediate laboratory processing. This study was therefore conducted to determine whether 48 h conservation at a mere 4 degrees C enables good culture reproducibility for both PSB and BAL., Design and Setting: Prospective study, evaluation of a conservation procedure for PSB and BAL, from February 1994 to February 1995, in the 12 bed ICU of a general hospital (938 beds)., Samples: Ninety-nine PSB and 86 BAL samples, obtained from 100 bronchoscopic procedures, were analyzed. Thresholds were 10(3) and 10(4) cfu/ml for PSB and BAL, respectively., Measurements and Results: Qualitative comparison between the immediate and 48 h procedures were, for PSB, specificity 100%, sensitivity 78%, positive predictive value 100%, negative predictive value 84% and overall accuracy 90%; and for BAL: 100%, 89%, 100%, 89% and 94%. Lowered 10(2) and 10(3) cfu/ml thresholds at the 48 h procedure for PSB and BAL reduce the false negatives from 10 to 3 and 5 to 1, respectively. Microorganism results were comparable for PSB and BAL ( r = 0.63 and 0.67), especially for the most resistant strains: Staphylococcus, Enterobacteriaceae and Pseudomonas. However, there was a decrease in the Neisseria and Haemophilus group ( p < 0.01)., Conclusion: There is a good culture reproducibility for both PSB and BAL after 48 h conservation at 4 degrees C, especially with lowered thresholds; this technique is therefore appropriate for routine use.

The aims of this study were to assess the repeatability of two pairs of protected specimen brushes (PSB) done successively in the same lung area and either processed at the bedside or in the laboratory, and to provide a description of the bacteriological findings in 39 cases of suspected nosocomial pneumonia occurring in nonventilated patients. Four PSB were divided into two pairs. One pair of brushes (PB) was prepared at bedside and then sent to the laboratory; the other pair (PL) was immediately sent to the laboratory for complete processing. According to a 10(3) colony forming units (cfu) x mL(-1) threshold, 49% out of 156 PSB were positive. Using the 10(3) cfu x mL threshold, the PL brushes were 89.7% concordant while the PB brushes were 76.9% concordant. The repeatability as expressed by K-value of the cultures of PSB was higher for PL brushes than for PB brushes (K-values of 0.795 and 0.537 respectively, p=0.12). Bacterial species were isolated in 58.3% of 156 PSB (176 isolates). In 14 cases, cultures of PSB disclosed more than one micro-organism in a concentration > 10(3) cfu x mL(-1). The most frequently isolated organisms were Pseudomonas spp. (23.9%), Enterobacteriaceae (23.3%), Streptococcus spp. (21.6%) and Staphylococcus spp. (13.1%). Polymicrobial cultures were more frequent if the patient had a tracheostomy (seven out of the nine patients with a tracheostomy versus seven out of the 30 patients without a tracheostomy, p<0.01). Bacteriological discrepancies leading to a potential troublesome choice in antibiotherapy were observed in 31.8% of the patients for PL brushes and 56.5% of the patients for PB brushes. There is a low degree of repeatability of protected specimen brushes outside intensive care units which seem dependent on sampling processing. The distribution of pathogens found in case of suspicion of nosocomial pneumonia in nonventilated patients appears to be similar to that obtained in ventilator-associated pneumonia.

We investigated the incidence, risk factors for, and outcome of ventilator-associated pneumonia (VAP) in patients with acute respiratory distress syndrome (ARDS). We compared 134 patients with ARDS with 744 patients without ARDS on mechanical ventilation. Fiberoptic bronchoscopic examination and quantitative bacterial cultures (protected brush or catheter sampling [threshold: 10(3) cfu/ml], or bronchoalveolar lavage [threshold: 10(4) cfu/ml]) were used to diagnose pneumonia. VAP occurred in 49 patients (36.5%). The incidence of pneumonia was 23% (173 of 744 patients) among patients without ARDS (p < 0.002). Nonfermenting gram-negative rods caused significantly more pneumonia in ARDS patients. Mortality rates were identical in ARDS patients with (28 of 49 patients, 57%) and without (50 of 85 patients, 59%) pulmonary infection (p = 0.8). VAP resulted in a considerable increase in attributable time on mechanical ventilation of both the overall population of ARDS patients and of survivors. Both the use of sucralfate (adjusted odds ratio [OR]: 4. 42; 95% confidence interval [CI]: 2.01 to 9.7, p = 0.0002) and the duration of exposure to sucralfate (adjusted OR: 1.206; 95% CI: 1. 095 to 1.328, p = 0.0002) were associated with an increased risk of VAP during ARDS. VAP considerably prolongs the time on mechanical ventilation without affecting survival. Patients given sucralfate may be at greater risk of developing pulmonary infection during ARDS.

Q fever is a worldwide zoonosis but is not often a common cause of fever among travellers returning from the tropics. We report a case of acute Q fever, revealed by a pneumonia and acquired by a traveller in French Guyana. The chest radiography showed alveolar opacities and pleural effusion. Biological abnormalities were elevated liver enzyme levels and thrombocytopenia. The patient improved or the third day of antibiotic treatment. She mentioned that 3 other people she lived with during her trip had been diagnosed with Q fever. A common source outbreak was then suspected. They all stayed in the same farm in French Guyana. Animal exposure occurred there, in particular with a goat and a dog (both were parturient). The disease was probably transmitted by airborne dust to our patient, as no other vectors of transmission were found. Since the clinical presentation of Q fever is not specific, in order for the physician to diagnose it, he must have an awareness of the disease. Our case emphasised that looking for risk factors of Coxiella burnetii exposures is particularly important. Amongst them, the most important seems to be contact with farm animals. The clinician should thus try to trace such a possible contact when treating a case of traveler's Q fever.

Q fever is a widespread zoonosis caused by Coxiella burnetii, an obligate intracellular bacterium, which humans usually acquire through the inhalation of infected dust from subclinically infected mammals. Human infection commonly takes place when an infected mammal gives birth, since high concentrations of the organism are found in the products of conception. Worldwide, cattle, sheep, and goats are the most common reservoirs for C. burnetii. A few investigators have also reported parturient cats and dogs as the sources of human outbreaks of Q fever. During a 10-day period in May 1996, all five members of one family living on a farm in Provence, in the south of France, became ill with fever, general malaise, and cough. All of them had acute Q fever. An epidemiological investigation suggested that this outbreak resulted from exposure to contaminated pigeon feces and ticks.

Due to the increasingly widespread development of international exchanges, physicians, particularly pneumologists, working in metropolitan France may encounter patients with respiratory signs who have travelled or lived in tropical zones. In such cases, history taking, physical examination, imaging, bacteriological and parasitological explorations, pathology and immunology are all precious tools for diagnosis. All possible tropical diseases should be entertained, taking into account the geographical setting and the patient's lifestyle. The pneumologist must not forget that these exotic tropical diseases remain uncommon compared with cosmopolitan causes of lung disease: bacterial infections, tuberculosis, cancer.

Chlamydia pneumoniae and Mycoplasma pneumoniae are frequently involved in lower respiratory tract infections in children. Their responsibility must be evoked whenever an antibiotic treatment has been prescribed for a suspected bacterial origin, without clinical improvement (persistent fever particularly) after 48 hours. This must lead to the prescription of a macrolide.