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Molecular typing of extended spectrum beta lactamase producing nbsp klebsiella pneumoniae nbsp strains isolated in the university hospital center of Dakar

In head and neck cancer surgery antibiotic prophylaxis is effective in reducing the incidence of surgical site infections (SSI). However, controversies between antibiotic prophylaxis and curative antibiotic therapy exist, particularly when complex and decaying surgeries are performed in risky underlying conditions, with a risk of persisting salivary effusion in the postoperative period, or in the case of reconstruction with myo-cutaneous flaps. We have performed a systematic review of the literature according to PRISMA recommendations to answer the following questions: indications for antibiotic prophylaxis and curative antibiotic therapy, optimal duration, and choice of antibiotics for prophylaxis in head and neck cancer surgery. Literature analysis allows to conclude that patients undergoing Altemeier classes 2 and 3 surgical procedures should receive perioperative antibiotic prophylaxis restricted to the first 24 postoperative hours. No benefit has been shown with its extension beyond these 24 hours. The most adapted combinations of antibiotics in this setting are "amoxicillin+clavulanic acid" and "clindamycin+gentamicin". However, the level of evidence regarding the most decaying surgeries with high risk of SSI is low, making it necessary to perform new high-powered randomized trials in these patients. Eventually, it should be noted that antibiotic prophylaxis should be an integral part of SSI preventive measures, including application of hygiene measures, and postoperative monitoring of SSI clinical signs.

Resume Parmi les bacilles a Gram negatif, le role des β-lactamases dans les resistances naturelles ou acquises est essentiel et de plus en plus complexe. De nombreux genes gouvernant ces resistances sont chromosomiques, ou portes par des plasmides, des integrons ou encore lies au CR (Common Region) : ils ont ete clones et sequences, montrant une considerable diversite parmi les enzymes inactivant les s-lactamines. Une serie de reponses genetiques sont developpees par les bacteries apres introductions successives de nouveaux antibiotiques tels que les β-lactamines. Cette adaptabilite du monde bacterien doit conduire a limiter l’abus de prescriptions et un meilleur usage des antibiotiques.

We aimed to detect the extended-spectrum β-lactamases (ESBLs) secreted by clinical strains of Escherichia coli at Fann University Hospital in Dakar and to characterize them molecularly. We identified 32 isolates producing ESBLs. The CTX-M-15 gene was the most frequently detected ESBL gene, detected in 90.63% of the isolates studied.

Background: There is little information on the incidence of AIDS-defining events which have been reported in the literature to be associated with immune reconstitution inflammatory syndrome (IRIS) after combined antiretroviral therapy (cART) initiation. These events include tuberculosis, mycobacterium avium complex (MAC), cytomegalovirus (CMV) retinitis, progressive multifocal leukoencephalopathy (PML), herpes simplex virus (HSV), Kaposi sarcoma, non-Hodgkin lymphoma (NHL), cryptococcosis and candidiasis. Methods: We identified individuals in the HIV-CAUSAL Collaboration, which includes data from six European countries and the US, who were HIV-positive between 1996 and 2013, antiretroviral therapy naive, aged at least 18 years, hadCD4+ cell count and HIV-RNA measurements and had been AIDS-free for at least 1 month between those measurements and the start of follow-up. For each AIDS-defining event, we estimated the hazard ratio for no cART versus less than 3 and at least 3 months since cART initiation, adjusting for time-varying CD4+ cell count and HIV-RNA via inverse probability weighting. Results: Out of 96 562 eligible individuals (78% men) with median (interquantile range) follow-up of 31 [13,65] months, 55 144 initiated cART. The number of cases varied between 898 for tuberculosis and 113 for PML. Compared with non-cART initiation, the hazard ratio (95% confidence intervals) up to 3 months after cART initiation were 1.21 (0.90-1.63) for tuberculosis, 2.61 (1.05-6.49) for MAC, 1.17 (0.34-4.08) for CMV retinitis, 1.18 (0.62-2.26) for PML, 1.21 (0.83-1.75) for HSV, 1.18 (0.87-1.58) for Kaposi sarcoma, 1.56 (0.82-2.95) for NHL, 1.11 (0.56-2.18) for cryptococcosis and 0.77 (0.40-1.49) for candidiasis. Conclusion: With the potential exception of mycobacterial infections, unmasking IRIS does not appear to be a common complication of cART initiation in high-income countries. © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Les methodes d'epidemilogie moleculaire ont beaucoup evolue ces dernieres annees. Elles fournissent une empreinte genetique des bacteries soit de leur chromosome, soit de leur contenu en ADN plasmidique. Leur mise en œuvre necessite une bonne maitrise des techniques de biologie moleculaire. Elles font parfois appel a des methodes recentes comme l'electroporese en champ pulse ou la PCR, egalement parfois a des techniques tres minutieuses comme les techniques d'hybridation, et utilisent dans certains cas des produits dangereux comme des isotopes radioactifs, des solvants comme le phenol et des agents intercalants comme le bromure d'ethidium. C'est, entre autre, une des raisons pour lesquelles l'utilisation de ces methodes doit etre faite a bon escient. L'utilisation d'etalon interlaboratoire a chaque manipulation et de logiciels informatiques permettra bientot une lecture et une interpretation objective et fiable des profils obtenus.

Antibiotic resistance has become a major public health problem in Algeria. Indeed the past decade, we have seen a significant increase in resistance to antibiotics especially in Gram-negative bacilli. Resistance to β-lactams in enterobacteria is dominated by the production of ESBL CTX-M-3 and CTX-M-15. The strains producing these enzymes are often the cause of potentially serious infections in both hospital and community settings. Identified plasmid cephalosporinases are CMY-2, CMY-12 and DHA-1. The isolation of strains of Enterobacteriaceae and Pseudomonas aeruginosa producing carbapenemases is rare in Algeria. Some Enterobacteriaceae producing OXA-48 or VIM-19 have been reported; so far, only VIM-2 has been identified in P. aeruginosa. However, the situation regarding the strains of Acinetobacter baumannii resistant to carbapenemases seems to be more disturbing. The carbapenemase OXA-23 is the most common and seems to be endemic in the north. The carbapenemase NDM-1 has also been identified. Resistance to aminoglycosides is marked by the identification armA gene associated with blaCTX-M genes in strains of Salmonella sp. Several other resistance genes have been identified sporadically in strains of Enterobacteriaceae, P. aeruginosa and A. baumannii. Resistance genes to fluoroquinolones are more recent identification in Algeria. The most common are the Qnr determinants followed by the bifunctional enzyme AAC[6']-Ib-cr. Resistance to sulfonamides and trimethoprim was also reported in Enterobacteriaceae strains in the west of the country.

In head and neck cancer surgery antibiotic prophylaxis is effective in reducing the incidence of surgical site infections (SSI). However, controversies between antibiotic prophylaxis and curative antibiotic therapy exist, particularly when complex and decaying surgeries are performed in risky underlying conditions, with a risk of persisting salivary effusion in the postoperative period, or in the case of reconstruction with myo-cutaneous flaps. We have performed a systematic review of the literature according to PRISMA recommendations to answer the following questions: indications for antibiotic prophylaxis and curative antibiotic therapy, optimal duration, and choice of antibiotics for prophylaxis in head and neck cancer surgery. Literature analysis allows to conclude that patients undergoing Altemeier classes 2 and 3 surgical procedures should receive perioperative antibiotic prophylaxis restricted to the first 24 postoperative hours. No benefit has been shown with its extension beyond these 24 hours. The most adapted combinations of antibiotics in this setting are "amoxicillin+clavulanic acid" and "clindamycin+gentamicin". However, the level of evidence regarding the most decaying surgeries with high risk of SSI is low, making it necessary to perform new high-powered randomized trials in these patients. Eventually, it should be noted that antibiotic prophylaxis should be an integral part of SSI preventive measures, including application of hygiene measures, and postoperative monitoring of SSI clinical signs.

Four susceptibility patterns of wild types of enterobacteria against old beta-lactams including aminopenicillins, carboxypenicillins and first-generation cephalosporins were individualized during the 1980s : susceptible, penicillinase low level, cephalosporinase and a combination of penicillinase and cephalosporinase. Such indirect detection of a mechanism of resistance allowed an interpretative reading for this class of antibiotics. At the present time, seven susceptibility patterns were proposed for this family of gram negative bacilli. Nevertheless, an analysis of results in terms of MICs and diameters of inhibition zone sizes of the main bacterial species of enterobacteria, mainly obtained from the databank of European Committee on Antimicrobial Susceptibility Testing (EUCAST), compared to that observed when overproducing strains were isolated in vivo and in vitro and to the type of beta-lactamase identified and their amino acid sequences conducted to a proposal of five susceptibility patterns. The fifth wild type individualized in several enterobacteria since 2005 is related to the synthesis of various chromosomal extended-spectrum beta-lactamases (ESBL) which hydrolyze many beta-lactams including oxyimino-cephalosporins such as ceftriaxone or cefotaxime. Their expression in a wild strain is characteristic and conducted to our interest for their role as progenitors of the transferable CTM-M types. Otherwise, a medical biologist must consider the possibility of selection of a mutant with a chromosomal overproduced beta-lactamase. But within the same beta-lactam susceptibility pattern such as for Klebsiella pneumoniae and K. oxytoca or Citrobacter amalonaticus, the spectrum of inactivation will be highly variable according to the type of enzyme overproduced. Finally, a nice synergy observed between clavulanic acid and cefotaxime or ceftriaxone or even aztreonam does not mean anytime a transferable ESBL. In some cases according to the result of enterobacterial identification, the epidemiological impact will be very low, because without multidrug resistance (MDR).

Resume Compte tenu de l'eventualite actuelle plus grande d'isoler chez l'homme des souches de Bordetella bronchiseptica, la sensibilite de 23 souches a ete determinee, par la methode de diffusion, vis-a-vis de 35 antibiotiques et comparee a celle d'Alcaligenes (A. faecalis, A. denitrificans subsp. xylosoxydans) qui presentent des caracteres proches de ceux de B. bronchiseptica. Toutes les souches testees sont sensibles a: amoxicilline, ticarcilline, mezlocilline, piperacilline, cefoperazone, latamoxef, imipeneme, kanamycine, neomycine, gentamicine, tobramycine, netilmicine, amikacine, acide nalidixique, pefloxacine, colistine, tetracycline, minocycline et erythromycine. Mais elles sont intermediaires ou resistantes a : mecillinam, cefalotine, cefamandole, cefoxitine, cefuroxime, cefotaxime, aztreonam, streptomycine, spectinomycine, acide pipemidique, rifampicine, fosfomycine et trimethoprime. Enfin une faible synergie est observee entre l'amoxicilline et l'acide clavulanique. L'etude comparative de la sensibilite, en particulier aux β-lactamines et aux aminosides a permis de differencier les souches de B. bronchiseptica de celles d'A. faecalis ou d'A. denitrificans subsp. xylosoxydans. Ce phenotype de resistance propre a B. bronchiseptica constitue donc, une aide au diagnostic d'autant plus utile que ces trois especes presentent des caracteres d'identification tres voisins.

Intragenic DNA probes were synthesized by polymerase chain reaction using fragments of the genes of three major types of β-lactamases (TEM, SHV, CARB) as templates. The TEM probe hybridized with the genes encoding TEM-1, TEM-2 and six extended-spectrum related enzymes (TEM-3 to TEM-7, TEM-20) in colony hybridizations and Southern-blot analysis. The SHV probe hybridized with the genes for SHV-1, OHIO-1 and four derived extended-spectrum β-lactamases (SHV-2, SHV-3, SHV-4 and SHV-5). The CARB probe hybridized with the genes for PSE-1 (CARB-2), PSE-4 (CARB-1), CARB-3 and CARB-4. None of the probes hybridized with genes for any of eight oxacillin-hydrolysing enzymes, PSE-2, OXA-1 to OXA-7, ROB-1 and chromosomal β-lactamases of various Enterobacteriaceae (except Klebsiella pneumoniae) and Pseudomonas aeruginosa. Investigations of Escherichia coli clinical isolates using these probes indicate the presence of a novel type of extended-spectrum, transferable β-lactamase.

We report a case of actinomycosis caused by actinomyces israelii, related to the removal of intrauterine device (IUD). Diagnosing actinomycosis is difficult but should be considered in the event of any acute abdominal problems in a woman carrying an IUD. All abdominal organs may be affected. Even with a disseminated infection, the combination of appropriate antibiotic therapy (penicillin G) and surgery ensures a full recovery in most cases.

The acquired resistance against the wide-spectrum and highly stable beta-lactams including third-generation cephalosporins (3GC) and carbapenems is constinuously increasing and widespead with the discovery of various plasmid-encoded, or genes cassette or integrons coding for a novel beta-lactamase, always a major mechanism of resistance. To explain resistance against 3GC, with the continuing story with TEM and SHV mutated enzymes, several types of ESBL (class A) emerge the CTX-M type, at least CTX-M-40, but also other non predominant types intitled BES, GES, PLA, PER, VEB. The wider resistance including 3GC, cephamycins and beta-lactamase inhibitor is correlated to synthesis of transferable cephalosporinases (class C) usually located in the chromosome but mobilized from Enterobacter spp., Citrobacter freundii, Hafnia alvei, Morganella morganii, Aeromonas caviae. Such genes encoded the following types: ACC-1, ACT-1, CFE-1, CMY group, DHA-1, FOX group, MIR-1, MOX-1. Finally the resistance against carbapemens e.g. imipenem originally restricted to Pseudomonas aeruginosa, then to Acinetobacter baumannii and finally to enterobacteria is related to production of novel enzymes (classes B, D and A) denominated IMP, VIM SME, GIM, OXA, KPC. A striking exemple of evolution towards more and more resistance is given by Salmonella, even from animal origins, a great threat fo public health. So far it appears necessary to perform molecular approaches to identify such enzymatic production. Finally because the absence of real new drugs, the discovery of some progenitors of the gene beta-lactamase, a strict control of beta-lactam antibiotics must be provide not only in medecine or veterinary field but also in agriculture, including aquaculture for example.

Since nonfermenting, Gram negative bacilli recovered from patients with cystic fibrosis could be misidentified with phenotypic procedures, we used partial 16S ribosomal RNA gene (16S gene) sequencing to identify these "Pseudomonas-like" isolates. 473 isolates were recovered from 66 patients in 2003. Sequencing was used to identify 29 (from 24 patients) of the 473 isolates, showing unclear results with routine tests. PCR with specific primers was carried out to amplify a 995 bp fragment, which was then sequenced. The sequences were analyzed with GenBank database for species assignment. Phenotypic and genotypic results were concordant for 20/29 isolates (10 Pseudomonas aeruginosa, 5 Burkholderia cepacia, 3 Stenotrophomonas maltophilia, 2 Achromobacter xylosoxidans). However, 3 of the 5 B. cepacia isolates were then identified as Burkholderia multivorans with a PCR-RFLP procedure. Phenotypic misidentification was observed for 9/29 isolates: 4 A. xylosoxidans, 1 P. aeruginosa, 1 Bordetella petrii, 1 Bordetella bronchiseptica, 1 Ralstonia respiraculi and 1 Ralstonia mannitolilytica. Partial 16S gene sequencing improved the identification of "Pseudomonas-like" isolates from cystic fibrosis patients, but the accuracy to distinguish between genomovars of the B. cepacia complex was inadequate.

Because a multiresistant K. pneumoniae outbreak detected in an intensive care unit of a parisian hospital, combined to the production of the plasmid-encoded cephalosporinase ACC-1, a probable importation via a patient was suggested from another country (Tunisia). The investigation was conducted to examine 35 clinical strains of enterobacteria resistant to ceftazidime without synergy towards Augmentin. Other test of synergy with two inhibitors, BRL 42715, Ro 48-5545 was performed by diffusion method and deposit of 10 micrograms of inhibitor on disks containing ceftazidime, cefoxitin and cefotetan. Synergies were obtained suggesting a probable production of ACC-1 type among six isolates of K. pneumoniae (two), Proteus mirabilis (one) and Salmonella (three) issued from different units. The isoelectric focusing on gel revealed at least one band of beta-lactamase activity at 7.8 but also demonstrated the simultaneous production of several probable beta-lactamases including TEM-type, SHV-2 and ACC-1 among S. enterica ser. Livingstone. The PCR of the gene blaacc-1 was positive. The sequencing (1160 pb) of two products showed high identity (99-100%) with the gene blaacc-1 deposited in 1999. Finally the ACC-1 type reported in Tunisia was probably imported in France via a patient. Because a simultaneous synthesis of ESBL and ACC-1 type, its presence may be invisible and need more investigation.

The genetic organization of the gene coding for DHA-1 and the corresponding ampR gene was determined by PCR mapping. These genes have been mobilized from the Morganella morganii chromosome and inserted into a complex sulI-type integron, similar to In6 and In7. However, they are not themselves mobile cassettes. This integron probably includes a specific site for recombination allowing the mobilization of diverse resistance genes, as observed for bla(CMY-1) and bla(MOX-1).

Background The optimization of antibiotic therapy has become a major issue. Indeed, the evolution of bacterial resistance requires prescribers to reserve use of antibiotics and especially carbapenems. Various bodies have made recommendations to improve antibiotic regimens and thus preserve the effectiveness of these major antibiotics. At Tenon Hospital, a multidisciplinary unit was created in May 2011. It includes clinicians, bacteriologists, hygienists and pharmacists. Meropenem and ertapenem were already controlled whereas imipenem and doripenem were given without restrictions before May 2011. Purpose To assess the impact of this new organisation, a study compared the requirements for carbapenems before and after the antibiotic management team was created. Materials and Methods All patients who received at least one dose of carbapenem were included. Bacteriological and biological characteristics of each patient were found. The compliance of each prescription with the available guidelines was assessed studying the duration of treatment, dose and indications. Two periods were defined: the first between January 2009 and September 2010 and the second between June 2011 and May 2012. Results Duration of the treatment was the single criteria that had changed for ertapenem and meropenem. The impact of this team is greater for the prescriptions of doripenem and imipenem. Establishment of that team shortened the duration of treatment: 2 days for doripenem and 4 days for imipenem. The number of unjustified prescriptions of imipenem decreased from 45% to 5% for empirical treatments and from 51% to 20% for documented treatments. Conclusions Reduced length of treatment is important and reduces the selection pressure. This explains why carbapenem-resistant bacteria have been isolated only four times in the past year. Results obtained are similar to those obtained in two Parisian hospitals. No conflict of interest.

Three cases of cutaneous bacillary angiomatosis in HIV-infected patients are reported. They differed profoundly with respect to the extent of the lesions and the clinical course. In two cases, Rochalimaea quintana was identified by direct sequencing of the DNA amplified with the polymerase chain reaction (PCR), whereas an easy, rapid method based on the restriction length of polymorphism analysis of PCR products (PCR-RFLP) was used in the third case. This report illustrates the variations in clinical presentations and evolutive profiles in patients with bacillary angiomatosis, and confirms the causal role of R. quintana in this disease.

The accuracy of paired quantitative blood cultures (PQtBCs) collected in pediatric Isolator 1.5-ml tubes compared to central venous catheter (CVC) segment cultures (hub and tip) to diagnose catheter-related bacteremia (CRB) was evaluated in 58 bacteremic adult patients. The second aim of this study was to state precisely whether the tip or the hub (or both) of the infected device was the source of the bacteremia in case of significant results of PQtBC. Fifty-eight bacteremic patients with suspected CRB entered the study. In 52 patients, the diagnosis was obtained before CVC removal by PQtBC and was confirmed by CVC segment cultures: CRB in 30 patients, non-catheter-related bacteremia in 22 patients. Six patients had CRB not found by PQtBC. 1) PQtBC is 83% sensitive, 100% specific (negative predictive values 78%, positive predictive values 100%). 2) Sixteen bacteremic patients had authentic hub-related bacteremia (positive hub culture associated with negative tip cultures). When CRB is suspected in bacteremic patients, a negative tip culture cannot exclude the diagnosis of CRB. In all cases, CVC tip culture must be associated either with PQtBC or with hub cultures.

At least 30 extended-spectrum beta-lactamases (ESB) have emerged responsible for resistance to indigestible beta-lactams (C3G) since their discovery in West Germany in 1983. Most of them are produced by enterobacteria and essentially K. pneumoniae which appeared susceptible to oxyimino-beta-lactams. A double-disk test was useful to detect such nosocomial isolates of enterobacteria (urines, blood, wound, sputum cultures) mostly recovered from patients in intensive care units. These have spread through hospital and outbreaks were described. Because plasmid-encoded this resistance mechanism was spreading among enterobacteria with other resistance markers (e.g. netilmicin, amikacin). It seems highly likely that the use of newer antibiotics favors the appearance of ESB obtained by selection of mutated genes coding for penicillinases (TEM, SHV). Treatment including a beta-lactam is still possible because of the stability of some beta-lactams e.g. cefamycins, carbapenems and the sensitivity to beta-lactam inhibitors. Digestive selective decontamination may overcome outbreak.

Intragenic DNA probes were synthesized by polymerase chain reaction using fragments of the genes of three major types of beta-lactamases (TEM, SHV, CARB) as templates. The TEM probe hybridized with the genes encoding TEM-1, TEM-2 and six extended-spectrum related enzymes (TEM-3 to TEM-7, TEM-2O) in colony hybridizations and Southern-blot analysis. The SHV probe hybridized with the genes for SHV-1, OHIO-1 and four derived extended-spectrum beta-lactamases (SHV-2, SHV-3, SHV-4 and SHV-5). The CARB probe hybridized with the genes for PSE-1 (CARB-2), PSE-4 (CARB-1), CARB-3 and CARB-4. None of the probes hybridized with genes for any of eight oxacillin-hydrolysing enzymes, PSE-2, OXA-1 to OXA-7, ROB-1 and chromosomal beta-lactamases of various Enterobacteriaceae (except Klebsiella pneumoniae) and Pseudomonas aeruginosa. Investigations of Escherichia coli clinical isolates using these probes indicate the presence of a novel type of extended-spectrum, transferable beta-lactamase.

A clinical isolate of Klebsiella pneumoniae sensu lato isolated from throat and a blood culture taken from a neutropenic patient treated for 2 weeks with ceftazidime and vancomycin was resistant to ceftazidime (MIC: 32 micrograms/ml) and moderately susceptible to aztreonam (MIC: 4 micrograms/ml). The isolate contained a plasmid of 180 kb which, when transferred to Escherichia coli by conjugation, conferred resistance to ceftazidime and tetracycline. The transconjugant had decreased susceptibility to ceftazidime (128-fold) and aztreonam (8-fold). Clavulanic acid and sulbactam each inhibited the resistance and clavulanic acid showed a synergistic effect when associated with ceftazidime and aztreonam. An extended-spectrum beta-lactamase with an isoelectric point of 7.6 was detected in the clinical isolates from blood and its transconjugant. This beta-lactamase showed similar substrate and inhibition profiles to SHV-1. In particular it did not hydrolyse ceftazidime. Hybridization with an intragenic probe for SHV-3 indicates that this beta-lactamase is an SHV-type enzyme. We propose that this novel CAZ-type extended-spectrum beta-lactamase be named SHV-6.

Cat-scratch disease (CSD) is a benign inoculative lymphoreticulosis, first described in independent reports by Pierre Mollaret [1] and Robert Debre in 1950 [2]. The disease usually self-limited, with spontaneous resolution occurring after several weeks, appears to be related to the presence of an identified gram-negative bacteria.

Paired quantitative blood cultures collected simultaneously via catheter and peripheral vein in Isolator 1.5 ml tubes, were performed in 50 febrile hematology children. Samples were taken to diagnose catheter-related sepsis (CRS) without catheter removal and to monitor the therapeutic efficiency of antimicrobials administered through the infected device by infusion and/or by the antibiotic lock technique (ALT). In 7 children (14%) the colony counts from catheter blood samples were 30-fold higher than the colony counts from peripheral samples, suggesting CRS; in 7 other patients (14%), identical colony counts in both samples suggested sepsis was not catheter-related. One patient (2%) had septicemia caused by E. coli found in the urinary tract; only the peripheral blood cultures were positive. In 6 patients (12%), the Isolator system was not effective for diagnosing bacteremia or CRS; in 29 patients (58%) the febrile episode was not microbiologically documented. All episodes of CRS were cured whatever the treatment was: infusion or ALT.

We have shown that the combination of teicoplanin (T) and ceftriaxone (C) given once daily as first-line empirical antimicrobial therapy is very effective (85%) and safe in febrile neutropenic children (ICAAC, 1988). Like others (ICAAC, 1989) we have stressed the new life-threatening problems with Streptococcus mitis and Strep. sanguis. Considering the regular sensitivity of Gram-positive organisms to T, it is possible that the introduction of the glycopeptide at the onset of aplasia may be helpful. The high incidence of fungal infection or superinfection supports the routine use of an effective antifungal agent when fever is still present or relapse occurs. Our study was designed to assess the prevention of (1) staphylococcal and streptococcal infections using T when the central catheter is being placed, and (2) candida infection by the simultaneous use of a new anti-mycotic agent fluconazole (F) administered once-daily. Patients were randomized into two arms of the study. Arm A received T 6 mg/kg/d and F 3 mg/kg/d starting when the catheter was put in place. If fever occurred, C 50 mg/kg/d and amikacin (A) 15 mg/kg/d were added and T increased to 10 mg/kg/d. If a febrile relapse occurred, amphotericin B was added. In arm B the combination of the three agents T 10 mg/kg/d, C 50 mg/kg/d and A 15 mg/kg/d was started only if there was fever. Amphotericin B was used in febrile relapses. Forty-six patients were eligible (23 in each arm; no statistically significant differences between the two groups). The mean age of the patients was 8 years and mean duration of aplasia 23 and 24 d. Results were as follows: arm A the duration of T + F alone was 10 d, 22 patients had a febrile episode with 1 Gram-positive, 11 Gram-negative and one candida strain isolated in eight patients. C + A were effective in 72% of these patients. There were no deaths. In arm B, fever occurred in all patients during the first 6 d, with eight Gram-positive and six Gram-negative organisms isolated in nine patients. C + T + A were successful in 83% of patients. A bacterial superinfection was documented in four patients, candida superinfection in seven patients and one patient died from Candida parakrusei septicaemia. When the total amount of C and A used in both arms was compared, there was a reduction in 20% of the two agents in arm A, but T was equivalent in both arms. Treatment was well tolerated in both arms.(ABSTRACT TRUNCATED AT 400 WORDS)

Cat-scratch disease is a benign inoculative lymphoreticulosis, related to the presence of a polymorph bacillus, Warthin-Stary silver stained, Gram negative as assessed by Brown-Hopp staining. It is found in the capillary walls and in macrophages bordering the lymph node sinusoids at the site of inoculation, in regional subacute adenopathy before softening, in internal organs and blood cultures of systemic infections, occurring more often in immuno-compromised patients. These bacteria have been demonstrated in subcutaneous vascular nodules, near to histiocytoid hemangioma in AIDS patients; these lesions are very similar to early stage Kaposi's sarcomas. This bacteria is provisionally listed as G 1492 by the Center for Disease Control.

We evaluated air contamination with bacteria and fungi in a transplantation unit, successively housed in two buildings. Bacterial air contamination was least in laminar air flow rooms, and reduced in ultraclean air rooms in comparison with conventional rooms. Similar results were obtained with culture of air for fungi.

Resume Nous avons realise durant 6 mois une etude prospective dont le but etait de tester l'interet du systeme d'hemocultures quantitatives Isolator 1,5 ml chez des enfants febriles porteurs d'un catheter veineux central (CVC) hospitalises en hematologie pediatrique. 54 enfants d'âge moyen 7 ans, traites pour leucemie aigue (45), lymphome (5), tumeur solide (3), aplasie idiopathique (1), ont ete inclus. En cas de syndrome febrile, etaient prelevees de facon simultanee au CVC et sur une veine peripherique (VP), des hemocultures sur tube Isolator et sur flacon Bactec. Sur 50 observations exploitables, 15 enfants ont eu des hemocultures positives sur tube Isolator. Chez 7 d'entre eux le nombre d'unites formant colonies (UFC)/ml etait tres superieur (x 2.10 a 1.10 6 ) dans l'echantillon sanguin preleve au CVC par rapport a l'echantillon preleve en peripherie, il s'agissait donc d'une septicemie a point de depart du CVC. Tous ont gueri CVC en place. Chez les 8 autres le nombre d'UFC/ml etait identique dans les prelevements au CVC et en VP permettant d'exclure la responsabilite du CVC dans l'infection. La sensibilite d'Isolator 1,5 ml dans notre etude est de 71,5 % et sa specificite de 100 %. Cette methode permet donc de diagnostiquer les septicemies a point de depart du CVC et de surveiller l'efficacite therapeutique de l'antibiotherapie CVC en place.

Fifteen cases of Aeromonas hydrophila septicaemia, characterized by their frequent pulmonary lesions and the severity of their course, are reported. The delay observed between admission to hospital and first symptoms, together with the presence of anatomical lesions or physiological disturbances suggesting bacterial invasion by the intestinal route, have led the authors to postulate a nosocomial digestive contamination, probably from water, as suggested by the particular ecology of this micro-organism. This hypothesis was supported by the finding of Aeromonas hydrophila in large numbers at the different points of the hospital water distribution system where samples were taken.

Four patients developed legionnaires' disease after bone marrow transplantation. Two cases occurred early after transplant and were considered as part of a hospital epidemic due to contamination of water supply. The other two cases were considered to be sporadic because they occurred 3-4 weeks after hospital discharge. The outcome was good in two patients. In the third patient, recurrent disease was probably due to acquired resistance to macrolides, and complete cure was achieved after treatment with pefloxacin and rifampicin. The fourth patient died of overwhelming infection despite early treatment with erythromycin and pefloxacin. During the same period we treated 14 patients with pefloxacin for prevention of bacterial infection, of whom none developed Legionella pneumophila infection, while three of the patients reported here were in a group of 11 patients who received only oral non-absorbable antibiotics for gut decontamination. The fourth patient in this report was receiving no antibiotics. Thus pefloxacin seems to be effective as prophylaxis against L. pneumophila infection. When the hospital water supply was heated to 60 degrees C and chlorinated, the nosocomial cases in the hospital completely disappeared.

Infection is the most common cause of mortality in neutropenic patients. Although fever does not necessarily mean infection, it must be regarded as its first sign and treated, within hours of its onset, on the basis of probability before a pathogen is isolated. The first-line treatment must cover a wide antibacterial spectrum corresponding to the usual bacteriological flora and to the patient's underlying pathology. The risk of Gram-negative septicaemia in infants and elderly people and the frequency of staphylococcal infections in patients with an indwelling central catheter are well-known. The "best guess" treatment should consist of a third generation cephalosporin, notably ceftazidime, and an antistaphylococcal antibiotic. This treatment should be pursued throughout the period of neutropenia. Due to advances in antibacterial therapy, more aggressive chemotherapeutic regimens can now be prescribed to improve the prognosis of acute blood diseases and of numerous carcinomas.

Eight Capnocytophaga infections are described: bacteremia in immunodepressed patients (three cases), endocarditis (one case), pneumopathy (one case), buccal infection (two cases) and endometritis during use of an intrauterine contraceptive device (one case). The role of this bacterium in infections presented by immunodepressed patients is discussed in terms of literature data. Identification of the genus posed no problems. Species diagnosis is considered in terms of the use of conventional biochemical tests and the API ZYM collection.

In a consecutive series of 65 patients treated by allogeneic bone marrow transplantation, we have compared the efficacy on prevention of bacterial infection of total gut decontamination with oral non absorbable antibiotics or with oral absorbable broad spectrum antibiotics. On day-8, all patients were randomly allocated to one group: Group I received orally pefloxacin 400 mg/day and penicillin 3 M UI/day. Group II received capsules containing cephalothin 250 mg, gentamicin 20 mg and bacitracin 150 UI. Each patient received 9 to 12 capsules per day according to body weight. Patients less than 5 years old or with severe hepatic abnormalities were excluded from the study. All patients were treated in LAF room with usual precautions of asepsis. They received sterile food. In addition, they were on ketoconazole for prophylaxis of fungal infections and acyclovir for prevention of herpes infections. Antibiotics were started on day-8 before bone marrow transplantation and stopped 15 days after discharge from the hospital. 32 patients were allocated to Group I and 33 in Group II. There was no difference between both groups according to age, sex, diagnosis. After transplant, the one year survival and the complications were similar in both groups. The median time of decontamination was 65 days, the mean number of days of agranulocytosis was 20 days, the mean number of days of fever was 7 days in both groups. The compliance was better in Group I but the treatment had to be modified in 9 patients of Group I because of liver abnormalities.(ABSTRACT TRUNCATED AT 250 WORDS)

Ceftazidime was tested against 2,224 strains of Pseudomonas aeruginosa obtained from 17 hospitals in April, May and June, 1986 and against 607 strains of Klebsiella pneumoniae and 234 strains of K. oxytoca obtained from 16 hospitals in October, 1987. The MIC's of ceftazidime against P. aeruginosa were distributed normally, with an MIC50 of 2 mg/l and an MIC90 of 4 mg/l. Depending on critical concentrations, 80 per cent of strains were sensitive, 11.4 per cent were of intermediate sensitivity and 0.54 per cent were resistant. There were few differences in results between hospitals. Ninety-two per cent of resistant strains and 45 per cent of intermediate strains (as opposed to 6 per cent of all strains) produced a high-level constitutive cephalosporinase with little variations between centres. The MIC's of ceftazidime against K. pneumoniae and K. oxytoca had a bimodal distribution: 91 per cent of strains were sensitive to 0.25 mg/l, 6 per cent of strains showed intermediate sensitivity and 3 per cent were resistant. All intermediate and resistant strains produced a very broad spectrum beta-lactamase which hydrolyzed some of the third generation cephalosporins: K. pneumoniae 36 CTX-1, 5 SHV-2, and 14 strains producing a recently identified beta-lactamase "CAZ-5/SHV-4"; K. oxytoca 3 CTX-1. These strains were isolated in 10 of the 16 hospitals which took part in the 1987 study. Comparison of these results with those of studies performed in 1984 and 1985 showed a moderate increase in the number of intermediate sensitivity strains of P. aeruginosa and the occasional occurrence, of the epidemic type, in some hospitals of Klebsiella spp. producing very broad spectrum beta-lactamases which were rare in 1985.

No preventive treatment other than intestinal decontamination with oral colimycin was given. Antibiotic therapy with piperacillin 200-300 mg/kg, netilmicin 6-7.5 mg/kg and cloxacillin 50-100 mg/kg was initiated within 6 to 12 hours of clinical onset, using a central catheter. Twenty-nine children with bone marrow aplasia and less than 1000 leucocytes/mm3 were treated: 20 had acute lymphoblastic leukaemia or lymphoma (first episode 13, relapse 7, including 3 undergoing bone marrow transplantation), 6 had acute myeloblastic leukaemia (first episode 4, relapse during transplantation 2), and there was 1 case each of idiopathic bone marrow aplasia, metastatic sympathico-blastoma and lymphohistiocytosis. Mean age was 9 years (range: 2-19 years). The combined antibiotic therapy was continued until recovery from aplasia in case of success and discontinued after 48 hours in case of failure. Bacteriological examinations were negative in 19 patients and positive in 10; 13 strains were isolated, mostly staphylococci and streptococci. Apyrexia was obtained in 24 patients, 11 of whom had a rise of temperature with negative bacteriology about 10 days later. There were 4 initial failures and one unassessable result. An atopic patient developed a skin rash on the 3rd day of treatment. There was no death, no superinfection and non clinical or biochemical side-effect. It is concluded that the piperacillin-netilmicin -cloxacillin combination, which gave a high success rate and was well tolerated, can be recommended in neutropenic children with febrile episodes.

Ceftazidime in doses of 100 mg/kg/day was used, combined with netilmicin 6 mg/kg/day, as first-line treatment in two successive studies conducted on febrile neutropenic children (neutrophils less than 500/mm3). Study n. 1, performed at the Infantile Haematology unit of Saint Louis hospital, Paris, included 75 children. Study n. 2 was a multicentre study involving 88 children from 11 medical centres. The children's age in both studies ranged from 2 months to 16 1/2 years (mean 7 years). The percentage of bacteriologically documented febrile episodes was 45 per cent (34/75 and 39/88), and the most frequent infections were those caused by Gram-positive cocci (56 and 58 per cent respectively of the cases). Vancomycin 40 mg/kg/day was introduced if fever was still present 48 hours after the beginning of the antibiotic therapy. Effective treatments were continued until the neutropenia was corrected. These children were being treated for acute leukaemia, lymphoma, solid tumours or bone marrow aplasia. In study n. 1 apyrexia was obtained in 85 per cent of the cases with the ceftazidime-netilmicin combination and in 91 per cent of the cases after addition of vancomycin. The initial therapy was effective in all patients with a documented infection. There were tow super-infections with septicaemia: one due to Streptococcus D, the other to Staph. epidermidis. In study n. 2 73 per cent of the patients were apyretic after the first combination and 85 per cent after vancomycin was introduced. In proven infections the ceftazidime-netilmicin combination was effective in 30 cases and in another 6 cases after addition of vancomycin. Three patients remained febrile until they came out of aplasia. In all cases the bacterial cultures were sterilized by the ceftazidime-netilmicin combination. There was no superinfection. The mean duration of antibiotic therapy was 21 days in study n. 1 and 14 days in study n. 2. The drugs were perfectly tolerated both clinically and biochemically. No death occurred in the two studies. Thus, owing to its broad spectrum, effectiveness and safety ceftazidime is a very useful antibiotic when combined with netilmicin as first-line treatment of febrile neutropenic children.