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Background It is unclear whether Staphylococcus aureus with heterogeneous intermediate vancomycin resistance (hVISA) can develop vancomycin resistance faster than vancomycin-susceptible S. aureus (VSSA) strains. Methods We compared the kinetics of vancomycin MIC increase for 15 days of sustained in vitro vancomycin exposure for clinical hVISA (n = 12) and VSSA (n = 24) isolates, as well as for reference strains Mu3 (hVISA) and ATCC 29213 (VSSA). Clinical isolates were categorized as hVISA using the population analysis profile method. MICs were monitored for 15 days and the rate of MIC increase under exposure, for each strain, was evaluated in a linear regression model relative to time. Results All isolates acquired vancomycin resistance upon exposure. Vancomycin MICs increased faster for VSSA compared with hVISA isolates (P < 0.01). Conclusions The hVISA phenotype does not correspond to an enhanced adaptation potential to in vitro vancomycin pressure.

Introduction Lemierre’s syndrome is a rare but serious complication of an oral infection mostly related to Fusobacterium necrophorum. This condition combines jugular vein thrombosis and septic emboli to the lungs or other organs. Case presentation We report here an original case of a pharyngeal abscess complicated by Lemierre’s syndrome in a young healthy male patient. Samples taken from the pus of the pharyngeal abscess showed the presence of Gardnerella vaginalis associated with Fusobacterium necrophorum. The patient was treated by draining the abscess, antibiotic therapy and preventive anticoagulation for 1 month. The evolution was good with a resolution of the thrombosis. Conclusions This case highlights the need for bacterial identification to adapt antibiotic therapy in Lemierre’s syndrome. It also shows the possibility of extragenital localization of Gardnerella vaginalis in a male patient having oral sex with women. In contrast to sexually transmitted infections such as syphilis and pharyngeal gonococcus, this oral localization of Gardnerella vaginalis has not been described previously in the literature.

International audience; According to the World Health Organization (WHO), Plasmodium falciparum malaria during pregnancy is responsible for deleterious consequences for the mother and her child. The administration of intermittent preventive treatment (IPTp) with sulfadoxine-pyrimethamine (SP) at each antenatal care visit as early as 13weeks of gestation until the time of delivery is a strategy that is currently recommended by WHO for the prevention of malaria in pregnancy. However, the emergence and the spread of the resistance to SP in Africa raise the question of the short-term effectiveness of the strategy. Dihydroartemisinin-piperaquine 120mg/960mg once a day for 3consecutive days administered at least three times during the pregnancy might be an option for IPTp. The combination of 200mg of doxycycline once a day for 3consecutive days seems to be a good option to retard the emergence and the spread of resistance to artemisinin-based combination therapy (ACT) in Africa and improve the effectiveness of ACT in term of preterm births, neonatal morbidity and mortality. Contrary to preconceived ideas, scientific and medical data suggest that the risk of congenital malformations in the fetus or of tooth staining in infants whose mothers take doxycycline and hepatotoxicity during pregnancy is very low or non-existent. Additionally, the use of doxycycline during the first and second trimesters leads to an increase in gestational age at delivery, a decrease in the number of preterm births and a reduction in neonatal morbidity and mortality due to the beneficial antimicrobial activity of doxycycline against other infections during pregnancy. Furthermore, doxycycline has anti-malarial properties and is already recommended as prophylaxis for travellers and for treatment of falciparum malaria in combination with other anti-malarial drugs.

We report three cases of pruritic dermatitis with erythematous maculopapules, having a similar clinical presentation, in summer, and caused by two different arthropods. In wandering diagnosis since sometimes several months, patients have made entomologic investigations in their home. Two of three samples, have shown an infestation by Anobium punctatum, the common furniture beetle, a xylophagous beetle (usually harmless for human). It may be parasited by Pyemotes ventricosus, a mite known since the 19th century to cause this type of hurt. The third sample contained Cimex lectularius or bedbug, haematophagous insect, classically looked for in endemic zone.

International audience; Malaria, a parasite vector-borne disease, is one of the most significant health threats in tropical regions, despite the availability of individual chemoprophylaxis. Malaria chemoprophylaxis and chemotherapy remain a major area of research, and new drug molecules are constantly being developed before drug-resistant parasites strains emerge. The use of anti-malarial drugs is challenged by contra-indications, the level of resistance of Plasmodium falciparum in endemic areas, clinical tolerance and financial cost. New therapeutic approaches are currently needed to fight against this disease. Some antibiotics that have shown potential effects on malaria parasite have been recently studied in vitro or in vivo intensively. Two families, tetracyclines and macrolides and their derivatives have been particularly studied in recent years. However, other less well-known have been tested or are being used for malaria treatment. Some of these belong to older families, such as quinolones, co-trimoxazole or fusidic acid, while others are new drug molecules such as tigecycline. These emerging antibiotics could be used to prevent malaria in the future. In this review, the authors overview the use of antibiotics for malaria treatment.

More than 97% of imported Plasmodium falciparum malaria infections in France in 2014 were diagnosed within 2 months after returning from an area of endemicity (B. Pradines, personal data). The onset of malaria symptoms occurred a median of 6 days after arrival in France (25th to 75th percentile, 2

In 2015, the French Armed Forces deployed a biosafety level 3 (BSL3) field laboratory as a part of an Ebola treatment center in Guinea. When closing the center, laboratory decontamination operations were necessary. We present the decontamination protocols applied for the BSL3 field laboratory, making the entire module ready for a future use.

International audience; Malaria, a parasite vector-borne disease, is one of the biggest health threats in tropical regions, despite the availability of malaria chemoprophylaxis. The emergence and rapid extension of Plasmodium falciparum resistance to various anti-malarial drugs has gradually limited the potential malaria therapeutics available to clinicians. In this context, macrolides and associated antibiotics based on similar mechanism of action like lincosamides constitute an interesting alternative in the treatment of malaria. These molecules, whose action spectrum is similar to that of tetracyclines, are typically administered to children and pregnant women. Recent studies have examined the effects of azithromycin and the lincosamide clindamycin, on isolates from different continents. Azithromycin and clindamycin are effective and well tolerated in the treatment of uncomplicated malaria in combination with quinine. This literature review assesses the roles of macrolides and lincosamides in the prophylaxis and treatment of malaria.

Four cases of Streptococcus pyogenes infection due to an emm-type 11 strain, including one with a fatal outcome, occurred within a seven-member family. All strains shared biotype 5, pyrogenic exotoxin genes speB and speC, and resistance to kanamycin, tetracycline, macrolides and lincosamides. The identity of SmaI pulsed-field gel electrophoresis patterns confirmed their clonal origin. This highlights the ability of S. pyogenes to spread rapidly among family members. This first report of a family outbreak due to emm11 S. pyogenes reinforces the importance of surveillance of close family contacts of individuals with invasive streptococcal disease, and provides further support for antibiotic prophylaxis among the elderly.

Malaria, a parasite vector-borne disease, is one of the greatest health threats in tropical regions, despite the availability of malaria chemoprophylaxis. The emergence and rapid extension of Plasmodium falciparum resistance to various anti-malarial drugs has gradually limited the number of potential malaria therapeutics available to clinicians. In this context, doxycycline, a synthetically derived tetracycline, constitutes an interesting alternative for malaria treatment and prophylaxis. Doxycycline is a slow-acting blood schizontocidal agent that is highly effective at preventing malaria. In areas with chloroquine and multidrug-resistant P. falciparum parasites, doxycycline has already been successfully used in combination with quinine to treat malaria, and it has been proven to be effective and well-tolerated. Although not recommended for pregnant women and children younger than 8 years of age, severe adverse effects are rarely reported. In addition, resistance to doxycycline is rarely described. Prophylactic and clinical failures of doxycycline have been associated with both inadequate doses and poor patient compliance. The effects of tetracyclines on parasites are not completely understood. A better comprehension of the mechanisms underlying drug resistance would facilitate the identification of molecular markers of resistance to predict and survey the emergence of resistance.

The objective of this study was to validate the use of pftetQ and pfmdt genes as molecular markers of decreased in vitro susceptibility to doxycycline in 113 Plasmodium falciparum isolates from Dakar, Senegal. The results show that copy numbers of pftetQ and pfmdt , estimated by TaqMan real-time PCR, are not significantly associated with reduced susceptibility to doxycycline in vitro ; however, the number of samples with a high doxycycline IC 50 was likely to be too low to derive statistically significant results. Thus, no definitive conclusions could be drawn. The markers should be further tested by analysing more isolates.

International audience; Background: Doxycycline is an antibiotic used in combination with quinine or artesunate for malaria treatment or alone for malaria chemoprophylaxis. Recently, one prophylactic failure has been reported, and several studies have highlighted in vitro doxycycline decreased susceptibility in Plasmodium falciparum isolates from different areas. The genetic markers that contribute to detecting and monitoring the susceptibility of P. falciparum to doxycycline, the pfmdt and pftetQ genes, have recently been identified. However, these markers are not sufficient to explain in vitro decreased susceptibility of P. falciparum to doxycycline. In this paper, the association between polymorphism of the small sub-unit ribosomal RNA apicoplastic gene pfssrRNA (PFC10_API0057) and in vitro susceptibilities of P. falciparum isolates to doxycycline were investigated.Methods: Doxycycline IC50 determinations using the hypoxanthine uptake inhibition assay were performed on 178 African and Thai P. falciparum isolates. The polymorphism of pfssrRNA was investigated in these samples by standard PCR followed by sequencing.Results: No point mutations were found in pfssrRNA in the Thai or African isolates, regardless of the determined IC50 values.Conclusions: The pfssrRNA gene is not associated with in vitro decreased susceptibility of P. falciparum to doxycycline. Identifying new in vitro molecular markers associated with reduced susceptibility is needed, to survey the emergence of doxycycline resistance.

Determinations of doxycycline 50% inhibitory concentrations (IC 50 ) for 620 isolates from northwest Thailand were performed via the isotopic method, and the data were analyzed by the Bayesian method and distributed into two populations (mean IC 50 s of 13.15 μM and 31.60 μM). There was no significant difference between the group with low IC 50 s versus the group with high IC 50 s with regard to copy numbers of the Plasmodium falciparum tetQ ( pftetQ ) gene ( P = 0.11) or pfmdt gene ( P = 0.87) or the number of PfTetQ KYNNNN repeats ( P = 0.72).

International audience; Background: In 2002, the World Health Organization recommended that artemisinin-based combination therapy (ACT) be used to treat uncomplicated malaria. Dihydroartemisinin-piperaquine and artesunate-pyronaridine are two of these new combinations. The aim of the present work was to assess the distribution of the in vitro values of pyronaridine (PND) and piperaquine (PPQ) and to define a cutoff for reduced susceptibility for the two anti-malarial drugs. Methods: The distribution and range of the 50% inhibitory concentration values (IC 50) of PND and PPQ were determined for 313 isolates obtained between 2008 and 2012 from patients hospitalized in France for imported malaria. The statistical Bayesian analysis was designed to answer the specific question of whether Plasmodium falciparum has different phenotypes of susceptibility to PND and PPQ. Results: The PND IC 50 values ranged from 0.6 to 84.6 nM, with a geometric mean of 21.1 ± 16.0 nM (standard deviation). These values were classified into three components. The PPQ IC 50 values ranged from 9.8 to 217.3 nM, and the geometric mean was 58.0 ± 34.5 nM. All 313 PPQ values were classified into four components. Isolates with IC 50 values greater than 60 nM or four-fold greater than 3D7 IC 50 are considered isolates that have reduced susceptibility to PND and those with IC 50 values greater than 135 nM or 2.3-fold greater than 3D7 IC 50 are considered isolates that have reduced susceptibility to PPQ. Conclusion: The existence of at least three phenotypes for PND and four phenotypes for PPQ was demonstrated. Based on the cutoff values, 18 isolates (5.8%) and 13 isolates (4.2%) demonstrated reduced susceptibility to PND and PPQ, respectively.

Nocardia spp. are a group of aerobic actinomycetes widely distributed in soil, and associated with severe opportunistic infections, essentially pulmonary infections.We report the first case of disseminated infection associated with urinary tract infection caused by Nocardia veterana. The diagnosis was difficult; despite the presence of pulmonary nodules, the lung biopsies remained negative while only one aerobic blood culture and the urine culture were positive for N. veterana, identified after a 16S rDNA gene sequence analysis.Few cases of clinical importance due to N. veterana have been published since its characterization. The bacteriological diagnosis of nocardiosis can be difficult to establish because of the delayed growth and the specific techniques that are required. This case illustrates the necessity of performing specific investigations in immunocompromised patients who present with infectious disease because the severity of this infection requires early diagnosis and quick initiation of appropriate antibiotic therapy. Keywords: Nocardia veterana, Urinary tract infection, MALDI-TOF MS system, 16S rDNA gene sequencing

To the Editor: Infectious diseases are the main cause of illness for armed forces in conflict (1), resulting in decreases in operational efficiency. The International Security Assistance Force (ISAF) in Afghanistan is a multinational force operating under the auspices of the North Atlantic Treaty Organization (NATO). As part of ISAF, French troops operate in Kabul and its surroundings, within a 70-km radius. French medical facilities consist of a French field hospital and a primary care center. The facilities support 4,000 soldiers, 1,048 of whom are French. Troop disease, including acute respiratory disease (ARD), is routinely monitored through French Army and NATO surveillance systems. We report an outbreak of ARD in the multinational force in which pertussis cases were identified by using laboratory tests and epidemiologic criteria. In November 2006, a substantial increase of ARD was detected in soldiers of different nationalities (Figure), with a 10-fold increase among French troops at week 51. Patients with persistent cough or dyspnea were referred to the field hospital, in a nonrandomized manner, and those with a 2-week history of cough underwent serologic tests. Samples were sent to France and were analyzed at Hopital Saint Anne, Toulon, France. Immunoglobulin (Ig) G antibodies to Bordetella pertussis antigens (pertussis toxin, filamentous hemagglutinin, and adenylcyclase) were determined by a Western blot assay (MarDx Diagnostics, Carlsbad, CA, USA). Recent infection was diagnosed by finding high levels of antibodies to pertussis toxin compared to results for standardized positive and negative samples, in concurrence with the fact that no soldier had been vaccinated against pertussis after childhood. IgG and IgA antibodies to Chlamydia pneumoniae were determined by a semiquantitative method that assessed samples’ absorbance value in optical density (SeroCP Quant IgG and Quant IgA, Savyon Diangostics, Ashdod, Israel). Recent infection to Mycoplasma pneumoniae was assessed by detecting IgM antibodies with a specific enzyme immunoassay (Platelia Mycoplasma pneumoniae, Biorad, Hercules, CA, USA) and by using a semiquantitative method to detect IgM and IgG antibodies with patented gelatin particles sensitized with cell membrane components of M. pneumoniae (Serodia Myco II, Fujirebio, Malvern, PA, USA). Coxiella burnetii infection was assessed by indirect immunofluorescence assay (Coxiella burnetii Spot IF, bioMerieux, Marcy l’Etoile, France). Figure Number of acute respiratory diseases cases, according to troop nationality. UK, United Kingdom. A color version of this figure is available online: www.cdc.gov/EID/content/14/7/1173-G.htm Statistical analysis was performed with Epi Info v3.4 software package (Centers for Disease Control [CDC], Atlanta, GA, USA). Quantitative variables were compared by using the Kruskall-Wallis test. From the third week of December 2006 until the third week of January 2007, 209 French soldiers sought treatment at the French medical facilities for stereotyped acute febrile respiratory infection, which represents a cumulative attack rate of 20% on clinical grounds. Thirty-nine French soldiers and 10 non-French soldiers or local civilian workers were then referred to the field hospital. All patients had a 24-h history of fever >38.5°C and nonspecific ear, nose, and throat symptoms, mainly a sore throat. Cough was unremarkable, without whoops. Fourteen of the 49 patients were hospitalized for severe dyspnea. The difference in median age was not significant between inpatients (26 [range 20–57] years) and outpatients (36 [range 21–53] years, p = 0.15). Twenty-seven blood samples were taken, 24 from French troops, 2 from British troops, and 1 from Polish patients. Six patients, including 3 French soldiers, had recent pertussis. No significant difference in age was found between patients with pertussis and those with non–pertussis ARD (36 [range 27–51] versus 33 [range 20–63] years; p = 0.39). No pertussis patient had been vaccinated against the illness since childhood. One patient had evidence of recent infection with M. pneumoniae, and another with C. pneumoniae. No recent infection involved C. burnetii. All patients with ARD had a favorable outcome. This outbreak of ARD among troops in Afghanistan highlights the importance of nontraumatic illness in wartime when military field conditions enhance exposure to, and incidence of, endemic diseases. Although our study did not include systematic laboratory confirmation for all cases of ARD in soldiers because of field conditions, this outbreak was mainly due to pertussis: most cases were defined by a cough lasting >2 wk, took place in an outbreak setting, and were (for 6 patients) confirmed by laboratory tests. CDC requirements were followed to ascertain confirmed cases (2). This outbreak also involved British troops; after the 2 cases we described, 2 additional serologically confirmed cases and 1 probable confirmed case were discovered among symptomatic British returnees (3). Pertussis, which remains endemic in developing countries (4), was reported in northeastern Afghanistan in 2002 (5), but was never biologically ascertained nor reported in Kabul. This outbreak elicits 3 main questions. First, how can ARD transmission be stopped under field conditions? Besides prophylactic antibiotherapy, isolation of suspected case-patients is not achievable because of limited number of beds in medical facilities and high-person density in barracks and dining halls. To minimize transmission, patients and caregivers should wear masks. Second, what prophylactic antibiotherapy should be given? We recommend a 3-day regimen of azithromycin because it is as efficient as erythromycin in preventing spread of pertussis (6), targets most intracellular bacteria involved in ARD, and offers the best compliance (7). Finally, should soldiers be vaccinated against pertussis for overseas campaigns? In France, no booster vaccination is given after 13 years of age (8). Because acellular vaccines do not ensure immunity for >6 years (5), no French soldier has immunity to pertussis. We therefore advocate booster vaccination before overseas campaigns. Pertussis vaccination is widely available in combination with vaccination against, at minimum, diphtheria and tetanus, but these combination vaccines can only be administered once in an adult’s life and only 2 years after previous vaccination against diphtheria or tetanus. Monovalent vaccines against pertussis must be made more widely available for multinational troops in field conditions.

To the Editor: Doxycycline is an effective antimalarial prophylactic drug when administered as a monotherapy 1 day before, daily during, and for 4 weeks after travel to an area where malaria is endemic (1). Doxycycline is currently a recommended chemoprophylactic regimen for travelers visiting areas where malaria is endemic and has a high prevalence of chloroquine or multidrug resistance (2). The World Health Organization also recommends doxycycline in combination with quinine or artesunate as the second-line treatment for uncomplicated Plasmodium falciparum malaria (3). Prophylactic and clinical failures of doxycycline against P. falciparum have been associated with both inadequate doses (4) and poor patient compliance (5). However, resistance can also explain failures of prophylaxis. Cycline resistance in Plasmodium spp. has been documented as a consequence of selective drug pressure in a P. berghei murine malaria model (6). The administration of increasing doses of minocycline to mice infected with 1 × 107 parasites for 86 successive passages over 600 days made it possible to obtain a resistant P. berghei strain with a median drug inhibitory concentration (IC50) of 600 mg/kg/d, which is 6-fold higher than that of the susceptible starting strain (100 mg/kg/d) (6). A Bayesian mixture modeling approach identified 3 different phenotypes (low, medium, and high doxycycline IC50 phenotypic groups) among P. falciparum clinical isolates (7,8). Using 90 isolates from 14 countries, we demonstrated that increases in copy numbers of P. falciparum metabolite drug transporter gene (Pfmdt, PFE0825w) and P. falciparum GTPase TetQ gene (PfTetQ, PFL1710c) are associated with reduced susceptibility to doxycycline (9); this association was later confirmed (7). In addition, isolates with PfTetQ KYNNNN motif repeats are associated with in vitro reduced susceptibility to doxycycline and with a significantly higher probability of having an IC50 above the doxycycline resistance threshold of 35 μM (9,10). We report a case of documented malaria prophylactic failure with doxycycline in a 26-year-old soldier from France who was infected during a 6-week peacekeeping mission in the Central African Republic in 2014. According to his colleagues and the collective prophylaxis intake, the patient had been compliant with doxycycline prophylaxis. On admission to a hospital in Bangui, Central African Republic, the patient had fever (temperature 40°C), alteration of consciousness, and hypotension. The diagnosis of severe P. falciparum malaria was made on the basis of a rapid diagnostic test confirmed by a blood smear test (parasitemia 8% on day 0). Intravenous artesunate was immediately started, in accordance with World Health Organization recommendations (3). The patient’s clinical condition worsened, and kidney failure developed. Twenty-four hours later (day 1), he was transported by airplane to Begin Military Teaching Hospital (Saint-Mande, France). On admission, he had cerebral edema and a P. falciparum parasitemia level of 0.7%. The patient died 1 day later (day 2). A blood sample obtained from the patient on day 1 in France showed a doxycycline concentration of 195 μg/mL plasma. This concentration, which was determined by liquid chromatography coupled with tandem mass spectrometry, was compatible with a last doxycycline uptake 1 day before diagnosis (day −1). The finding of the expected doxycycline plasma concentration, together with assurances (colleague’s statements and collective intake of doxycycline) that the patient had followed the drug regimen, was sufficient to suggest prophylaxis failure in a treatment-compliant patient. The P. falciparum sample obtained from the patient on arrival in France was evaluated for in vitro susceptibility to doxycycline, but the evaluation was unsuccessful. The number of copies of PfTetQ and Pfmdt genes were evaluated relative to the single-copy P. falciparum β-tubulin gene (pfβtubulin), as previously described (7,8). The sample was assayed in triplicate. The 2–ΔΔCt method (where Ct indicates cycle threshold) of relative quantification was used and adapted to estimate the number of copies of Pfmdt and PfTetQ by using the formula ΔΔCt = (Ct (PfTetQ or Pfmdt) − Ct (Pfβtubulin))Sample – (Ct (PfTetQ or Pfmdt) − Ct (Pfβtubulin))Calibrator. Genomic DNA extracted from 3D7 P. falciparum, which has a single copy of each gene, was used for calibrator sample; Pfβtubulin served as the control housekeeping gene. The experiment was assayed twice. The sample had 2 copies of PfTetQ and Pfmdt genes, which suggested decreased in vitro susceptibility of the sample to doxycycline (8,9). The genotyping of PfTetQ sequence polymorphisms was done by using conventional methods with the primers PfTetQ forward (5′-TCACGACAAATGTGCTAGATAC-3′) and PfTetQ reverse (5′-ATCATCATTTGTGGTGGATAT-3′), as previously described (10). Two PfTetQ KYNNNN motif repeats were found in the sample; 35 μM (odds ratio 15) (10). The 2 copies of Pfmdt and the 2 KYNNNN motif repeats have been shown to be associated with parasites with in vitro resistance to doxycycline (9,10). The association of doxycycline resistance (prophylactic failure with statement of correct intake and the presence of an expected concentration) with increased Pfmdt copies and decreased PfTetQ KYNNNN motif repeats suggest that these molecular markers are predictive markers of doxycycline resistance that can be used for resistance surveillance.

Background The objective of this study was to evaluate the distribution of a series of independent doxycycline inhibitory concentration 50% (IC50) values to validate the trimodal distribution previously described and to validate the use of the pftetQ and pfmdt genes as molecular markers of decreased in vitro doxycycline susceptibility in Plasmodium falciparum malaria. Methods Doxycycline IC50 values, from 484 isolates obtained at the French National Reference Centre for Imported Malaria (Paris) between January 2006 and December 2010, were analysed for the first time by a Bayesian mixture modelling approach to distinguish the different in vitro phenotypic groups by their IC50 values. Quantitative real-time polymerase chain reaction was used to evaluate the pftetQ and pfmdt copy numbers of 89 African P. falciparum isolates that were randomly chosen from the phenotypic groups. Results The existence of at least three doxycycline phenotypes was demonstrated. The mean doxycycline IC50 was significantly higher in the group with a pftetQ copy number >1 compared to the group with a pftetQ copy number = 1 (33.17 μM versus 17.23 μM) and the group with a pfmdt copy number >1 (28.28 μM versus 16.11 μM). There was a significant difference between the combined low and medium doxycycline IC50 group and the high IC50 group in terms of the per cent of isolates with one or more copy numbers of the pftetQ gene (0% versus 20.69%) or pfmdt gene (8.33% versus 37.93%). In the logistic regression model, the pfmdt and pftetQ copy numbers >1 (odds ratio = 4.65 and 11.47) were independently associated with the high IC50 group. Conclusions Copy numbers of pftetQ and pfmdt are potential predictive molecular markers of decreased susceptibility to doxycycline.

We report 3 clinical cases of septic nonunions of lower limb long bones in which the pathogenicity of Propionibacterium acnes was retained after several weeks of poor outcome. The patients had fractures that were treated by internal fixation, without initially suspected infection. The diagnosis of delayed union coincided with the onset of treatment. Support was performed in 2 steps, allowing for the collection of several deep samples that were referred for microbiological analysis. Molecular techniques for microbiological investigation were performed on perioperative samples and were not contributive. The detection of P acnes, which was identified after several days of incubation, prompted us to consider the role of this bacterium. The presence of P acnes is regularly interpreted as contamination of samples during collection or handling in the laboratory. A multidisciplinary decision to make the diagnosis of surgical site infection with P acnes and specific antibiotic treatment for several months led to consolidation in all the patients. The ability of bacteria of the genus Propionibacterium to cause insidious surgical site infections should not be underestimated, and more extensive sample incubation is essential to diagnose such infections.

Clinicians are generally familiar with Acinetobacter baumannii as an aetiological agent of serious nosocomial infections in intensive care units. Other Acinetobacter species can also be responsible for life-threatening sepsis. Here, we report about a bacteraemia caused by Acinetobacter parvus, community-acquired, identified with a 16S rRNA gene sequence analysis and the MALDI-TOF mass spectrometry system.

Objectives: Plasmodium falciparum and Plasmodium vivax occur in Mauritania. Drug-resistant P. falciparum has been reported, but the drug-resistance status of P. vivax is unknown. The aims of the present study were to determine the prevalence of mutant pvdhfr, pvdhps and pvmdr1 genes and of pvmdr1 gene amplification in P. vivax isolates in Nouakchott, the capital city of Mauritania, and to establish a baseline for molecular surveillance of drug-resistant P. vivax in the country. Patients and methods: Between 2007 and 2009, 439 febrile patients were screened for malaria in Nouakchott. The sequences of pvdhfr, pvdhps and pvmdr1 markers in 110 P. vivax isolates were determined by direct sequencing of PCR products. The pvmdr1 gene copy number was determined by real-time PCR. Results: The majority of the isolates with a successful PCR amplification (76/86, 88%) were characterized to be of the wild-type pvdhfr genotype, while the remaining 10 isolates carried the S58R and S117N double mutations. All isolates had the wild-type pvdhps genotype SAKAV. For pvmdr1, 75 of 103 (73%) had the wild-type Y976, and 28 (27%) carried the mutant F976. Most (98%) carried the mutant L1076 codon. Of 105 isolates, 102 (97%) had one copy and 3 (3%) had two copies of the pvmdr1 gene. Conclusions: The prevalence of mutations associated with antifolate resistance is low in Mauritania. Further studies are required to determine the roles of pvmdr1 mutations and gene amplification in conferring drug resistance. These data will serve as a baseline for further monitoring of drug-resistant malaria.

Successful control of tuberculosis relies on the rapid detection of Mycobacterium tuberculosis. Few chromatographic lateral flow assays for the discrimination of the M. tuberculosis complex were developed from culture media. We compared the values of 2 assays to assess their place in diagnosis of tuberculosis. We conclude of their efficiency and relevance to supplant the conventional methods.

L'hospitalisation d'un patient consommateur de creatine nous a amene a suspecter une interference sur l'evaluation de la creatinine plasmatique. La creatine est une petite molecule derivee d'un acide amine ; elle provient en partie de l'alimentation (viande rouge) ou est synthetisee par l'organisme au niveau du foie et liberee dans le flux sanguin. Le taux de creatine serique est voisin de 15 mg/l soit 115 umol/1. Une partie de la creatine vehiculee par le sang est transformee dans le muscle par une creatine kinase en phosphocreatine, molecule a potentiel energetique eleve qui intervient lors des contractions musculaires. Une supplementation alimentaire en creatine vise essentiellement a permettre une augmentation de la masse musculaire (1 , 2). La creatine utilisee en tant que supplement nutritionnel est parfois associee a d'autres substances dopantes ; elle joue alors un role d'excipient. Elle est generalement consommee a raison de 20 grammes par 24 heures, en 4 a 6 prises. Seule une faible quantite de la creatine ingeree (5 a 25 %) serait effectivement absorbee ; elle est rapidement eliminee dans les selles et les urines, l'elimination totale intervenant dans les 24 heures suivant la prise (3). Certains sujets utilisent la creatine par injections intra(Recu le 27 octobre 2003 ; accepte le 10 decembre 2003)

Cytomegalovirus (CMV) reactivation has been widely documented in the past 10 years in critically ill patients [1]. Conversely, few data are available on burn patients despite experimental studies showing that these patients are predisposed to herpes virus infections [2]. To our knowledge, only two studies reported the incidence of CMV infection in burn patients using a modern technique, such as PCR, which has become the gold standard [3,4]. These two studies demonstrated a high rate of CMV reactivation, 55% and 71%, respectively. Moreover, CMV reactivation in burn patients has been proven to be intense. Indeed, in the study of Bordes and colleagues [4], 67% of patients who reactivated CMV experienced viremia greater than 1,000 copies/ml, and 33% viremia greater than 10,000 copies/ml. These results may reflect the severe immunosuppression that characterizes thermally injured patients. Consequently, severe burn patients could be considered as a model for CMV reactivation in critically ill patients. However, the precise kinetics of CMV DNA load in these patients is still poorly documented. That is why we would like to briefly present data from longitudinal monitoring of CMV infection by real-time PCR (RT-PCR) in four severe burn patients during their ICU stay (Figure ​(Figure11). Figure 1 Cytomegalovirus plasma load measurements during ICU stay of four severe burn patients. All the patients were CMV IgG seropositive on admission. They were monitored for CMV reactivation once to twice a week. Detection of CMV DNA in blood samples was performed by quantitative RT-PCR on whole blood. The patients' characteristics are described in Table ​Table1.1. Patient 2 presented a CMV-associated hemophagocytic syndrome and was treated by ganciclovir for a duration of 21 days. DNAemia became undetectable in patients 3 and 4 spontaneously. These examples demonstrate that critically ill patients may experience several episodes of CMV reactivation during their ICU stay, and that CMV viral load can be very changeable. Furthermore, CMV viremia may be highly variable over a short period. Table 1 Patient characteristics In our opinion, CMV reactivation in critically ill patients should be monitored with quantitative methods of detection, such as RT-PCR. Indeed, we hypothesize that the potential role of CMV on patient outcome is mostly due to the intensity of CMV reactivation rather than the CMV reactivation per se. That is why we suggest that studies aimed at determining the role of CMV reactivation as a contributor to outcome in critically ill patients should use quantitative methods of detection. Consequently, a CMV viremia threshold could be determined to guide preemptive therapy in these patients. Written consent for publication was obtained from the patients or patients' relatives.

Diagnosis: Plasmodium vivax infection with microgametes. Diagnosis relied on microscopic examination of blood smears (figures 1-3) and the results of an antigen detection test. Microgametes are dense, curved organisms containing nuclei. The estimated parasite density was 0.7%. Our patient received an oral course of chloroquine and recovered well. Blood film examination showed decreasing parasitemia on day 3 after presentation and no parasitemia on day 7. P. vivaxy which causes a non-lethal form of malaria, is the most widespread etiological agent of human malaria. Recrudescence and relapse are classically described and are related to the presence of dormant liver parasites, called hypnozoites, that are not susceptible to prophylaxis. Plasmodium microgametes are produced from the gametocytes by exflagellation, which takes place in the mosquito gut cavity immediately after the blood meal [ 1 ]. They are rarely observed in human blood; to date, only a few cases have been reported, and these, interestingly, have mainly been due to P. vivax [2-4]. The primary factor that controls exflagellation is pH. Decreasing pH initiates exflagellation: exposition of the blood to air for several minutes provokes a decrease in the CO2 level, to equilibrate with the surrounding air, which allows exflagellation [5]. Microgametes have no clinical significance except for the possibility of misdiagnosis as Borrelia infection and unusual flagellated trypanosomes, spirochetes, or microfilaria, which can be associated with malaria [6]. In our case, the size and morphological characteristics of P. vivax allowed it to be easily distinguished from Borrelia species; moreover, the results of serological testing for Borrelia species, microfilaria, and trypanosomes were negative.

Introduction Health care-associated pneumonia (HCAP) has been proposed as a new category of respiratory infection to identify patients at risk of multidrug-resistant (MDR) pathogens. The American Thoracic Society's recommendation for HCAP treatment is to use broad-spectrum and multiple antibiotics. However, this strategy may be economically expensive and promote antimicrobial resistance when a multisensitive pathogen is not identified. Methods We prospectively included all patients presenting with HCAP in the emergency department. Blood cultures and fiberoptic bronchoscope-guided distal protected small volume bronchoalveolar lavage (FODP mini-BAL) were performed in each patient. Empirical antibiotic therapy was adapted when microbiological findings were available. The primary objective was to assess whether FODP mini-BAL is more efficient than blood cultures in identifying pathogens with the ratio of identification between both techniques as principal criteria. Results We included 54 patients with HCAP. Pathogens were identified in 46.3% of cases using mini-BAL and in 11.1% of cases using blood cultures (P