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Purpose: A variety of preoperative provocative tests have been used to define the risk of cardiac morbidity and mortality after peripheral vascular procedures, including dipyridamole myocardial scintigraphy and dobutamine stress echocardiography. Although highly sensitive, these tests are time-consuming and associated with significant expense. We investigated outpatient echocardiography as a less resource-intensive means of assessing cardiac risk with operation. Methods: Over a 2-year period 250 consecutive patients underwent outpatient transthoracic echocardiography before elective peripheral vascular operation was performed. The accuracy of the Goldman, Detsky, and the American Society of Anesthesiologists' Physical Status Classification clinical indexes of cardiac risk were assessed with regard to the development of cardiac complications such as unstable angina, myocardial infarction, life-threatening ventricular arrhythmias, severe congestive heart failure, and cardiogenic shock. The accuracy of echocardiographically determined left ventricular ejection fraction was determined at threshold values between 20% and 60%. Results: Perioperative cardiac events developed in 23 (9.2%) of the patients, and nine (3.6%) of the patients died as a result of these complications. Clinical indexes lacked sensitivity in the preoperative prediction of cardiac complications. Receiver operating curve analysis defined a left ventricular ejection fraction of less than 50% as an appropriate threshold for defining patients at high risk, with a sensitivity of 78% and a specificity of 81% in the identification of patients who had cardiac morbidity. The positive predictive value was 27%, and the negative predictive value was 97%. The economic impact of outpatient echocardiography was well below that of dipyridamole myocardial scintigraphy or dobutamine stress echocardiography. Conclusions: Outpatient echocardiography appears to offer a cost-efficient compromise between clinical criteria alone and provocative cardiac testing such as dipyridamole myocardial scintigraphy and dobutamine stress echocardiography in the preoperative screening of patients undergoing peripheral vascular surgical procedures. (J VASC SURG 1995;22:671-9.)

Invasive pneumococcal diseases (IPD) remain frequent and severe events in human immunodeficiency virus (HIV)-infected subjects despite the use of antiretroviral therapy and the availability of vaccines. Our aim was to assess the antibiotic susceptibilities and serotypes of strains responsible for IPD in HIV-infected patients.We retrospectively analyzed all Streptococcus pneumoniae strains isolated from normally sterile sites between 2000 and 2011 in HIV-infected patients from a single reference center in Paris. The minimum inhibitory concentrations were determined by the E-test, and serotyping was performed by the antiserum agglutination method.Among our study group, 41 HIV-infected adults presented 43 IPD during the study period. Of these 41 patients, 78 % were men, and the median age was 43 (range 23-62) years. the median CD4 cell count was 184/mm(3) (6-1,090/mm(3)), 51 % were receiving antiretroviral therapy, and 24 % had plasma HIV-RNA levels of400 copies/mL. Only two patients had received the pneumococcal polysaccharide 23-valent vaccine (PPV23). Isolates were susceptible to penicillin G, amoxicillin, and cotrimoxazole in 44, 70, and 59 % of cases, respectively, and were significantly less susceptible to these antibiotics than isolates in the French general population during the same period. Among the 27 strains serotyped, 18 different serotypes were observed, of which 19A, 14, 7F, and 6A were the most frequent. Serotype distribution was similar to that in the French general population. The PPV23 vaccine and the 13-valent conjugate vaccine (PCV13) would have theoretically covered 78 and 70 % of cases, respectively.In our HIV-infected patient cohort, S. pneumoniae isolates demonstrated higher levels of resistance to beta-lactamines and cotrimoxazole than in the French general population. HIV-infected patients should benefit from the herd protection effect expected from the large-scale vaccination of children by PCV13.

Since 2001 in France, a nasopharyngeal carriage study was set up for children six to 24 months old. Any data are available for older children (25 to 60 months). The aim of this study is to compare the nasopharyngeal carriage in children with acute otitis media (AOM) or healthy between both age groups (6/24 months versus 25/60 months). Moreover, during the study period, the 13-valent pneumococcal conjugate vaccine (PCV13) has replaced PCV7 in June 2010.From October 2010 to June 2011, 58 pediatricians obtained nasopharyngeal swabs from children 6-60 months with acute otitis media (AOM) or healthy controls, to analyse the carriage of pneumococcus, Haemophilus influenzae, Moraxella catarrhalis, group A streptococcus and Staphylococcus aureus.Of the 1557 enrolled children, 1258 were 6 to 24 months old (315 healthy and 943 AOM) and 299 were 25 to 60 months (102 healthy and 197 AOM). More then 85% were PCV7 vaccinated and the children of 25/60 months were rarely PCV13 vaccinated (14.1%) compared to younger children (69.9%, P0.001). For children 6/24 months, the Streptococcus pneumoniae carriage was higher in AOM group (57.3%) versus healthy (28.9%). By contrast for older children, the difference (58.4% versus 50%) was not significant. In the healthy group, older children carried more often S. pneumoniae than younger children (50% versus 28.9%, P0.0001). This trend was also observed for H. influenzae carriage (49% versus 18.7%, P0.0001). Multivariate analysis in the healthy group showed that siblings and day care center (or school) increased the carriage of S. pneumoniae and H. influenzae.These data from nasopharyngeal carriage in children 6 to 60 months old showed that pneumococcus and H. influenzae carriage is high for patients under 2 years, especially in the healthy group. Moreover, these data from the transition PCV7/PCV13, will serve as baseline in France to evaluate the impact of PCV13.

International audience; OBJECTIVES: To evaluate the feasibility of a point prevalence survey for monitoring antibiotic use in a voluntary sample of French hospitals. METHODS: Demographic and medical data were collected for all inpatients. Additional characteristics regarding antimicrobial treatment, type of infection and microbiological results were collected only for patients receiving antimicrobials. RESULTS: Among 3964 patients in 38 hospitals, 343 (8.7%) received antimicrobial prophylaxis and 1276 (32.2%) antimicrobial therapy. The duration of surgical antimicrobial prophylaxis was >1 day in 41 out of 200 (21%) of the cases. Among patients with antimicrobial therapy, 959 (75.2%) received β-lactams (including 34.8% penicillins with β-lactam inhibitors, 22.1% third-generation cephalosporins and 7.8% carbapenems) and 301 (23.6%) received fluoroquinolones (50% orally). A total of 518 (40.6%) patients were treated with more than one drug and 345 (27.2%) were treated for >7 days. Patients treated for hospital-acquired infections (39.2%) were more likely to receive combinations (47.6% versus 34.4%, P < 0.01), carbapenems (14.4% versus 2.6%, P < 0.01), glycopeptides (14.4% versus 3.7%, P < 0.01) and antifungals (17% versus 5.3%, P < 0.01) for a longer duration (7.8 versus 6 days, P < 0.01). Fifty-six patients (4.4%) were treated for >7 days and did not have any microbiological sample drawn. The time allocated for the survey represented 18.3-25.0 h for 100 patients. CONCLUSIONS: The data provide directions for further interventions, such as better use of diagnostic tools, decreasing the treatment duration and the use of combinations. In addition, the survey shows that, although cumbersome, it is feasible to improve the representativeness of national data in European surveys.

Resume La resistance aux β-lactamines des pneumocoques est l'expression de modifications structurales des proteines de liaison a la penicilline (PLP). Des echanges genomiques entre especes transformables voisines, conduisent a des genes de structure mosaiques. Les produits de ces genes remanies sont des PLP de profils electrophoretiques variables et d'affinite diminuee pour les β-lactamines. Les transferts horizontaux peuvent se faire dans les deux sens, permettant la dissemination des genes de resistance independamment de celle des souches de pneumocoques resistants aux β-lactamines. Des mutations ponctuelles obtenues in vitro dans les genes des PLP 2x et 2b, peuvent egalement reduire l'affinite de ces PLP pour les β-lactamines.

The choice of antibiotics (ATB) to treat acute otitis media (AOM) has to take into account the level of resistance of bacteria species implicated. The aim of this study was to evaluate in France, ATB resistance of pneumococci and H. influenzae isolated from the nasopharyngeal flora, in children with AOM, vaccinated with 7 valent pneumococcal conjugate vaccine (PCV7).From 2006 to 2010, 66 pediatricians performed nasopharyngeal specimens of children 6 to 24 months with AOM. Demographic characteristics, history, vaccination status and symptoms were reported on a case report form transmitted to ACTIV.Of the 3,501 children included (mean age 13.5 ± 5 months), over 98% were PCV7 vaccinated and 41.1% were cared in day care center. A total of 47.3% of children had received ATB within 3 months before inclusion (cephalosporins, 22.6% and amoxicillin clavulanate, 19.2%). Pneumococcus and H. influenzae carriage was respectively 57.9% and 48.2%. Pneumococcal strains with reduced susceptibility to penicillin represented 46.3% of cases (3.9% highly resistant strains and 42.4% intermediate resistant strains). Factors that increased the risk of carrying these strains were: day care center (OR: 1.5, 95% CI: [1.2, 1.9]) and two courses or more of ATB before inclusion (OR: 2.6 (95% CI: [2.0, 3.4]). For H. influenzae strains the proportion of ßlactamases+ producing strains was 17.1% and those with reduced susceptibility due to penicillin binding protein changes (BLNAR+ strains+) accounted for 7.7% of cases. Three factors increased the risk of carriage BLNAR+ ßlactamase+ producing strains: age equal or greater than 12 months (OR: 3.5, 95% CI: [1.2, 10.3]), cephalosporin use (OR: 2.5, 95% CI: [1.0, 6.1]) and two courses or more of ATB before inclusion (OR: 3.1, 95% CI: [1.2, 8.0]).The data in this study (reduction of ßlactamase producing H. influenzae strains and increase of intermediate penicillin pneumococcal strains) should help to change the choice of antibiotics for AOM in children in France, by reducing the role of oral cephalosporins and secondly, by giving frontline amoxicillin ± clavulanic acid.

Introduction – objectifs Determiner les facteurs de risque d’infections invasives a pneumocoque (IIP) chez les patients infectes par le VIH. Evaluer l’epidemiologie microbienne dans cette population. Materiels et methodes Les IIP survenues chez les patients infectes par le VIH entre 2000 et 2011 a l’Hopital Saint-Louis a Paris ont ete etudiees. Cette population a ete comparee a une population VIH n’ayant pas eu d’infection a pneumocoque dans le cadre d’une etude retrospective cas-temoin. Les souches de pneumocoque disponibles ont ete etudiees sur le plan microbiologique. Resultats Quarante-deux patients infectes par le VIH ont presente 44 episodes d’IIP pendant la periode de l’etude et ont ete compares a 84 temoins. En analyse multivariee, les facteurs de risque d’IIP chez le patient infecte par le VIH etaient un score de Charlson ≥ 2 (OR ajuste = 7,07, 95 % IC 1,99–25,1 , p = 0,003), un taux de CD4 400 copies/mL (aOR = 5,56, 95 % IC 1,58–19,5, p = 0,007) et une origine non europeenne (aOR = 4,26, 95 % CI 1,02–17,9, p = 0,047). Les souches de pneumocoque etaient sensibles a la penicilline G et l’amoxicilline dans 44 et 70 % des cas respectivement et etaient significativement moins sensibles a ces antibiotiques que les souches de la population generale. Dix-huit serotypes differents ont ete retrouves parmi les 27 souches testees. Les serotypes 19A, 14, 7F, et 6A etaient les plus frequents. La distribution des serotypes etaient similaire a celle de la population generale. Le vaccin polysaccharidique antipneumococcique et le vaccin conjugue a 13 valences aurait theoriquement couvert 78 et 70 % des cas respectivement. Conclusion Les IIP restent un probleme majeur de sante publique chez les patients infectes par le VIH. Le meilleur controle de la maladie virale, une meilleure prise en charge des comorbidites et une meilleure couverture vaccinale pourraient diminuer le risque infectieux.

To determine whether the recent emergence of nonvaccine pneumococcal serotypes has affected the incidence of pneumococcal meningitis in children a few years after the introduction of the heptavalent pneumococcal conjugate vaccine.We conducted a multicentre retrospective cohort study from 2005 to 2008 in all hospitals with paediatric units in northern France. It included all patients18 years of age who were admitted for laboratory-confirmed pneumococcal meningitis during the study period. Data were collected from medical files and laboratory records at each hospital and compared with the regional hospital discharge codes. We assessed global and age-specific incidence rates of pneumococcal meningitis from 2005 through 2008, compared them with those from the prevaccine era (2000-2002) and evaluated pneumococcal serotypes.In all, 41 cases were found during the study period. The incidence rate of pneumococcal meningitis varied from 0.8/100,000 children18 years in 2005 to 1.8/100,000 children in 2008 (2.2-fold increase, p = 0.06); and from 1.8 to 11.9/100,000 children2 years (6.5-fold increase, p = 0.004). This increase was caused by nonvaccine pneumococcal serotypes.The incidence of pneumococcal meningitis in infants has rebounded in northern France during the pneumococcal conjugate vaccine programme, with the emergence of nonvaccine pneumococcal serotypes.

The aim of this study was to investigate the nasal carriage of Streptococcus pneumoniae (SP) and Haemophilus influenzae (HI) in children.Nasal samples were swabbed from children 3 months to 3 years of age, between December 2006 and April 2007, in 10 day-care centers in Dijon.Three hundred and eighty-five children, 22.7 ± 8.4 months, were included. All were vaccinated against H1 and 92% had received at least one dose of PCV7 vaccine. HI colonization (55%) was associated with young age and concomitant pneumococcal carriage (52.4% vs. 39%). Amoxicillin/clavulanate and cefotaxime resistance rates were 17% and 0.5%. Pneumococcal carriage (48%) was increased in case of prior hospitalization. The rate of PDSP, 50%, was increased in case of recent infection (91% vs. 81%), previous antibiotherapy (64% vs. 41%), and decreased if PCV7 was completed (40.2% vs. 61,8%). There was no resistance to amoxicillin. The erythromycin resistance rate was 50.5%. 15% of the strains were vaccinal serotypes. Thirty-six and 41% of the strains were related and non-related to vaccine serotypes. Twenty-four and 11.6% of the strains were serotypes 19A and 6A respectively.Over the last 10 years the global antibiotic resistance in children decreased for SP (22.9%) but nasal colonization remained stable due to the increase of some serotypes, such as 19A, most often resistant to antibiotics. The vaccine effectiveness against HI is optimal since no HIb serotypes were detected; resistance to betalactam is currently due equally to enzymatic mechanism and alteration of protein binding penicillin.

The BinaxNOW Streptococcus pneumoniae urinary antigen test is a rapid and reliable immunochromatographic test (ICT) for the identification of a pneumococcal aetiology of pneumonia. The aim of this study was to evaluate the attitude of clinicians in their everyday practice towards prescription of the ICT and the impact of its results on the adaptation of the antibiotic therapy when pneumonia is suspected. From October 2007 to March 2008, we prospectively evaluated 541 consecutive inpatients for whom the ICT was performed in our institution. Of the 541 patients evaluated, only 233 (43%) were suspected by the treating physicians to have a pneumonia, 58 of whom had a positive ICT result. Among these 58 patients, four (7%) and 26 (45%), respectively, were treated with amoxycillin monotherapy before and after the ICT result had been obtained (p10(-4)). Although a positive ICT result led to a rise in the proportion of patients treated with amoxycillin alone, a large number continued to be treated with broader-spectrum antibiotics. These results suggest that prescription monitoring of the ICT should be implemented along with encouragement to adhere more strictly to treatment guidelines.

The pneumococcal antigens contained in the polysaccharide (PPV23) and conjugate (7-valent, PCV7; 13-valent, PCV13) vaccines have been chosen since they represent the serotypes that more frequently cause invasive pneumococcal disease. Whether these vaccines cover the serotypes most frequently isolated in haematology patients is unclear. The serotype distribution among Streptococcus pneumoniae in 25 consecutive pneumococcal infections that occurred over the last 3 years in two French haematology departments was investigated. The pneumococcal vaccines PCV7, PCV13 and PPV23 were found to cover 76, 84 and 92%, respectively, of the serotypes found.

Delayed cerebrospinal fluid sterilization is defined by a positive second lumbar puncture, recommanded according to the guidelines from the French Consensus Conference of 1996 between the 36th and 48th hours after the beginning of antibiotics prescribed for pneumococcal meningitis. The aim of this study was to analyze specifically delayed cerebrospinal fluid sterilization, identified during the first 5 years of the French observatory of children bacterial meningitis.The Groupe de Pathologie Infectieuse Pédiatrique (GPIP) and Association Clinique et Thérapeutique Infantile du Val de Marne (ACTIV) has set up since the first of January 2001 a descriptive national multicenter network, to determine incidence, main characteristics, and prognosis of bacterial meningitis in children. A questionnaire, available in all paediatric unit taking care of bacterial meningitis, was completed by a referral doctor. It contained reasons for inclusion in the study, anamnesis, clinical examination, treatment, pneumococcal characteristics, and short term prognosis. Delayed cerebrospinal fluid sterilization were identified, and the analysis of their medical records completed the questionnaire.From 1st January 2001 to 31 December 2005, 616 pneumococcal meningitis were identified. Among them, 442 had a second lumbar puncture, and 8 had delayed cerebrospinal fluid sterilization. The analyis of their medical records were reviewed to describe their characteristics. Two had an osteomeningeal breach, one a ventriculoperitoneal valve. All received previously an antibiotic, and were treated with a curative antibiotic by cephalosporins. Vancomycin was given in 6 cases. The antibiotic was inadapted to the French guidelines for 1 patient. There are 4 vaccine type pneumococci and only 1 strain was resistant to penicillin, and intermediate to cephalosporins. The controlled lumbar puncture was made between 36.5 and 179.4hours after beginning antibiotics. One patient has received a double dose of steroids. Three were in a coma, had convulsions, and were ventilated, none died. One patient has a sequellar paired deafness, two a severe disability, four a normal psychomotor development.The delay of sterilization is a rare situation and represented only 1.8 % of pneumococcal meningitis during the first five years of the observatory. These results suggest that a second lumbar puncture to assess sterilization could be proposed only in cases of unfavourable clinical course, MIC greater than or equal 0.5mg/l to 3GC, risk factors for delayed cerebrospinal fluid sterilization and high bacterial inoculum.

Pneumococcal meningitis represents one major cause of morbidity and mortality in children in France. The GPIP/ACTIV (Groupe de Pathologie Infectieuse Pédiatrique and Association Clinique et Thérapeutique Infantile du Val de Marne) set up an active surveillance network to analyze the clinical and biological features of pneumococcal meningitis and the impact of 7-valent pneumococcal conjugate vaccine (PCV7).From 2001 to 2007, 252 French pediatric wards working with 168 microbiology laboratories enrolled all children (0-18 years old) with bacterial meningitis. Risk factors, signs and symptoms, vaccination status, cerebrospinal fluid analysis, treatments and case fatality rate were recorded.Within the 7 years study period, 832 pneumococcal meningitis were reported among 2951 bacterial meningitis. In 2001 as in 2007, excluding the neonatal period, pneumococal meningitis represented nearly 1/3 of bacterial meningitis without significant decline in the number of reported cases (less than 30% for children under 2 years old). The peak of incidence was at 5 months of age and 61.7% of cases occured in children 2 to 24 months old. PCV7 vaccinated patients represented 154 cases from 2003 to 2007. In the vaccinated population, serotypes were identified in 136 cases. Few vaccine serotypes (VT) were identified (n=18). The most important was serotype 19F (n=8) followed by 6B (n=4) and 14 (n=3). Three vaccine failures (case occurring after complete vaccination) were observed (serotypes 6B, 4 and 19F). Remaining cases (n=118) were mainly due to non vaccine serotypes (NVT): serotypes 19A, 15B/C and 7F. In 2007, the serotype 19A, more often intermediary strains to cytoxin, represented about 20% of cases. Among non vaccinated children, VT decreased between 2001 and 2007 (59/92 in 2001 vs 15/39 in 2007). Case fatality rate was stable around 11.4%.In France, probably because of the insufficient vaccination coverage and the slow implementation of the PCV7, the expected decline in the number of cases of pneumococcal meningitis has not been observed. The impact of PCV7 appeared clearly since only few cases of VT pneumococcal meningitis were reported in vaccinated children.

In 2006, the number of bacterial meningitis cases was estimated at 1375 (2.23/100,000). The leading pathogens involved in adult meningitis were, according to frequency, Streptococcus pneumoniae, Neisseria meningitidis, Listeria monocytogenes, Streptococcus agalactiae, and Haemophilus influenzae. The overall mortality rate averaged 20%, higher among patients with pneumococcal meningitis or in individuals over 65 years of age. Sequels were observed in 30% of cases and more frequent after pneumococcal meningitis. A decrease in susceptibility to antibiotics was reported for N. meningitidis, S. pneumoniae and H. influenzae. Generalized vaccination of children less than two years of age with H. influenzae type b conjugate vaccine has lead to a dramatic decrease in adult H. influenza meningitis. The few cases involved almost exclusively non-typeable strains, presenting in 12% of cases, a modified penicillin binding protein leading to a decreased susceptibility to aminopenicillins. Decreased susceptibility to amoxicillin was observed in 30% of meningococcal isolates, but all strains remained susceptible to parenteral third generation cephalosporins. Resistances to rifampicin or to ciprofloxacin, recommended in meningococcal meningitis prophylaxis, were unusual, but had to be documented. Finally, the proportion of pneumococcal strains with decreased susceptibility to beta-lactams has decreased since 2002. In adult meningitis, pneumococcal isolates with decreased susceptibility to penicillin, amoxicillin, and cefotaxime or ceftriaxone accounted for 37, 18, and 4% of cases respectively. It should be noted that for these isolates, no parenteral third generation cephalosporins MIC was above 2mg/l. Resistance to rifampin was very unusual and all pneumococcal isolates were fully susceptible to glycopeptides.

Resume Les diarrees infectieuses ne necessitent que rarement la prescription de traitement antibiotique. En effet beaucoup sont d'origine virale, et meme quand elles sont d'origine bacterienne, elles guerissent souvent en quelques jours, sans que la prescription d'anti-infectieux soit necessaire. La pierre angulaire du traitement reste dans tous les cas la rehydratation, le plus souvent par voie orale, et la renutrition precoce des patients. La prescription injustifiee d'antibiotiques facilite l'emergence de souches pathogenes resistantes. Le traitement anti-infectieux a 3 objectifs : diminuer la frequence des complications, ameliorer rapidement la symptomatologie, eradiquer la bacterie responsable. Si les shigelloses, le cholera, les colites pseudo-membraneuses necessitent le plus souvent un traitement antibiotique, celui-ci ne se justifie pour les infections a salmonelles, campylobacter, yersinia , colibacilles enteropathogenes qu'en fonction du terrain (âge, deficit immunitaire) de la gravite ou de la duree du tableau clinique. Dans certains cas l'antibiotherapie est indiquee avant meme le resultat de la coproculture. Une diarrhee glaireuse, sanglante, tres febrile, surtout si elle survient sur un terrain a risque, doit etre traitee d'emblee. L'antibiotique initial devant couvrir avant tout une shigellose.

In France, the overall proportion of penicillin-non-susceptible Streptococcus pneumoniae has decreased from 53% in 2002 to 38% in 2006, and the proportion of methicillin-resistant Staphylococcus aureus from 33% in 2001 to 26% in 2007. Although the rates remain very high compared to Northern European countries, these trends suggest that the prevention efforts implemented since 2000 are successful.

We investigated nasopharyngeal carriage of Streptococcus pneumoniae and Staphylococcus aureus among infants and young children with acute otitis media in a country where use of 7-valent pneumococcal conjugate vaccine (PCV7) has been progressively implemented. Among 1783 children enrolled, 60.8% carried S. pneumoniae, and 9% carried S. aureus. Among S. pneumoniae carriers, the rate of S. aureus carriage was 8.4%, compared with 9.9% among S. pneumoniae noncarriers. The rate of S. pneumoniae carriage in the PCV7-vaccinated population was lower (59.8%) than that observed in the nonvaccinated population (66.2%; P.04). In contrast, in young children (age,2 years) with acute otitis media, our study suggests that the S. aureus carriage rate is not affected by PCV7 immunization (9.0% in vaccinated children vs. 8.7% in nonvaccinated children). Furthermore, in children aged1 year, the booster dose induces a sharp reduction in the carriage of vaccine serotypes of S. pneumoniae, without any change in S. aureus carriage.

Streptococcus pneumoniae is actually the first most likely organism to cause meningitis in children 2 months to 2 years old and in adults older than 65 years. From January 1990 to December 2005, 72 cases of S. pneumoniae-positive cerebrospinal fluid culture were indexed in our hospital. Among the 72 cases, 25 came from children, and 60% of these came from children under two years of age and 47 came from adults whose the mean age was 55 years. The first penicillin-resistant S. pneumoniae (PNSP) meningitis was identified in 1993. The susceptibility to penicillin of pneumococcal isolates causing meningitis varied according to time; until 1995, 25% of the strains were PNSP, then from 1996 to 2005, 50% of strains were PNSP. The overall prevalence of non-susceptible was 34.7% (25/72). Among the 25 PNSP, 21 were intermediate to penicillin G and four of them were resistant. Among children, seven PNSP meningitis were indexed and one of them was resistant. The antimicrobial MICs of amoxicillin and cefotaxim varied from 0.064 to 1 mg/l and from 0.016 to 0.5 mg/l respectively. Among adults, 18 PNSP meningitis were indexed. Three strains were penicillin-resistant. The antimicrobial MICs of amoxicillin varied from 0.064 to 2 mg/l. Nine strains of 18 PNSP had cefotaxim MIC/=0.5 mg/l and, four of them had MIC 1 mg/l. None amoxicillin and cefotaxim-resistant strain was isolated. Serotyping of all strains was performed in the Reference Center. Serotypes 6B, 9V and 19 were the most frequent in child and serotypes 6B, 23F, 19, 9, 4 were the most frequent in adult. So, all serotypes were represented.

This work was aimed to analyze trends in susceptibility to antibiotics among the main species of beta-hemolytic streptococci involved in community-acquired infections in human (Streptococcus pyogenes and Streptococcus agalactiae), or in animals (Streptococcus suis and Streptococcus uberis) and also among the main enterocci species, Enterococcus faecalis and Enterococcus faecium. Data were recorded since 1996 through the Onerba networks. S. pyogenes, as the other beta-hemolytic streptococci studied remained fully susceptible to beta-lactam antibiotics. However, susceptibility to macrolides is clearly decreasing in S. pyogenes. In 2002, only 62 to 65% of the strains according to the network considered, were susceptible to erythromycin. A similar trend was observed for S. agalactiae with only 75% of erythromycin susceptibility in 2002, and for both species isolated from animals S. suis and S. uberis, with respectively 35 and 76% of strains susceptible to erythromycin. In enterococci, susceptibility to beta-lactams remained stable between 2000 and 2004. Indeed, the susceptibility to aminopenicillins remained high in E. faecalis (about 98%), whereas the proportion of E. faecium isolates susceptible to these antibiotics were lower than 60%. From 1999 to 2004, various studies conducted in French hospitals showed that the vancomycin resistance among enterococci accounted for less than 2%. However, the recent emergence of glycopeptide resistant enterococci clusters in French hospitals is a matter of concern and emphasizes the need for an ongoing surveillance. Such trend in macrolide resistance among S. pyogenes or S. agalactiae should consequently lead to propose other alternatives in case of beta-lactam allergy, and for pharyngitis, to rethink the place of the culture for susceptibility testing.

Objective: To identify factors associated with mortality and morbidity among adults admitted to intensive care units (ICUs) for pneumococcal meningitis, particularly the impact of delayed antibiotic administration. Design: We conducted a prospective, multicenter, observational study of 156 consecutive adults hospitalized for pneumococcal meningitis. We analyzed parameters associated with 3-month survival. Setting: Fifty-six medical and medical-surgical ICUs in France. Intervention: None. Results: Of the 148 strains isolated, 56 (38%) were nonsusceptible to penicillin G. At 3 months after ICU admission, the mortality rate was 33% (51/156), and 34% of survivors (36/105) had neurologic sequelae. Multivariate analysis identified three variables as independently associated with 3-month mortality: Simplified Acute Physiology Score II (odds ration [OR], 1.12; 95% confidence interval [CI], 1.072‐1.153; p .002); isolation of a nonsusceptible strain (OR, 6.83; 95% CI, 2.94‐20.8; p 3 hrs between hospital admission and administration of antibiotics (OR, 14.12; 95% CI, 3.93‐50.9; p 10 3 cells/L had a protective effect (OR, 0.30; 95% CI, 0.10‐0.944; p 0.04). Conclusions: Independent of severity at the time of ICU admission, isolation of penicillin-nonsusceptible strains and a delay in antibiotic treatment following admission were predictors of mortality among patients with pneumococcal meningitis. (Crit Care Med 2006; 34:2758‐2765)

This review concerning the major lower respiratory tract pathogens in France has for aim to describe the epidemiology of resistance to beta-lactams, macrolides, ketolides, and fluoroquinolones especially in Streptococcus pneumoniae and Haemophilus influenzae. It should also provide new insights on the mechanisms of acquired resistance and the level of resistance conferred, highlighting the related ecological impact. In the context of this XVth consensus conference, this review should contribute to the elaboration of guidelines for the treatment of lower respiratory tract infections in adults.

It has been suggested that the incidence of childhood empyema have increased during the last years in France without clear explanation. Streptococcus pneumoniae is responsible for the vast majority of bacteriological documented cases. Potential prevention of pleural empyemas by the heptavalent pneumococcal conjugate vaccine is dependent on adequation between specific pneumococcal serogroups present in vaccine and those responsible for empyemas.We retrospectively collected cases of pleural empyemas registered at the National Reference Center for pneumococci (December 2002 to February 2004). Thirty children, aged 4.1+/-3.3 (SD) years, were included.Ten specific serogroups were identified: 1, 3, 5, 6B, 7F, 9V, 14, 18C, 19A, and 23F. Serogroups 19A and 1 were the 2 dominant serogroups and represented 50% of cases. All children infected with serotype 19A were younger than 5 years, whereas serotype 1 was identified in 80% of empyemas in children older than 5 years. Among the 30 patients enrolled, 20 (69%) were infected with serotypes not included in the conjugate vaccine.These results thus limit the potential impact of the heptavalent pneumococcal conjugate vaccine on the frequency of pleural empyemas in children.

There have been relatively few studies concerning the epidemiology of Streptococcus pneumoniae infections in asplenic subjects, and even fewer concerning pneumococcal carriage. A small number of studies provide data on serotype frequency, or simply on serogroups. The frequency of pneumococcal carriers among sickle-cell anemia children varies from 6% to 27% depending on the series and the type of sampling used (rhinopharyngeal or oropharyngeal).It is particularly important to carefully follow the evolution of the serotypes and sensitivities of pneumococci isolated from carriers in order to assess the selective pressure of the antibiotic prophylaxis and to determine the impact of anti-pneumococcal vaccination in this population, as in the general population.

To compare four sampling methods: blind tracheal aspirate (blind TA), blind protected telescoping catheter (blind PTC), bronchoscopic PTC and bronchoscopic bronchoalveolar lavage (bronchoscopic BAL), for diagnosis of ventilator-associated pneumonia (VAP).Prospective multicentre study.Five intensive care units in France.Sixty-three patients with mechanical ventilation for more than 48 h, no recent antibiotic change (72 h) and suspected nosocomial pneumonia.All patients underwent the four sampling methods. Direct examination and quantitative cultures of the four specimens were performed.Visible secretions expelled from the catheter were present 40 times (63%) for blind PTC and 45 times (71%) for bronchoscopic PTC. After exclusion of 11 uncertain cases, 34 VAP were diagnosed. Direct examination of PTC (either blind or bronchoscopic) did not differ from direct examination of bronchoscopic BAL in predicting VAP diagnosis and in guiding initial antibiotic treatment correctly. Compared to that of bronchoscopic BAL (0.98), the area under receiver operating characteristics (ROC) curve was smaller for blind TA (0.78, p=0.002), blind PTC (0.83, p=0.009) and bronchoscopic PTC (0.85, p=0.01). When samples with visible secretions expelled from the catheter were considered, blind and bronchoscopic PTC had areas under ROC curve close to that of bronchoscopic BAL (0.90, p=0.22 and 0.91, p=0.27, respectively).Blind PTC appears to be a good alternative to bronchoscopic sampling for VAP diagnosis, provided that the sample contains visible secretions expelled from the catheter.

For many years, the virulence of S. pneumoniae has largely been attributed to its anti-phagocytic capsule. However S. pneumoniae elaborate other various factors that contribute to virulence. These include the toxin pneumolysin, lytic for all eukaryotic cells, and a variety of choline-binding surface proteins; the most abundant CbpA and PsaA function as cell surface adhesins, the autolysin LytA is responsible for release of lipoteichoic and techoic acids which are mediators of host inflammatory response, the role of PspA remains to be demonstrated. These factors contribute together to the colonization, protection from phagocytosis, invasion, inflammatory response, and tissue damage.

We report a case of Streptococcus milleri (S. intermedius) pulmonary infection in a 66-year-old woman. The patient was a heavy smoker and had diabetes. The diagnosis was proven by transparietal pulmonary aspiration.

The calcium-channel blockers are an ever-enlarging, heterogeneous group of drugs with widely variable effects on myocardium, sinoatrial and atrioventricular nodal function and conduction, peripheral blood vessels, and coronary circulation. Since the development and characterization of calcium-channel antagonists in the 1960s, these agents have become increasingly important in the treatment of many cardiovascular diseases. Nine calcium-channel blockers-nifedipine, nicardipine, amlodipine, felodipine, isradipine, nimodipine, diltiazem, verapamil, and bepridil-are all approved for use in the United States. Each major category has its own unique physiologic features. These drugs are extremely useful in the management of cardiac arrhythmias (particularly supraventricular arrhythmias) and/or ischemia. As future generations of calcium-channel blockers are developed with greater vasoselectivity, less negative inotropic effects, and reduced tendency to activate the renin-angiotensin system, their indications for use will continue to grow.

The choice of antibiotics in bacterial meningitis must integrate several parameters. i) The bacterial epidemiology of community acquired meningitis: Haemophilus influenzae (Hi) Neisseria meningitidis (Nm), Streptococcus pneumoniae (Sp) represents more than 95% of cases; ii) The increase of antibiotic bacterial resistance, particularly preoccupying for Sp; iii) The microbiological properties and pharmacokinetics of antibiotics, especially their penetration in CSF: the concentrations achieved must be several times higher than the MBC. In fact, CSF is not favourable to the antibiotic activity; iv) The results of clinical comparative trials; v) The contribution of animal models to the knowledge of meningitis physiopathology. Third generation cephalosporins (cefotaxime, ceftriaxone) satisfy this objective for Hi, Nm, and penicillin sensitive strains of Sp. For penicillin resistant Sp, no treatment can achieve antibiotic CSF concentrations higher than ten times the MBC. An increase in dosage of cephalosporins, the use of an other regimen (Vancomycin or imipenem) and antibiotic association (rifamycin, fosfomycin) are needed.

We present a rare case of recurrent sustained maternal ventricular tachycardia associated with hypomagnesemia. The frequency of this arrhythmia was markedly reduced with magnesium sulfate therapy. Both maternal and fetal outcomes were good. To the best of our knowledge this is the first description of maternal ventricular tachycardia that was associated with hypomagnesemia and did not require treatment with conventional antiarrhythmic medications. We discuss the possible underlying pathophysiologic causes of this condition.

Vancomycin and teicoplanin are two commercially available glycopeptide antibiotics. They have identical spectra of activity and similar mechanisms of action, and both are complex molecules. In vitro, vancomycin is more active against coagulase-negative staphylococci, while teicoplanin is more active against enterococci and pneumococci. The activity of the two antibiotics against Staphylococcus aureus is similar. The serum pharmacokinetics of vancomycin and teicoplanin are highly different, teicoplanin having a longer elimination half-life (40 hours versus 6-8 hours for vancomycin), but a higher degree of protein binding (90% versus 55%). We compared the two antibiotics on the basis of their inhibitory quotient kinetics, using the MIC90 values for the above bacterial species as the microbiological parameters, and the total and free (non-protein bound) serum concentrations as the pharmacokinetic parameters. The inhibitory quotient kinetics of vancomycin were always more favorable in terms of the free concentrations, even against those bacteria for which the teicoplanin MIC was lower.

During the course of a bronchiolitis in a 3 month-old child, one blood culture yielded Brucella melitensis. The diagnosis of brucellosis is difficult in infancy because the symptoms are nonspecific and the disease may be mild and self-limited. The child received only breast milk and dietetic preparations. So, the detection in the maternal serum of a significant titer of Brucella agglutinin enabled us to consider the very rare human-to-human transmission from mother to child. Because the efficacy of ceftriaxone assessed by a favorable initial response, and in order to avoid complications due to the use of tetracyclines and cotrimoxazole in infant, our patient was successfully treated with ceftriaxone plus rifampin.

Resume L'acces grave a Plasmodium falciparum justifie l'administration de quinine intraveineuse. Le protocole de White permet d'obtenir des quininemies rapidement efficaces. Ni le double parasitisme, ni le Tumor Necrosis Factor (dont les taux etaient bas) n'ont ete des facteurs pejoratifs. Le retard au traitement, du a une evolution negligee par le malade, peut etre implique dans l'issue fatale.

The activity of transglutaminase (TG) was examined in the rat superior cervical ganglion (SCG) during development and after postganglionic nerve crush. During postnatal development the enzyme activity is increased by sevenfold in parallel to protein content of the ganglion and reaches adult levels by day 35 after birth. The endogenous activity (enzyme activity assayed in the absence of the exogenous substrate) during development is transiently elevated with a peak at day 21 postnatal. In the adult ganglion the enzyme specific activity is evenly distributed in all subcellular compartments, but most of it is contained in the cytosol. Within the first hour after axotomy TG activity is rapidly and transiently elevated. The peak value, 80% above control levels, is attained by 30 min postoperative. At this time the activity is increased in all subcellular fractions, but the endogenous activity is selectively increased in the fraction containing nuclei. The enhanced TG activity after axotomy can be prevented by topical treatments with verapamil, an inhibitor of voltage-dependent calcium fluxes across excitable membranes, or with the calcium chelator EGTA. The results show that intracellular TG activity is present in the SCG and that it increases with postnatal growth of the ganglion. After axotomy the enzyme activity is rapidly and transiently increased in the ganglion and this elevation critically depends on calcium fluxes.

The activity of transglutaminase was characterized in the rat brain. In adults, comparable levels of transglutaminase activity are present in all brain regions examined. The activity is present in all subcellular fractions, as studied by differential centrifugation, but the soluble fraction contains the highest specific activity. The endogenous activity (enzyme activity assayed in the absence of the exogenous substrate casein) is very low in all subcellular fractions, except in the synaptosomal fraction where its highest levels are about 40–60% of the activity assayed in the presence of casein. Furthermore, enzyme activity is present on the external surface of synaptosomes. In the soluble fraction, maximal activity can be detected between pH values of 9 and 10 when assayed in the presence of 5 mM CaCl2 (with half-maximal activity requiring 0.75 mM CaCl2) and 0.4 mM putrescine (with an apparent Km for putrescine of 0.1 mM). The activity can be partially inhibited by ZnCl2 (with an IC50 of 4.5 mM) and by AlCl3 (with an IC50 of 5.1 mM). In the cerebellum, where the full span of neuronal development can be studied after birth, the highest specific activity is observed just after birth, thereafter the activity starts to decline and by 14 days, after a reduction of about 65%, it reaches levels observed throughout life.

The authors describe an unusual infestation of an ulcerative squamous cell carcinoma of the scalp and skull with Diptera Sarcophaga larvae. Human myiasis is rare in temperate zones and presents a rather unique neurosurgical challenge. The clinical presentation and treatment of human myiasis are briefly discussed.