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IntroductionBurns are common injuries on the battlefield. Given austere environments, surgical debridement of injured service members is often not feasible in these settings. Delays in surgical debridement create a risk of infection and deranged healing for burn patients. As such, this study attempts to identify the best commercially available off-the-shelf (OTS) therapies with field-deployable potential to improve prolonged field care (PFC) of burn-injured soldiers.MethodsDeep partial-thickness (DPT) burns (25 cm2) were created on the dorsum of 5 anesthetized pigs utilizing a thermocouple burn device at 100°C for 15 seconds. Nonsurgical debridement was done 1-hour after burn creation using sterile saline water and gauze to remove excess eschar tissue. Animals were then randomized into 5 experimental groups, and OTS therapies were applied to 6 of the 12 created DPT burns. The remaining 6 burns were treated with 1% silver sulfadiazine cream (Ascend Laboratories, LLC, Parsippany, NJ) as the PFC standard of care (SOC) controls. The 5 randomized OTS therapies were: irradiated sterile human skin allograft (IHS), biodegradable temporizing matrix (BTM), polylactic acid skin substitute, hyaluronic acid ester matrix (HAM), and decellularized fish skin graft (FSG). Wounds were serially assessed on post-burn days 3, 7, 14, 21, and 28. Assessments were conducted using a combination of photographs, histology, and quantitative bacteriology. Endpoints included burn wound progression, re-epithelialization, wound contraction, scar elevation index, and colony-forming units (CFU).ResultsThe analysis demonstrated that by day 3, the FSG prevented burn wound progression the most efficiently. In terms of wound healing, the results showed re-epithelialization percentages close to 100% by day 28 for all treatment groups. No statically significant differences were observed. Quality of healing analyses demonstrated that the BTM-treated wounds had contracted less and the difference to the IHS-treated wounds was statistically significant (P ConclusionsThe impact of Food and Drug Administration-approved OTS therapies was compared to the current PFC SOC for the treatment of DPT burns in a porcine model. Several topical options exist for the management of burns prior to definitive treatment in the operating room and warrant further evaluation. These therapies are actively used on civilian burn counterparts and have far-forward, field-deployable potential for use at the point of injury so that injured service members may not need evacuation to higher roles of care and combat power may be preserved. Our results demonstrated that all the studied OTS therapies performed well when compared to the SOC in terms of burn wound progression, wound healing, quality of healing, and quantitative bacteriology.

Background The presence of bacteraemia in pneumococcal pneumonia in critically ill patients does not appear to be a strong independent prognostic factor in the existing literature. However, there may be a specific pattern of factors associated with mortality for ICU patients with bacteraemic pneumococcal community-acquired pneumonia (CAP). We aimed to compare the factors associated with mortality, according to the presence of bacteraemia or not on admission, for patients hospitalised in intensive care for severe pneumococcal CAP. Methods This was a post hoc analysis of data from the prospective, observational, multicentre STREPTOGENE study in immunocompetent Caucasian adults admitted to intensive care in France between 2008 and 2012 for pneumococcal CAP. Patients were divided into two groups based on initial blood culture (positive vs. negative) for Streptococcus pneumoniae. The primary outcome was hospital mortality, which was compared between the two groups using odds ratios according to predefined variables to search for a prognostic interaction present in bacterial patients but not non-bacteraemic patients. Potential differences in the distribution of serotypes between the two groups were assessed. The prognostic consequences of the presence or not of initial bi-antibiotic therapy were assessed, specifically in bacteraemic patients. Results Among 614 included patients, 274 had a blood culture positive for S. pneumoniae at admission and 340 did not. The baseline difference between the groups was more frequent leukopaenia (26% vs. 14%, p = 0.0002) and less frequent pre-hospital antibiotic therapy (10% vs. 16.3%, p = 0.024) for the bacteraemic patients. Hospital mortality was not significantly different between the two groups (p = 0.11). We did not observe any prognostic factors specific to the bacteraemic patient population, as the statistical comparison of the odds ratios, as an indication of the association between the predefined prognostic parameters and mortality, showed them to be similar for the two groups. Bacteraemic patients more often had invasive serotypes but less often serotypes associated with high case fatality rates (p = 0.003). The antibiotic regimens were similar for the two groups. There was no difference in mortality for patients in either group given a beta-lactam alone vs. a beta-lactam combined with a macrolide or fluoroquinolone. Conclusion Bacteraemia had no influence on the mortality of immunocompetent Caucasian adults admitted to intensive care for severe pneumococcal CAP, regardless of the profile of the associated prognostic factors.

Introduction Burns are common injuries in the battlefield. Given austere environments, prolonged field care (PFC) is often necessary. Delays in surgical debridement create a risk of infection and deranged healing for burn patients. As such, this study attempts to identify the best commercially available off-the-shelf (OTS) dressings with field-deployable potential. Methods Deep-partial thickness burns (1" diameter) were created on the dorsum of 3 anesthetized pigs utilizing a thermocoupled burn device at 100°C for 15s. Non-surgical debridement was done 1-h post-burn creation and either an OTS dressing or standard-of-care (SOC) treatment (Silver Sulfadiazine) was applied to the wound in order to simulate a PFC environment. OTS dressings were randomized and included irradiated sterile human skin allograft (ISHSA), alloplastic absorbable skin substitute (AASS), and synthetic polyurethane dermal matrix (SPDM). Wounds were serially assessed on post-burn days 3, 7, 14, 21, and 28. Assessments were conducted using a combination of photographs, histology, and quantitative bacteriology. Endpoints included burn wound progression, re-epithelialization, wound contraction, scar elevation index (SEI), and colony forming units (CFU). Results No statistically significant differences in burn wound progression were seen on days 3 and 7 for the ISHSA or SPDM and the SOC. The differences between the AASS and the SOC were statistically significant on both days (p≤0.05). Day 21 re-epithelialization results for the ISHSA, AASS, SPDM and SOC treated wounds were 30%, 85%, 95%, and 78% re-epithelialized, respectively. The difference between the AASS and the SOC was statistically significant (p≤0.05). Results showed that by day 28, wound contraction for the ISHSA, AASS, SPDM and SOC treated wounds were 65%, 80%, 82%, and 78%, respectively. No statistically significant differences in wound contraction were seen for any of the OTS dressings and the SOC. SEI showed no statistically significant difference in scar hypertrophy between the OTS dressings and the SOC on day 28. CFU results showed no statistically significant differences between the OTS dressings and the SOC on days 3 and 7. Conclusions Three OTS dressings were compared to the SOC for use in the PFC setting. Generally, all the dressings performed well when compared to the SOC in terms of burn wound progression, re-epithelialization, wound contraction, SEI, and CFU. Although significant differences in burn progression and re-epithelialization for burns treated with AASS were seen. In the future, we hope to continue to discover and test various OTS dressings to determine their appropriateness for use in the PFC setting.

Introduction Infection and prolonged inflammation in deep partial-thickness burns can lead to inadequate healing. In addition to their role in hemostasis, activated platelets also contain granules with anti-inflammatory properties which may impact wound healing. However, portability and storage of platelets remain a challenge. Synthetic platelet-mimetics (SPM) avoid these difficulties, but like natural platelets, SPM have vesicles that can transport bioactive agents, such as antibiotics. We sought to evaluate wound healing outcomes in deep partial-thickness burns treated topically with SPM. Methods A total of 30 circular, deep partial-thickness burns were created on the dorsum of 2 porcine models. Each wound measured 5cm in diameter and was standardized using a thermocoupled burn device. Sets of six wounds were randomized into five groups: SPM, gentamicin alone, SPM with gentamicin, a vehicle control (saline), or dry gauze (the standard of care, SOC). Additionally, two separate 5cm diameter circular areas were demarcated to serve as normal skin controls. Wounds were assessed at post-burn days 3, 7, 14, 21, 28, 60 and 90 with a variety of non-invasive imaging and punch biopsies. Treatments were re-applied at each assessment. The primary outcome was the amount of wound re-epithelialization, measured histologically, at post-burn day 28. Secondary outcomes consisted of the percentage of wound contraction, amount of superficial blood flow, and mean bacterial load. Results The amount of wound re-epithelialization in wounds treated with SPM was 96% whereas those treated with the SOC measured only slightly less at 92% (p = 0.56). The percentage of wound contraction was 39% in the SPM with gentamicin group, while in the SOC group contraction was higher at 45% (p = 0.20). Moreover, superficial blood flow in the SPM group was measured to be 168% of normal skin controls, while wounds in the SPM with gentamicin group were slightly lower at 160%, and in wounds treated with the SOC blood flow was 110% of normal skin controls (p = 0.27). The mean bacterial load in each group was measured at post-burn day 3 and notably consisted of bacterial load being the lowest in wounds treated with gentamicin alone at 17/100, meanwhile in wounds treated with the SOC or those in the SPM with gentamicin group, mean bacterial loads were significantly higher at 43/100 and 47/100, respectively (p = 0.02). Conclusions SPM applied to deep partial-thickness burns did not significantly improve measured outcomes over the SOC. Although numerical improvements were shown in all measured outcomes, no significant differences were noted. The theoretical and observed potential for SPM to improve wound healing deserves additional evaluation in larger preclinical studies.

Background: The presence of bacteraemia in pneumococcal pneumonia in critically ill patient does not appear to be a strong prognostic factor on its own from the existing literature, but there may be a specific pattern of factors associated with mortality in ICU patients with bacteraemic pneumococcal pneumococcal community-acquired pneumonia (CAP).We aimed to identify factors associated with mortality in patients admitted to intensive care for severe bacteraemic CAP. Methods: This is a post-hoc analysis of data from the prospective, observational, multicentre STREPTOGENE study in immunocompetent Caucasian adults admitted to intensive care in France, between 2008 and 2012, for bacteraemic pneumococcal CAP documented by culture and/or urinary antigenuria. Patients were divided into two groups based on initial blood culture positivity for Streptococcus pneumoniae. The primary outcome was hospital mortality. Serotypes of 339 S. pneumoniae strains were determined. Results: Of 614 included patients, 274 did and 340 did not have a blood culture positive for S. pneumoniae at admission. The only baseline difference between the groups was more frequent leukopenia in bacteraemic patients (26% vs. 14%, p =0.0002). Hospital mortality was not significantly different between groups ( p =0.11). The associations between the various prognostic parameters studied and mortality were similar in the two groups. Bacteraemic patients more often had invasive serotypes but less often had serotypes associated with high case-fatality rates ( p =0.003). Antibiotic regimens were similar in the two groups. In neither group was mortality different in patients given a beta-lactam alone vs. a beta-lactam combined with a macrolide or fluoroquinolone. Interpretation: In immunocompetent Caucasian adults admitted to intensive care for severe pneumococcal CAP, bacteraemia had no influence on mortality, regardless of the prognostic factor profile. A prospective randomised trial is warranted to confirm the absence of superiority of one treatment over others.

Introduction Deep and large burns require hospitalization and, without exception, surgical treatment. Skin graft expansion in major burns currently is restricted to a 1:6 expansion ratio (possibly 1:9) by current methods. For this reason, skin transplants are limited by donor site availability for patients with extensive burns, who may have only small areas of healthy skin for use as donor sites. The objective of this project is to demonstrate the efficacy of pixel grafting, to produce split-thickness skin grafts (STSG) and dermal grafts which can be expanded at least 100 times (1 cm2 donor skin will cover 100 cm2). Pixel grafts are skin grafts that are prepared from split-thickness donor skin that is 0.3 mm (12/1000 of an inch) thick and minced into pieces that are 0.3 x 0.3 mm. The methodology relies on mincing a small area of donor skin using a hand-held mincer to create uniform skin pieces, each of which will serve as a small center of skin regeneration. Methods Deep partial-thickness burns were created on the dorsum of Yorkshire pigs. Three days post injury the burns were debrided and grafted with epidermal/dermal and dermal pixel grafts using expansion ratios from 1:2 to 1:500. The pixel grafts were prepared by harvesting 0.3 mm thick skin grafts from the same donor site going down in depth (Layer 1: STSG; Layer 2: dermal graft). Subsequently, the grafts were minced to 0.3 x 0.3 x 0.3 mm pixel grafts, suspended in a small volume of hydrogel and transplanted onto debrided porcine burn wounds. Healing was monitored up to 28 days and biopsies were collected on days 6, 10 and 14. The wounds were excised and fixed in formalin for histologic analysis. In addition, to measure wound area reduction and wound depth, wound images were taken. Multiple wound healing parameters were used to assess the quality of healing and the results were compared to STSG (standard of care treatment). Results Histology demonstrated that when both STSG pixel grafts and dermal grafts were transplanted onto porcine full-thickness wounds in a 1:2 ratio they were able to fully re-epithelialize the wounds in 14 days. At day 14, re-epithelialization-% using other expansion ratios varied from 46 % (1:500) to 64 % (1:10) and by day 28 all the wounds were fully re-epithelialized. Wound images obtained at different time points showed that by day 28 all the pixel graft grafted wounds had reduced in area efficiently, from 70 % (dermal pixel grafts 1:50) to 81% (STSG 1:100). No statistically significant differences were observed between the pixel graft study groups and STSG (standard of care). Conclusions This study concluded that both epidermal/dermal and dermal pixel grafts can be suspended in a hydrogel and transplanted onto wounds regardless of orientation (dermal side up or down), making the transplantation greatly simplified.

Objective: Split-thickness skin graft (STSG) donor site dressings can play an integral role in reducing donor site morbidity. This study tested a novel, chitosan-based wound dressing, Opticell Ag, as an STSG donor site dressing for wounds Method: Between January and December 2016, the chitosan-based dressing was placed on participating patients' donor sites immediately following graft harvest and covered with a transparent occlusive dressing. Pain was evaluated on postoperative day one, before dressing change between days 5–7, and before and after dressing removal between days 10–14 using the Visual Analog Scale (VAS). The extent of re-epithelialisation was determined between day 10–14 and at one month, and healing quality was also evaluated at one month post-operatively using the Vancouver Scar Scale (VSS). Results: A total of 19 patients were recruited, of which 16 completed the study. Patients experienced mild-to-moderate pain in their donor sites when the chitosan-based dressing was used. Pain decreased significantly between postoperative day one and days 10–14, as well as between days 5–7 and 10–14. The mean percentage of re-epithelialisation on days 10–14 was 92% and by one month was 99%. The mean VSS at one month was 3.2±1.4. There were no statistically significant differences between patients' re-epithelialisation rates or VSS scores. There were unplanned dressing changes in four patients. No donor site infections or other adverse events were identified. Conclusion: The chitosan-based dressing tested in this study is safe, effective, and associated with reasonable pain control and acceptable healing quality. The results suggest that it is a promising STSG donor site dressing.

Negative pressure wound therapy (NPWT) has become a widely used treatment for acute and chronic wounds. NPWT is indicated for a variety of complex wounds, and some studies validate its use for certain aspects of burn care. Although further research is needed to explore the benefits for burns, NPWT has proven beneficial in its use as a dressing that bolsters skin grafts, promotes integration of bilaminate dermal substitutes, promotes re-epithelialization of skin graft donor sites, and potentially reduces the zone of stasis. This article reviews the literature on NPWT in burns, based on indication/application, and describes our experience with the use of modified NPWT for large burns.

Objectives Reducing antibiotic consumption has now become a major public health priority. Reducing treatment duration is one of the means to achieve this objective. Guidelines on the therapeutic management of the most frequent infections recommend ranges of treatment duration in the ratio of one to two. The Recommendation Group of the French Infectious Diseases Society (SPILF) was asked to collect literature data to then recommend the shortest treatment durations possible for various infections. Methods Analysis of the literature focused on guidelines published in French and English, supported by a systematic search on PubMed. Articles dating from one year before the guidelines publication to August 31, 2015 were searched on the website. Results The shortest treatment durations based on the relevant clinical data were suggested for upper and lower respiratory tract infections, central venous catheter-related and uncomplicated primary bacteremia, infective endocarditis, bacterial meningitis, intra-abdominal, urinary tract, upper reproductive tract, bone and joint, skin and soft tissue infections, and febrile neutropenia. Details of analyzed articles were shown in tables. Conclusion This work stresses the need for new well-conducted studies evaluating treatment durations for some common infections. Following the above-mentioned work focusing on existing literature data, the Recommendation Group of the SPILF suggests specific study proposals.

Enteral nutrition support is a critical component of modern burn care for severely burned patients. However, tube feeds are frequently withheld during the perioperative period because of aspiration concerns. As a result, patients requiring multiple operative procedures risk accumulating significant protein-calorie deficits. The objective of this study was to describe our American Burn Association-certified burn center's experience implementing an intraoperative feeding protocol in severely burned patients defined as a cutaneous burn ≥20% TBSA. A retrospective review of patients with major thermal injuries (2008-2013). Thirty-three patients with an average of seven operating room trips (range, 2-21 trips) were evaluated. Seventeen patients received intraoperative enteral feeds (protocol group) and 16 patients did not (standard group). Feeding was performed using an enteral feeding tube placed postpylorically and was continued intraoperatively, regardless of operative positioning. There was no statistically significant difference in mortality between the groups (P = .62). No intraoperative aspiration or regurgitation events were recorded. The protocol group received significantly more calculated protein and caloric requirements, 98.06 and 98.4%, respectively, compared with 70.6 and 73.2% in the standard group (P < .001). Time to goal tube feed infusion rate was achieved on average 3 days sooner in the protocol group compared with the standard group (3.35 vs 6.18 days, P = .008). Early initiation and continuation of enteral feeds in severely burned patients led to higher percentages received of prescribed goal protein and caloric needs without increased rates of aspiration, regurgitation, or mortality.

Pneumococcal vaccine serotypes and host factors may increase the risk of severe invasive pneumococcal disease (IPD). In France, pneumococcal vaccination in adults is recommended for at-risk groups (immunosuppression or at-risk conditions/diseases). In 2014-2017, we conducted a study of IPD in adults to identify factors/serotypes associated with disease severity. We included IPD cases, excluding meningitis, in adults from 25 acute-care sentinel hospitals in six regions. Severe cases were IPD patients either admitted to an ICU or under mechanical ventilation or with severe sepsis or shock. Infectious disease specialists collected clinical/microbiological data on all cases. We calculated adjusted risk ratios (aRR) using binomial regression. In 2014-2017, 908 cases (median age 71 (range 18-101) years) were diagnosed; 48%(431/908) were severe and 84%(764/908) were at-risk. Compared with non-risk individuals, the risk of severe disease increased from 20% (aRR 1.2; 95%CI 1.0-1.4) in cases with 1-2 chronic diseases to 30% (aHR 1.3; 95%CI 1.0-7.0) in those with >2 chronic diseases. The risk of severe disease was 42% (aRR 1.4; 95%CI 1.2-1.6) higher for PCV13 serotypes compared with non-vaccine serotypes. Among cases infected with PCV13 serotypes, the risk of severe disease did not differ (aRR 0.96; 95%CI 1.2-23) between no-risk or at-risk cases. However, among cases infected with non-vaccine serotypes, the risk increased 49% (aRR 1.5; 95%CI 2.1-22) in at-risk compared with no-risk cases (homogeneity test p = 0.03). We observed a cumulative effect of concurrent comorbidities on severe IPD outcomes. The risk of severe IPD increased for vaccine serotypes regardless of risk status. However, non-vaccine serotypes increased the risk of severe outcomes only in risk groups, suggesting a different interplay between host factors and the pathogen in vulnerable groups. We recommend enhancing vaccination among risk groups and especially in those most at risk for poor IPD-related outcomes. Key messages Cumulative effect of concurrent comorbidities on severe invasive pneumococcal disease outcomes. Non-vaccine serotypes increase the risk of severe invasive pneumococcal disease outcomes only in vulnerable groups.

International audience; Objective: The aim was to create and validate a community-acquired pneumonia (CAP) diagnostic algorithm to facilitate diagnosis and guide chest computed tomography (CT) scan indication in patients with CAP suspicion in Emergency Departments (ED).Methods: We performed an analysis of CAP suspected patients enrolled in the ESCAPED study who had undergone chest CT scan and detection of respiratory pathogens through nasopharyngeal PCRs. An adjudication committee assigned the final CAP probability (reference standard). Variables associated with confirmed CAP were used to create weighted CAP diagnostic scores. We estimated the score values for which CT scans helped correctly identify CAP, therefore creating a CAP diagnosis algorithm. Algorithms were externally validated in an independent cohort of 200 patients consecutively admitted in a Swiss hospital for CAP suspicion.Results: Among the 319 patients included, 51% (163/319) were classified as confirmed CAP and 49% (156/319) as excluded CAP. Cough (weight = 1), chest pain (1), fever (1), positive PCR (except for rhinovirus) (1), C-reactive protein ≥50 mg/L (2) and chest X-ray parenchymal infiltrate (2) were associated with CAP. Patients with a score below 3 had a low probability of CAP (17%, 14/84), whereas those above 5 had a high probability (88%, 51/58). The algorithm (score calculation + CT scan in patients with score between 3 and 5) showed sensitivity 73% (95% CI 66-80), specificity 89% (95% CI 83-94), positive predictive value (PPV) 88% (95% CI 81-93), negative predictive value (NPV) 76% (95% CI 69-82) and area under the curve (AUC) 0.81 (95% CI 0.77-0.85). The algorithm displayed similar performance in the validation cohort (sensitivity 88% (95% CI 81-92), specificity 72% (95% CI 60-81), PPV 86% (95% CI 79-91), NPV 75% (95% CI 63-84) and AUC 0.80 (95% CI 0.73-0.87).Conclusion: Our CAP diagnostic algorithm may help reduce CAP misdiagnosis and optimize the use of chest CT scan.

IMPORTANCE: Age has historically been used to predict negative post-surgical outcomes. The concept of frailty was introduced to explain the discrepancies that exist between patients’ chronological and physiological age. The efficacy of the modified frailty index (mFI) to predict surgical risk is not clear. OBJECTIVE: We sought to synthesize the current literature to quantify the impact of frailty as a prognostic indicator across all surgical specialties. DATA SOURCES: Pubmed and Cochrane databases were screened from inception to 1 January 2018. STUDY SELECTION: Studies utilizing the modified Frailty Index (mFI) as a post-operative indicator of any type of surgery. The mFI was selected based on a preliminary search showing it to be the most commonly applied index in surgical cohorts. DATA EXTRACTION AND SYNTHESIS: Articles were selected via a two-stage process undertaken by two reviewers (AP and DS). Statistical analysis was performed in Revman (Review manager V5.3). The random-effects model was used to calculate the Risk Ratios (RR). MAIN OUTCOME(S) AND MEASURE(S): The primary outcomes: post-operative complications, re-admission, reoperation, discharge to a skilled care facility, and mortality. RESULTS: This meta-analysis of 16 studies randomizes 683,487 patients, 444,885 frail, from gastrointestinal, vascular, orthopedic, urogenital, head and neck, emergency, neurological, oncological, cardiothoracic, as well as general surgery cohorts. Frail patients were more likely to experience complications (RR 1.48, 95%CI 1.35–1.61; p

To assess the relative importance of host and bacterial factors associated with hospital mortality in patients admitted to the intensive care unit (ICU) for pneumococcal community-acquired pneumonia (PCAP). Immunocompetent Caucasian ICU patients with PCAP documented by cultures and/or pneumococcal urinary antigen (UAg Sp) test were included in this multicenter prospective study between 2008 and 2012. All pneumococcal strains were serotyped. Logistic regression analyses were performed to identify risk factors for hospital mortality. Of the 614 patients, 278 (45%) had septic shock, 270 (44%) had bacteremia, 307 (50%) required mechanical ventilation at admission, and 161 (26%) had a diagnosis based only on the UAg Sp test. No strains were penicillin-resistant, but 23% had decreased susceptibility. Of the 36 serotypes identified, 7 accounted for 72% of the isolates, with different distributions according to age. Although antibiotics were consistently appropriate and were started within 6 h after admission in 454 (74%) patients, 116 (18.9%) patients died. Independent predictors of hospital mortality in the adjusted analysis were platelets ≤ 100 × 109/L (OR, 7.7; 95% CI, 2.8–21.1), McCabe score ≥ 2 (4.58; 1.61–13), age > 65 years (2.92; 1.49–5.74), lactates > 4 mmol/L (2.41; 1.27–4.56), male gender and septic shock (2.23; 1.30–3.83 for each), invasive mechanical ventilation (1.78; 1–3.19), and bilateral pneumonia (1.59; 1.02–2.47). Women with platelets ≤ 100 × 109/L had the highest mortality risk (adjusted OR, 7.7; 2.8–21). In critically ill patients with PCAP, age, gender, and organ failures at ICU admission were more strongly associated with hospital mortality than were comorbidities. Neither pneumococcal serotype nor antibiotic regimen was associated with hospital mortality.

Background:. Many types of split-thickness skin graft (STSG) donor-site dressings are available with little consensus from the literature on the optimal dressing type. The purpose of this systematic review was to analyze the most recent outcomes regarding moist and nonmoist dressings for STSG donor sites. Methods:. A comprehensive systematic review was conducted across PubMed/MEDLINE, EMBASE, and Cochrane Library databases to search for comparative studies evaluating different STSG donor-site dressings in adult subjects published between 2008 and 2017. The quality of randomized controlled trials was assessed using the Jadad scale. Data were collected on donor-site pain, rate of epithelialization, infection rate, cosmetic appearance, and cost. Meta-analysis was performed for reported pain scores. Results:. A total of 41 articles were included comparing 44 dressings. Selected studies included analysis of donor-site pain (36 of 41 articles), rate of epithelialization (38 of 41), infection rate (25 of 41), cosmetic appearance (20 of 41), and cost (10 of 41). Meta-analysis revealed moist dressings result in lower pain (pooled effect size = 1.44). A majority of articles (73%) reported better reepithelialization rates with moist dressings. Conclusion:. The literature on STSG donor-site dressings has not yet identified an ideal dressing. Although moist dressings provide superior outcomes with regard to pain control and wound healing, there continues to be a lack of standardization. The increasing commercial availability and marketing of novel dressings necessitates the development of standardized research protocols to design better comparison studies and assess true efficacy.

Negative-pressure wound therapy (NPWT) has become a widely used and well-described treatment for acute and chronic wounds. The authors discuss advantages of XL-NPWT for large burns, infection prevention, promoting re-epithelialization, and fluid management. The techniques are described such as the “total body wrap” or “sandwich” technique, in which affected areas are sandwiched between large polyurethane dressings and silver-impregnated nonadherent foam that is applied to both recipient and donor sites, as well as over any intervening intact skin or burn wound. Although relatively new, XL-NPWT has proven to be safe and effective in treating burns ≥15% TBSA.

Oliver Robineau,1 Jérome Robert,2 Christian Rabaud,3 Jean-Pierre Bedos,4 Emmanuelle Varon,5 Yves Péan,6 Rémy Gauzit,7 Serge Alfandari8 On behalf of the Société de Pathologie Infectieuse de Langue Française (SPILF), the Observatoire National de l’Épidémiologie de la Résistance Bactérienne aux Antibiotiques (ONERBA), and the Surveillance de la Prescription des Antibiotiques (SPA) Group 1Infectious Disease Department, Dron Hospital, Univ Lille, Tourcoing, 2Sorbonne University, UPMC Univ Paris 06, CR7, CIMI, Team E13 (Bacteriology), Paris, 3Infectious Disease Department, Nancy University Hospital, Nancy, 4Intensive Care Unit, Henri Mignot Hospital, Le Chesnay, 5Bacteriology Laboratory, HEGP, 6Observatoire National de L’epidémiologie de la Résistance Bactérienne aux Antibiotiques (OneRBa), 7Intensive Care Unit, Cochin Hospital, APHP, Paris, 8Intensive Care Unit, Dron Hospital, Tourcoing, France Background: Bloodstream infections (BSIs) are severe infections that can be community or hospital acquired. Effects of time to appropriate treatment and impact of antimicrobial management team are discussed in terms of outcome of BSI. We sought to evaluate the impact of initial BSI management on short-term mortality. Patients and methods: A prospective, multicenter survey was conducted in 121 French hospitals. Participants declaring BSI during a 1-month period were included consecutively. Data on patient comorbidities, illness severity, BSI management, and resistance profile of bacterial strains were collected. Predictors of 10-day mortality were identified by multivariate regression for overall BSI, health care-related and hospital-acquired BSI. Results: We included 1,952 BSIs. More than a third of them were hospital acquired (39%). Multidrug resistance was identified in 10% of cases, mainly in health care-related BSI. Empirical therapy and targeted therapy were appropriate for 61% and 94% of cases, respectively. Increased 10-day mortality was associated with severe sepsis, septic shock, increasing age, and any focus other than the urinary tract. Decreased mortality was associated with receiving at least one active antibiotic within the first 48 hours. Intervention of antimicrobial management team during the acute phase of BSI was associated with a decreased mortality at day 10 in the overall population and in health care-related BSI. Conclusion: Optimizing BSI management by increasing rapidity of appropriate treatment initiation may decrease short-term mortality, even in countries with low rate of multidrug-resistant organisms. Early intervention of antimicrobial management team is crucial in terms of mortality. Keywords: mortality, bloodstream infections, antimicrobial management team, community-acquired infection, health care-related infection

Vaccination with the 7-valent pneumococcal conjugate vaccine (PCV7) was recommended in France in 2003 for children2 years. The 13-valent conjugate vaccine (PCV13) replaced PCV7 in 2010. We assessed the impact of PCVs vaccination on the incidence of invasive pneumococcal diseases (IPD) in French children (0-15 years) and adults (15 years).IPD rates were calculated using cases reported from 2001 to 2012 to Epibac, a laboratory network. The distribution of serotypes was assessed from invasive isolates serotyped at the National reference Centre for Pneumococci. IPD incidence rates were compared between the pre-PCV7 (2001-2002), late PCV7 (2008-2009) and post PCV13 (2012) periods.The PCVs coverage increased from 56% in the 2004 birth-cohort to 94% in the 2008 and following birth-cohorts. Following PCV7 introduction, IPD incidence decreased by 19% between 2001-2002 and 2008-2009 in children2 years, but increased in children aged 2-15 years and adults, despite a sharp decline in PCV7-IPD in all age-groups. After PCV13 introduction, IPD incidence decreased by 34% in children5 years, by 50% in those aged 5-15 years and 15% in adults from 2008-2009 to 2012. The incidence of PCV13-Non PCV7-IPD decreased by 74% in children5 years and by 60% in those aged 5-15 years.Vaccination with PCV13 was rapidly followed by a decrease in the incidence of all-type IPD in children, in relation with a sharp decrease in the incidence of PCV13-Non PCV7-IPD. Moreover, all-type IPD decreased after PCV13 introduction in older non-vaccinated age-groups, with a shift in the distribution of serotypes. Considering the whole 2001-2012 period, the vaccination with PCV7 and PCV13 resulted in a decline in the incidence of IPD in children up to the age of 5 but not in older children and adults.

Skeletal muscle maintenance is a dynamic process and undergoes constant repair and regeneration. However, skeletal muscle regenerative capacity declines in obesity. In this review, we focus on obesity-associated changes in inflammation, metabolism, and impaired insulin signaling, which are pathologically dysregulated and ultimately result in a loss of muscle mass and function. In addition, we examine the relationships between skeletal muscle, liver, and visceral adipose tissue in an obese state.

Streptococcus pneumoniae serotype 19A was the main serotype responsible for invasive pneumococcal disease (IPD) in the Paris area in 2007 and 2009 in both adults and children. To verify if a particular clone is emerging, we determined the populational structure of S. pneumoniae isolates. Eighty-four S. pneumoniae strains responsible for invasive infections isolated from 52 adults and 32 children hospitalized in Parisian hospitals were analyzed. Capsular typing was performed by polymerase chain reaction (PCR) using the semi-automated repetitive sequence-based (rep-PCR) DiversiLab® System. Multilocus sequence typing (MLST) was also performed on 26 strains (ten selected strains after cluster analysis and 16 control strains). In 2007 and 2009, S. pneumoniae serotype 19A represented, respectively, 28.6 % and 25 % of the serotypes involved in IPDs in children and 13 % and 13.7 % in adults. The rep-PCR DiversiLab® analysis showed that the 84 S. pneumoniae serotype 19A isolates were distributed in five clusters and four unique rep-PCR types. Overall, 77/84 (91.6 %) S. pneumoniae 19A serotypes grouped into three main genetically related clusters (71/77 belonged to the cluster I). The five other strains exhibited different profiles. Using MLST, we demonstrated that most strains of the main cluster belonged to clonal complex (CC) 230, sequence type (ST) 276. However, for the other strains, the DiversiLab® method cannot be used to predict to which ST a strain belongs. The DiversiLab® method allowed us to identify the clonal expansion of S. pneumoniae serotype 19A strains isolated from both children and adults in 2007 and 2009.

National audience

The epidemiology of S. pneumoniae invasive infections in France, over the last few years, was modified by two public health measures. A nationwide campaign for the rationalization of antibiotic prescription was implemented in 2001 and vaccination of young children with the pneumococcal 7-valent conjugate vaccine in 2003. These measures led to a decrease in antibiotic resistance in S. pneumoniae strains, a lower incidence of invasive infections due to vaccine serotypes, but a higher incidence of infections due to non-vaccine serotypes, especially 7F and 19A. Despite the replacement, the incidence of invasive pneumococcal infections in children less than 2 years of age remains lower than it was before introducing the 7-valent conjugate vaccine.

The purpose of this article was to describe the serotype incidence and antibiotic susceptibility of Streptococcus pneumoniae strains isolated from adults and children with invasive disease (IPD) or acute otitis media (AOM) before introduction of the 13-valent pneumococcal vaccine. During 2009, 494 strains of S. pneumoniae isolated were collected. Complete serotyping by latex antisera and molecular methods was performed. The most frequent serotypes isolated from children with IPD were 1 (26.2%), 19A (25%) and 7F (14.3%). Serotype 19A was predominant (42.1%) in children ≤ 2 years, whereas serotype 1 was predominant (63.3%) after the age of 5. Serotype 19A was the most frequently isolated serotype from AOM (62.3%). In adults, serotypes responsible for IPD were 7F (19.4%), 19A (13.7%), 1 (8.4%) and 3 (7.5%). The serotype 19A was predominant in adults older than 65 years (19.1%). The emergence of serotype 12F was observed in adults. Between 2007 and 2009, the introduction of PCV-7 has resulted in a significant decrease of IPD caused by serotypes included in the vaccine, in children as well as in adults, confirming the herd effect. Serotype coverage of PCV-13 was 70% and 80.9% for adult and children's IPD, respectively. PCV-13 will be more efficient in preventing invasive diseases among children and adults.

En 2006, le nombre de meningites bacteriennes aigues communautaires survenues en France a ete estime a 1375 (2,23/100000). Les pathogenes impliques chez l'adulte etaient, par ordre de frequence, Streptococcus pneumoniae, Neisseria meningitidis, puis Listeria monocytogenes, Streptococcus agalactiae et Haemophilus influenzae. La mortalite globale etait de 20 %. Les sequelles survennaient dans 30 % des cas, plus frequentes en cas de pneumocoque. La diminution de la sensibilite aux antibiotiques concerne surtout N. meningitidis, S. pneumoniae et H. influenzae. Avec la generalisation du vaccin conjugue anti-H. influenzae de type b pour les enfants de moins de deux ans en 1992, les meningites a H. influenzae sont devenues peu frequentes chez l'adulte; il s'agissait le plus souvent de souches non typables, de sensibilite diminuee aux aminopenicillines par diminution d'affinite d'une proteine de liaison aux penicillines (12 % des cas). Les souches de N. meningitidis etaient de sensibilite diminuee a l'amoxicilline dans 30% des cas, mais restaient sensibles aux cephalosporines de troisieme generation (C3G) injectables. La resistance a la rifampicine ou a la ciprofloxacine etait rare. La proportion de souches de S. pneumoniae de sensibilite diminuee aux beta-lactamines est en baisse reguliere depuis 2002. Dans les meningites de l'adulte, elle etait de 37 % pour la penicilline, 18 % pour l'amoxicilline et 4 % pour le cefotaxime ou la ceftriaxone. Pour aucune de ces souches, la CMI des C3G injectables n'excedait 2mg/l. Toutes les souches de pneumocoque etaient sensibles aux glycopeptides.

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.

The aim of this study was to assess the prevalence of the extended-spectrum beta-lactamase (ESBL)-producing enterobacteria (ESBLE) in the French community, during a 2006 survey.All enterobacteria isolated from urine samples of patients, exhibiting a decreased susceptibility to broad-spectrum cephalosporins, were analysed for their beta-lactamase content (synergy test, isoelectrofocusing, conjugation transfer, PCR amplification and/or cloning experiments and sequencing). Additional co-resistances were investigated by PCR, sequencing and/or cloning. Epidemiological relationship was studied by PFGE for all species and, in addition, for Escherichia coli by the determination of the phylogenetic group, multilocus sequence type (ST) and O25b antigen. Characteristics of CTX-M-producing E. coli carriers were compared with other ESBLE carriers.Seventy-two ESBLE were collected from 71 patients. Most of them expressed a CTX-M enzyme (n = 42, comprising 40 E. coli), with a predominance of CTX-M-15 (n = 24); 10 CTX-M-15-producing E. coli belonged to the same clone (phylogroup B2, ST131, serotype O25b). The 30 remaining strains possessed a TEM- or SHV-type ESBL. In addition, three strains presented unusual co-resistances such as DHA-1 (n = 2), QnrB4 and ArmA. Risk factors for ESBLE acquisition were substantially less frequent when the ESBL was of the CTX-M type, except for prior antimicrobial therapy. Eighteen percent of the patients were considered to have true community-acquired ESBLE; most of them harboured a CTX-M-producing E. coli.This first nationwide study reports an ESBLE prevalence of 1.1% in the French community setting in 2006, mainly related to the presence of CTX-M-producing E. coli strains; furthermore, unusual co-resistances rarely found in the community setting were occasionally observed, which may threaten future emergence.

Resume De janvier 1990 a decembre 2005, 72 cas de meningites a pneumocoque avec une culture positive du liquide cephalorachidien ont ete repertories dans notre hopital. Parmi ces cas, 25 sont des enfants dont la moyenne d'âge est de quatre ans avec 60 % d'enfants de moins de deux ans et 47 sont des adultes dont la moyenne d'âge est de 55 ans. Les premiers cas de meningites a pneumocoque de sensibilite diminuee a la penicilline (PSDP) sont apparus en 1993 ; jusqu'en 1995, 25 % des souches etaient des PSDP, puis de 1996 a 2005, pratiquement une souche sur deux est un PSDP. La prevalence globale des PSDP est de 34,7 % (25/72). Parmi ces PSDP, 21 sont de sensibilite intermediaire a la penicilline G et quatre sont resistants. Chez l'enfant, sept meningites a PSDP dont un resistant ont ete repertoriees. Les concentrations minimales inhibitrices (CMI) de l'amoxicilline et du cefotaxime varient respectivement de 0,064 a 1 mg/l et de 0,016 a 0,5 mg/l. Aucune souche de pneumocoque isolee n'est de sensibilite diminuee au cefotaxime cependant, trois PSDP ont une CMI a 0,5 mg/l (valeur seuil). Chez l'adulte, 18 meningites a PSDP dont trois resistants ont ete diagnostiquees avec une frequence annuelle quasi constante. La CMI de l'amoxicilline de ces souches varie de 0,064 a 2 mg/l. Neuf PSDP sur 18 ont une CMI superieure ou egale a 0,5 mg/l au cefotaxime dont quatre avec une CMI a 1 mg/l. Aucune souche de pneumocoque resistante a l'amoxicilline et au cefotaxime n'a ete isolee. Le serotypage des souches a ete realise au Centre national de reference successif des pneumocoques (CNRP). Les serotypes identifies par ordre de frequence, chez l'enfant, sont 6B, 9V, 19 et chez l'adulte le 6B, 23F, 19, 9, 4, mais tous les serotypes sont representes.

International audience; ObjectivesWe aimed to assess antibiotic prescriptions to identify potential targets for improvement.MethodsWe conducted a point prevalence survey (November 2010) of antibiotic use in 314 voluntary hospitals recruited by the French Infectious Diseases Society (SPILF) and the National Observatory for Epidemiology of Bacterial Resistance to Antimicrobials (ONERBA). Data were entered online, immediately analyzed and exported.ResultsThe prevalence of antibiotic use was 19.5% (9059/46,446patients). A higher prevalence was observed in the infectious disease (58.4%), hematology (58%), and intensive care (48.7%) units. The three most frequently used antibiotic classes were aminopenicillins (23.8%), fluoroquinolones (17.9%), and 3rd-generation cephalosporins (16.7%). A monotherapy was prescribed to 64% of patients. The reasons for the antibiotic prescription were written in the medical records of 74% of patients and 62% were consistent with the local guidelines.ConclusionOur results are similar to that of other studies. Various local targets for improvement have been identified to help hospitals define a better antibiotic stewardship.; ObjectifsÉvaluer les prescriptions antibiotiques afin de proposer des pistes d’amélioration.MéthodesNous avons réalisé une enquête de prévalence de l’antibiothérapie, en novembre 2010, dans 314 hôpitaux volontaires recrutés par les réseaux de la SPILF et de l’ONERBA. Les données étaient saisies en ligne avec une analyse instantanée et un export des données.RésultatsLa prévalence de l’antibiothérapie était de 19,5 % (9059/46 446patients). Elle était plus élevée en maladies infectieuses (58,4 %), hématologie (58 %) et réanimation (48,7 %). Les trois classes les plus fréquentes étaient les aminopénicillines (23,8 %), les fluoroquinolones (17,9 %) et les céphalosporines de 3e génération (16,7 %). Une monothérapie était utilisée dans 64 % des cas. Le motif de la prescription était noté dans le dossier médical dans 74 % des cas et était conforme aux recommandations locales dans 62 %.ConclusionsCes résultats sont similaires à ceux d’autres enquêtes. Des possibilités d’amélioration sur des critères locaux permettent aux établissements d’orienter leurs politiques d’amélioration de la prescription.

Resume Cette synthese concernant les principaux pathogenes impliques en France dans les infections respiratoires basses fait le point sur l'epidemiologie de la resistance aux β-lactamines, macrolides, ketolides et fluoroquinolones, en particulier pour Streptococcus pneumoniae et Haemophilus influenzae, passe en revue les mecanismes de resistance impliques en precisant leur impact sur le niveau de resistance confere, et souligne les risques ecologiques actuels ou previsibles. Cette revue s'inscrit dans le cadre de cette XVe conference de consensus, et contribuera a l'elaboration des recommandations pour la prise en charge des infections respiratoires basses de l'adulte.

Hyperhomocysteinaemia is a factor related to the development of atherosclerosis in rheumatoid arthritis (RA). However, Hispanics with RA develop high rates of coronary disease; there are no studies about the frequency and factors related to high levels of homocysteine in Mexican patients.To evaluate the prevalence and characteristics associated with hyperhomocysteinaemia in Mexican patients with RA.One hundred and fifty-two patients with RA were compared with 153 controls. The assessment in RA included clinical characteristics, disease activity (RADAR), functioning (HAQ-Di and global functional status), comorbidity, and radiological damage. Laboratory determinations included total serum homocysteine (tHcy), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor (RF), and lipid profile.Median levels of homocysteine were higher in RA compared with controls (11.3 vs. 9.3, p0.001). Twenty per cent of the patients with RA had hyperhomocysteinaemia (15 micromol/L) compared with 6% in controls (p0.001). There was statistical association between hyperhomocysteinaemia in RA with male gender (p0.001), impairment in the global functional status (p = 0.004), higher radiological damage (p = 0.001), and CRP (p = 0.04). There was no association with RADAR, HAQ-Di, or RF, methotrexate dose or duration of use. In the adjusted multivariate model, the two variables associated with higher risk for hyperhomocysteinaemia were male gender (OR = 4.2, 95% CI 2 to 12, p = 0.006) and higher radiological damage (III-IV) (OR = 3.4, 95% CI 1.3 to 9, p = 0.01).Our data show a high prevalence of hyperhomocysteinaemia in Mexican patients with RA. More effort is required to evaluate and treat earlier this coronary risk factor.

Summary: The deep inferior epigastric perforator flap has become increasingly popular for breast reconstruction with the most common recipient vessels being the internal mammary artery and vein. In certain cases, however, these recipient vessels are inadequate due to an absent or diminutive vein. Moreover, patients at high risk for future coronary artery disease may sacrifice the best conduit for coronary revascularization if the internal mammary recipients are used. Alternative recipient vessels, including the thoracodorsal, thoracoacromial, external jugular, and cephalic vessels have significant limitations. In this report, we describe a novel technique using unilateral internal mammary recipient vessels for bilateral free flap breast reconstruction. Two cases are presented that represent distinct indications for this technique: (1) absence or inadequacy of unilateral recipient vessels and (2) preservation of the left internal mammary system for future bypass in patients at high risk for coronary artery disease.

For the past 20 years, three vaccines against the three main bacterial species implicated in meningitis in children have been included in the French vaccine calendar: Haemophilus influenzae b in 1993, 7-valent pneumococcal conjugate vaccine (PCV7) in 2003 (replaced by 13-valent in 2010) and Neisseria meningitidis C in 2009. The French active surveillance network from the GPIP/ACTIV monitors the change in the epidemiological, clinical, and biological features of bacterial meningitis due to vaccine use.Over a 12-year period, 233 pediatric wards working with 168 microbiology departments throughout France were asked to report all cases of bacterial meningitis.From January 2001 to December 2012, 4808 bacterial meningitis cases were reported. Between 2001 and 2012, the number of pneumococcal meningitis (PM) cases decreased by 23.4%, and by 32.2% for children less than 2 years old. During this period, the proportion of cases attributable to PCV7 and six additional PCV13 types decreased from 63.3% to 8.1% and 83.7% to 32.4%, respectively. In 2012, the main vaccine types (accounting for 25.8% of cases) were 7F (12.2%), 19A (6.8%), and 19F (6.8%), and the most frequent non-vaccine types were 12F (14.9%), 24F (14.9%), 15B/C (6.8%), 22F (6.8%), and 10A (5.4%). In 2012, the rate of strains with decreased susceptibility to cefotaxime/ceftriaxone (MIC0.5 μg/mL) represented less than 3% of cases, with no identified resistant strain since 2010 (MIC2 μg/mL). Between 2001 (n=67) and 2012 (n=9), the number of NmC meningitis cases decreased by 87%.With more than 4800 bacterial meningitis cases reported in 12 years, this nationwide survey provides essential information on the microbiological and clinical characteristics of bacterial meningitis (epidemiology or resistance data). These results could lead to changing antibiotic treatment of pneumococcal meningitis before the results of antibiotic susceptibility tests.

Resume La resistance aux fluoroquinolones (FQ) observee chez Streptococcus pneumoniae et chez les streptocoques du groupe viridans (SGV) est associee, comme chez les autres bacteries a Gram positif, a deux mecanismes majeurs : la modification de leurs cibles naturelles, la gyrase et la topo-isomerase IV d'une part, l'expression d'un mecanisme d'efflux actif d'autre part. Pour S. pneumoniae , la cible preferentielle, dont les mutations sont associees au bas niveau de resistance, depend de la FQ etudiee. Par exemple, la trovafloxacine ou la pefloxacine vont plus souvent selectionner des mutants de topo-isomerase IV, alors que la sparfloxacine et la clinafloxacine selectionneront plus volontiers des mutants de gyrase. Lorsque des mutations touchent les deux cibles, on aboutit a un niveau de resistance elevee, croisee pour l'ensemble des FQ. Le niveau de resistance lie a l'efflux depend de chaque molecule. Ce mecanisme, present aussi bien chez S. pneumoniae que chez les SGV, pourrait toucher jusqu'a 20 % des souches de S. pneumoniae. En clinique, l'association des differents mecanismes pourrait aboutir dans ces especes a un niveau de resistance elevee.

Resume Pendant longtemps, la virulence du pneumocoque a ete attribuee a sa capsule, qui s'oppose a la phagocytose. En fait S. pneumoniae synthetise differents facteurs impliques dans la virulence. Ceux-ci comprennent une toxine puissante, la pneumolysine, capable de lyser n'importe quelle cellule eucaryote, et toute une serie de proteines de surface liant la choline : la proteine majoritaire CbpA et PsaA jouent le role d'adhesines, l'autolysine LytA libere les acides teichoiques et lipoteichoiques de la paroi, puissants mediateurs de l'inflammation ; le role de PspA n'est pas completement elucide. Ensemble, ces facteurs contribuent a la colonisation, l'inhibition de la phagocytose, l'invasion, l'inflammation et la destruction des tissus.

Resume Les effets des beta-lactamines vis-a-vis du pneumocoque, a l'exception de ceux de la penicilline G, sont peu connus. Nous avons compare l'effet lytique et bactericide de la penicilline G, de l'amoxicilline et du cefotaxime vis-a-vis de 4 souches de pneumocoque de sensibilite differente a la penicilline G. L'amoxicilline et la penicilline G ont un effet lytique comparable et les souches ainsi lysees sont rapidement tuees. Les effets du cefotaxime sont differents. Sur 3 des 4 souches etudiees, l'effet lytique du cefotaxime est inferieur a celui de la penicilline G ou de l'amoxicilline. Son activite bactericide est variable selon les souches independemment de leur sensibilite aux beta-lactamines, et peut s'observer en absence d'effet lytique. L'activite bactericide des penicillines resulte de la mise en jeu de systemes complexes qui ne dependent pas seulement du syteme autolytique. Les cephalosporines, qui n'inhibent pas les memes proteines de liaison aux penicillines, favoriseraient l'elaboration d'un peptidoglycane immature et pourraient impliquer ces systemes de facon differente.