The high microbiologic diversity encountered in prosthetic joint infection (PJI) makes the choice of empirical antimicrobial therapies challenging, especially in cases of implant retention or ...one-stage exchange. Despite the risk of dysbiosis and toxicity, the combination of vancomycin with a broad-spectrum β-lactam is currently recommended in all cases, even if Gram-negative bacilli (GNB) might be less represented in late PJI. In this context, this study aimed to describe the microbiologic epidemiology of PJI according to the chronology of infection.
This prospective cohort study (2011–2016) evaluated the microbiologic aetiology of 567 PJI according to time of occurrence from prosthesis implantation—early (<3 months), delayed (3–12 months) and late (>12 months)—as well as mechanism of acquisition.
Initial microbiologic documentation (n = 511; 90.1%) disclosed 164 (28.9%) Staphylococcus aureus (including 26 (16.1%) methicillin-resistant S. aureus), 162 (28.6%) coagulase-negative staphylococci (including 81 (59.1%) methicillin-resistant coagulase-negative staphylococci), 80 (14.1%) Enterobacteriaceae, 74 (13.1%) streptococci and 60 (10.6%) Cutibacterium acnes. Considering nonhaematogenous late PJI (n = 182), Enterobacteriaceae (n = 7; 3.8%) were less represented than in the first year after implantation (n = 56; 17.2%; p <0.001), without difference regarding nonfermenting GNB (4.6% and 2.7%, respectively). The prevalence of anaerobes (n = 40; 21.9%; including 32 (80.0%) C. acnes) was higher in late PJI (p <0.001). Consequently, a broad-spectrum β-lactam might be useful in 12 patients (6.6%) with late PJI only compared to 66 patients (20.3%) with early/delayed PJI (p <0.001).
Considering the minority amount of GNB in late postoperative PJI, the empirical use of a broad-spectrum β-lactam should be reconsidered, especially when a two-stage exchange is planned.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Introduction Une altération de la réponse vasodilatatrice cutanée à une pression progressive et non douloureuse (PIV : Pressure-Induced Vasodilation) appliquée localement a été observée chez des ...patients diabétiques de type 1 et chez la souris dans un diabète expérimental. Récemment, il a été montré que les inhibiteurs de l’aldose réductase (IAR) restaurent la PIV dans un modèle de diabète exprimant une neuropathie diabétique sévère. A cause de leurs effets indésirables importants, les IAR ne peuvent pas être utilisés en thérapeutique. En revanche, le candésartan, antihypertenseur fréquemment utilisé en thérapeutique chez le diabétique, pourrait-il restaurer la PIV chez la souris dans un diabète de 8 semaines induit par la streptozotocine ? Matériels et méthodes Cette étude a été effectuée sur des souris diabétiques (STZ) et contrôles (TEM) ne recevant aucun traitement ou un traitement au candésartan (Cand) à dose non-antihypertensive (1 mg/kg/jour) les deux dernières semaines de diabète. L’intégrité des fibres nerveuses de type C a été évaluée par la mesure de la sensibilité douloureuse mécanique. Les vasodilatations endothélium-dépendante et -indépendante ont été étudiées par la technique de iontophorèse. Les variations du flux sanguin cutané pendant la PIV et les iontophorèses ont été mesurées par la technique de fluxmétrie laser Doppler. Résultats Le candésartan restaure la sensibilité douloureuse mécanique passant par les fibres nerveuses de type C et la vasodilatation endothélium-dépendante de la microcirculation avec pour conséquence une restauration complète de la PIV chez les souris diabétiques (TEM : + 34 ± 8 %, STZ : −16 ± 6 %, Cand-STZ : +28 ± 10.5 %, P < 0,05 STZ vs Cand-STZ). Conclusion Ainsi, le candésartan à dose non antihypertensive, restaure les fonctions nerveuses de type C et la fonction vasodilatatrice endothéliale, nécessaires à la réponse vasodilatatrice normale en réponse à la pression ; ce qui pourrait limiter l’apparition des ulcères cutanés chez les diabétiques.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
MRSA is a therapeutic concern worldwide, and a major agent of community-acquired skin and soft tissue infections (CA-SSTIs). While the US epidemiology of MRSA in CA-SSTIs is well described and ...reports the high prevalence of the USA300 clone, data on the European situation are lacking.
To determine the prevalence and clonal characteristics of MRSA in CA-SSTIs in seven European emergency departments.
From April to June 2015, patients presenting to the tertiary hospital emergency department with a Staphylococcus aureus CA-SSTI were prospectively enrolled. S. aureus isolates were characterized by antimicrobial susceptibility testing, detection of Panton-Valentine leucocidin encoding genes and spa-typing, MLST and/or DNA microarray.
Two-hundred and five cases of S. aureus-associated CA-SSTIs were included, comprising folliculitis, furuncles, abscesses, paronychia, impetigo, carbuncles and cellulitis. Of the 205 cases, we report an MRSA prevalence rate of 15.1%, with a north (0%) to south (29%) increasing gradient. Fifty-one isolates were Panton-Valentine leucocidin-positive (24.9%), whether MSSA or MRSA, with a heterogeneous distribution between countries. Clonal distribution of MSSA and MRSA showed high diversity, with no predominant circulating clone and no archetypical USA300 CA-MRSA clone.
This original prospective multicentre study highlights stark differences in European MRSA epidemiology compared with the USA, and that the USA300 CA-MRSA clone is not predominant among community-infected patients in Europe.
The use of piperacillin/tazobactam with vancomycin as empirical antimicrobial therapy (EAT) for prosthetic joint infection (PJI) has been associated with an increased risk of acute kidney injury ...(AKI), leading us to propose cefepime as an alternative since 2017 in our reference centre.
To compare microbiological efficacy and tolerance of these two EAT strategies.
All adult patients with PJI empirically treated with vancomycin+cefepime (n = 89) were enrolled in a prospective observational study and matched with vancomycin+piperacillin/tazobactam-treated historical controls (n = 89) according to a propensity score including age, baseline renal function and concomitant use of other nephrotoxic agents. The two groups were compared using Kaplan-Meier curve analysis, and non-parametric tests regarding the proportion of efficacious empirical regimen and the incidence of empirical therapy-related adverse events (AE).
Among 146 (82.0%) documented infections, the EAT was considered efficacious in 77 (98.7%) and 65 (98.5%) of the piperacillin/tazobactam- and cefepime-treated patients, respectively (P = 1.000). The rate of AE, particularly AKI, was significantly higher in the vancomycin+piperacillin/tazobactam group n = 27 (30.3%) for all AE and 23 (25.8%) for AKI compared with the vancomycin+cefepime n = 13 (14.6%) and 6 (6.7%) group (P = 0.019 and <0.001, respectively), leading to premature EAT discontinuation in 20 (22.5%) and 5 (5.6%) patients (P = 0.002). The two groups were not significantly different regarding their comorbidities, and AKI incidence was not related to vancomycin plasma overexposure.
Based on the susceptibility profile of bacterial isolates from included patients, microbiological efficacy of both strategies was expected to be similar, but vancomycin + cefepime was associated with a significantly lower incidence of AKI.
We investigated the epidemiological, clinical, microbiological and genetic characteristics of linezolid-resistant (LZR) Staphylococcus capitis isolates from French ICUs, and compared them with LZR S. ...capitis isolates from other European countries.
All LZR isolates were subjected to antimicrobial susceptibility testing (AST) and the presence of cfr and optrA genes as well as mutations in the 23S rRNA and ribosomal proteins were investigated using specific PCR with sequencing. The genetic relationship between isolates was investigated using PFGE and WGS. Epidemiological data concerning LZR S. capitis were collected retrospectively in French microbiology laboratories.
Twenty-one LZR isolates were studied: 9 from France, 11 from Greece and 1 from Finland. All were resistant to methicillin and aminoglycosides. In addition, this unusual AST profile was identified in S. capitis isolates from seven French hospitals, and represented up to 12% of the S. capitis isolates in one centre. A G2576T mutation in 23S rRNA was identified in all isolates; cfr and optrA genes were absent. All isolates belonged to the same clone on the basis of their PFGE profiles, whatever their geographical origin. WGS found at most 212 SNPs between core genomes of the LZR isolates.
We identified and characterized an LZR S. capitis clone disseminated in three European countries, harbouring the same multiple resistance and a G2576T mutation in the 23S rRNA. The possible unrecognized wider distribution of this clone, belonging to a species classically regarded as a low-virulence skin colonizer, is of major concern not least because of the increasing use of oxazolidinones.
We describe two cases of human infections caused by Staphylococcus aureus clonal complex (CC) 75, also called Staphylococcus argenteus, harbouring the Panton-Valentine leucocidin (PVL). These two ...sporadic cases were community-acquired, and identified in France in 2014. Both had an epidemiological link with Mayotte, an overseas department of France located in the Indian Ocean off the south-eastern African coast. This report illustrates that, contrary to previous descriptions, S. argenteus can acquire important virulence factors and be responsible for severe infections.
L’antibiothérapie probabiliste est un enjeu clinique important dans le domaine des infections de prothèse articulaire (IPA), d’autant que le diagnostic microbiologique est incomplet ou non disponible ...en préopératoire. L’association vancomycine et pipéracilline/tazobactam est souvent utilisée dans les infections aiguës comme chroniques, alors que les infections à Gram négatifs sont probablement rares dans les formes tardives, du fait de leur moindre capacité à produire du biofilm et/ou à s’internaliser dans les cellules de l’hôte. De plus, cette association d’antibiotiques a probablement un fort impact écologique et demeure néphrotoxique. La connaissance de l’épidémiologie microbienne en fonction du délai de survenue de l’IPA est donc essentielle dans le choix des stratégies thérapeutiques.
L’ensemble des malades pris en charge pour une IPA dans un CRIOAc entre 2011 et 2016 ont été inclus dans une cohorte prospective. Les données microbiologiques au moment du diagnostic ont été recueillies, et comparées en fonction du délai de survenue de l’infection.
Cinq cent soixante-dix épisodes d’IPA ont été inclus (285 hommes, 50,0 % ; âge médian, 70,3 IQR 59,8–78,8 ans), survenant 25,4 (IQR 3,6–178,8) semaines après la pose d’une prothèse principalement de hanche (n=287 ; 50,4 %) ou de genou (n=255 ; 44,7 %), correspondant à une prothèse de révision chez 222 patients (40,9 %). Les prélèvements ostéo-articulaires réalisés lors de la prise en charge chirurgicale initiale retrouvaient 165 S. aureus (28,9 %) dont 26 (16,1 %) méti-R, 163 staphylocoques à coagulase négative (SCN, 28,6 %) dont 80 (58,4 %) méti-R, 80 (14,0 %) entérobactéries, 74 (13,0 %) streptocoques et 85 (14,9 %) anaérobies dont 60 (10,5 %) Propionibacterium spp. L’infection était plurimicrobienne chez 103 (18,1 %) patients, et non documentée dans 57 (10,1 %) cas. Deux cent quarante-six (43,2 %) épisodes était des IPA tardives, survenant plus d’un an après la pose. En excluant les 16 formes hématogènes documentées, et en comparaison aux IPA survenant moins d’un an après la pose, les entérobactéries (n=8 ; 3,5 % ; p<10-4) et les bacilles Gram négatif non fermentant (n=3 ; 1,3 % ; p=0,047) dont Pseudomonas spp (n=1 0,4 % ; p=0,0106) étaient largement moins représentés, menant à la nécessité théorique d’une béta-lactamine à large spectre chez seulement 10 (4,3 %) patients. Par ailleurs, on notait autant d’anaérobies totaux (n=42 18,3 % ; p=0,1203), mais plus de Propionibacterium (n=33 14,3 % ; p=0,0269).
La faible prévalence des BGN dans les IPA postopératoires tardives pose la question de la nécessité d’une béta-lactamine à large spectre dans le traitement probabiliste, notamment lorsqu’un changement en 2 temps est prévu. Une association de vancomycine et de clindamycine pourrait être proposée dans cette situation.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Bone and joint infections represent a potentially devastating complication of prosthetic orthopedic joint replacement, thus requiring both rapid and appropriate antibiotic treatment. Staphylococcus ...aureus is one of the most common pathogens involved in this pathology. Being able to assert its presence is the first step of efficient patient management. This monocenter study evaluated the MRSA/SA ELITe MGB assay for the molecular detection of S. aureus and methicillin-resistant S. aureus (MRSA) in bone and joint biopsy specimens and synovial fluids. This test, together with conventional techniques, including standard cultures and the 16S rRNA amplification assay, was performed on 208 successive perioperative samples collected prospectively for 1 year obtained from 129 patients. Using conventional techniques, we detected a microbial pathogen in 76 samples from 58 patients, 40 of which were identified as S. aureus. The limit of detection (LOD) of the MRSA/SA ELITe MGB assay was experimentally determined for bone and joint biopsy specimens and synovial fluids using negative samples spiked with S. aureus ATCC 43300. The sensitivities of S. aureus detection with the MRSA/SA ELITe MGB assay were 82.5% (33/40 samples) and 97.5% (39/40 samples) using the manufacturer's LOD and an experimentally determined LOD, respectively. Interestingly, using the osteoarticular specific LOD, 15 additional samples were determined to be positive for S. aureus DNA with the MRSA/SA ELITe MGB assay; in all cases, these samples were obtained from patients considered to be infected with S. aureus according to their clinical and microbiological records. The results were available within 24 h, which could help to expedite therapeutic decisions.
Actinomycosis is a rare chronic disease caused by Actinomyces spp., anaerobic Gram-positive bacteria that normally colonize the human mouth and digestive and genital tracts. Physicians must be aware ...of typical clinical presentations (such as cervicofacial actinomycosis following dental focus of infection, pelvic actinomycosis in women with an intrauterine device, and pulmonary actinomycosis in smokers with poor dental hygiene), but also that actinomycosis may mimic the malignancy process in various anatomical sites. Bacterial cultures and pathology are the cornerstone of diagnosis, but particular conditions are required in order to get the correct diagnosis. Prolonged bacterial cultures in anaerobic conditions are necessary to identify the bacterium and typical microscopic findings include necrosis with yellowish sulfur granules and filamentous Gram-positive fungal-like pathogens. Patients with actinomycosis require prolonged (6- to 12-month) high doses (to facilitate the drug penetration in abscess and in infected tissues) of penicillin G or amoxicillin, but the duration of antimicrobial therapy could probably be shortened to 3 months in patients in whom optimal surgical resection of infected tissues has been performed. Preventive measures, such as reduction of alcohol abuse and improvement of dental hygiene, may limit occurrence of pulmonary, cervicofacial, and central nervous system actinomycosis. In women, intrauterine devices must be changed every 5 years in order to limit the occurrence of pelvic actinomycosis.
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