Alcohol-based handwashing agent improves hand washing.
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Anti-Infective Agents, Local↗
Biomedical subjects
F Barbut
Publications and source records attributed to F Barbut.
[Role of the microbiology laboratory in the diagnosis of nosocomial diarrhea].
Diarrhea that occurs in hospitalized patients is frequent and may be due to infectious or noninfectious causes. In adults with nosocomial diarrhea, the most commonly detected agent is Clostridium difficile; in children, rotaviruses are predominant. Various studies have shown that bacterial enteric pathogens (e.g. Salmonella spp., Shigella spp., Campylobacter spp...) or parasites are common causes of community-acquired diarrhea but rarely cause nosocomial enteritis. Stool cultures for these pathogens and ova and parasite examination should not be performed in patients hospitalized for more than three days unless there are plausible clinical or epidemiological reasons to do so. In contrast, C. difficile toxins assay (and rotavirus screening in children) should be primarily requested. The detection of C. difficile toxin B by stool cytotoxicity assay remains the 'gold standard'. Identification of toxin A (or A + B) can also be performed by immuno-enzymatic (ELISA) tests: results may be obtained in three hours. Electronic microscopy is the standard method for rotavirus diagnosis but tests using latex agglutination or immuno-enzymatic assay are now available. Various typing methods have been developed and may be routinely used in epidemiological investigations.
Adult↗
[Epidemiology, risk factors and prevention of Clostridium difficile nosocomial infections].
Clostridium difficile is responsible for 10-25% of cases of antibiotic-associated diarrhea (AAD) and for virtually all cases of antibiotic-associated pseudo-membranous colitis (PMC). This anaerobic spore-forming bacterium has been identified as the leading cause of nosocomial infectious diarrhea in adults. Pathogenesis relies on a disruption of the normal bacterial flora of the colon, a colonization by C. difficile and the release of toxins A and B that cause mucosal damage and inflammation. Incidence of C. difficile intestinal disorders usually varies from one to 40 per thousand patient admissions. Risk factors for C. difficile-associated diarrhea include antimicrobial therapy, older age (> 65 years), antineoplastic chemotherapy, and length of hospital stay. Nosocomial transmission of C. difficile via oro-fecal route occurs in 3-30% of total patient admissions but it remains asymptomatic in more than 66% of cases. Persistent environmental contamination and carrying of the organism on the hands of hospital staff are common. Measures that are effective in reducing cross-infection consist of an accurate and rapid diagnosis, an appropriate treatment, an implementation of enteric precautions for symptomatic patients, a reinforcement of hand-washing and a daily environmental disinfection. C. difficile is a common cause of infectious diarrhea and should be therefore systematically investigated in patients with nosocomial diarrhea.
Clostridioides difficile↗
[Comparison of infectious complications of long-term and short-term central venous catheterization].
OBJECTIVES: Risk factors for infectious complications of central venous catheters (CVC) were compared between CVC used for short and long periods to identify patients at risk. PATIENTS AND METHODS: A prospective study was conducted over a 6 month period in two general intensive care units (87 patients with short duration CVC) and in 4 medical units (110 patients with cancer or HIV infection for whom long duration CVC was scheduled). The first CVC inserted was followed to withdrawal or for a minimal 3 months. RESULTS: The mean duration of CVC use was 7.5 and 106 days for the short and long duration groups respectively. A CVC-related infection occurred in 6 patients in the short duration group and in 14 patients in the long duration group giving an incidence of 1.0/100 CVC days (95% CI: 0.4-2.0) for the short-duration CVC group and 0.13/100 CVC days (95% CI: 0.07-0.21) for the long-duration CVC group. Intensive care patients with a skin lesion far from the CVC insertion point had a higher incidence of CVC-related infection than patients without a skin infection. Taking into account the indications for CVC, patients with cancer or HIV infection had equivalent risk of infection. For both short and long duration CVC use, parenteral nutrition was found to be a major risk factor for infectious complications. CONCLUSION: Rigorous regular surveillance of nosocomial infections on central catheters should be centered on those inserted for parenteral nutrition.
Aged↗
Development of a new PCR-ribotyping method for Clostridium difficile based on ribosomal RNA gene sequencing.
PCR-ribotying, a typing method based on polymorphism in the 16S-23S intergenic spacer region, has been recently used to investigate outbreaks due to Clostridium difficile. However, this method generates bands of high and close molecular masses which are difficult to separate on agarose gel electrophoresis. To improve reading of banding patterns of PCR-ribotyping applied to C. difficile, a partial sequencing of the rRNA genes (16S and 23S) and intergenic spacer region has been performed, then a new set of primers located closer to the intergenic spacer region has been defined. The new PCR gave reproducible patterns of bands easy to separate on agarose gel electrophoresis. Each of the 10 serogroups and 11 subgroups of serogroup A produced a different pattern. This typing method has evidenced major qualities such as easiness, rapidity and reproducibility. However, its discriminatory power has to be evaluated to validate its importance as a typing tool for C. difficile.
Bacterial Typing Techniques↗
Pseudomonas aeruginosa infection in human immunodeficiency virus infected patients.
OBJECTIVES: (1) To determine the incidence and outcome of Pseudomonas aeruginosa infection in HIV-infected patients. (2) To study the antimicrobial susceptibility of P. aeruginosa isolates in this particular population. (3) To identify risk factors for these infections. PATIENTS AND METHODS: A retrospective case-control study performed in a 28-bed infectious-diseases unit in a 940-bed university hospital. All cases were defined as HIV-infected patients with severe infections due to P. aeruginosa, including bacteremia, lower or upper respiratory tract infections, infections related to a central venous catheter, and cutaneous/muscular infection. Each case was matched with an HIV-seropositive control not infected by P. aeruginosa and hospitalized on the same dates as the cases. RESULTS: One thousand and thirty-five HIV-infected patients were hospitalized during the study period. A first severe P. aeruginosa infection was documented in 41 patients, giving an overall annual incidence note of 2.51 episodes per 100 admissions. Forty of the 41 case notes were available for analysis. They consisted of 17 cases of bacteraemia, four upper respiratory tract infections, 10 lower respiratory tract infections, three catheter-related infections, and six cutaneous/muscular infections. Of these 40 cases, 60% were nosocomial and the remainder were community-acquired. The overall mortality rate was 22% (47% in bacteraemic forms). Twenty five percent of patients relapsed after an average of 37 days. The case-control comparison showed that AIDS was more frequent among the cases (92% vs. 74%, P = 0.04), who also had a lower PN count (P = 0.005), and a lower CD4 cell count (15.7 +/- 18.8/mm3 vs. 118 +/- 211/mm3; P = 0.0007). The number of days spent in hospital in the previous 3 months (29.3 +/- 20.7 vs. 19.7 +/- 14, P = 0.04) was significantly higher among the cases. In a multivariate analysis, examining treatments received in the previous month, only co-trimoxazole [OR = 5.5 (1.1-26.9)], penicillins [OR = 5.2 (1.1-25.3)], steroids [OR = 5.5, (1.2-25.5)] and a CD4 cell count below 50/mm3 [OR = 13.2 (1.4-129.4)] were identified as risk factors. CONCLUSION: P. aeruginosa infection is a not frequent bacterial disease in highly immunodeficient HIV-infected patients. It is frequently fatal and must be borne in mind in the advanced stages of HIV disease, especially when patients have received co-trimoxazole (trianthoprim-sulphamethoxazole), penicillins or steroids.
AIDS-Related Opportunistic Infections↗
Comparative value of colonic biopsy and intraluminal fluid culture for diagnosis of bacterial acute colitis in immunocompetent patients. Infectious Colitis Study Group.
We compared the yield of intraluminal fluid culture to that of biopsy specimens obtained during colonoscopy for the diagnosis of bacterial colitis in 93 immunocompetent patients with a recent episode of diarrhea and macroscopic lesions of colitis. Stool culture findings were also available for 68 patients. At least one bacterial pathogen was isolated from the biopsy specimen, intraluminal fluid, or stool from 48 patients (51.6%). Salmonella species, Clostridium difficile, Klebsiella oxytoca, Shigella species, and Campylobacter species were recovered from 16 (17.2%), 15 (16.1%), 8 (8.6%), 7 (7.5%), and 4 (4.3%) of the patients, respectively. One Shigella species and one K. oxytoca strain were isolated from biopsy specimens but not from intraluminal fluid, and intraluminal fluid was the only positive specimen in 12 cases (yielding 1 Salmonella species, 2 Shigella species, 2 K. oxytoca, and 7 C. difficile isolates). In nine cases out of 10, toxin B was detected only in intraluminal fluid. A correlation of 91.2% was observed between stool and intraluminal fluid cultures for Salmonella, Shigella, and Campylobacter species isolations. Culture of biopsy specimens adds little to the diagnosis of infectious colitis, and stools and intraluminal fluids appear to have comparable value.
Acute Disease↗
Bacterial dissemination, rather than translocation, mediates hypermetabolic response in endotoxemic rats.
OBJECTIVE: To study the pathogenesis of the host response during bacterial translocation, a rat model was designed for prolonged follow-up after injury. DESIGN: A prospective, controlled animal study. SETTING: Animal laboratory. SUBJECTS: Young male Wistar rats. INTERVENTIONS: Antibiotic decontamination of rats was performed 4 days before intragastric inoculation with a selected Escherichia coli strain (10(10) bacteria/kg of body weight). Two days later, the rats received a lipopolysaccharide injection or not (control group) and were observed for 3 days. They were then killed. A reference group (pair-fed healthy animals) was studied in parallel. MEASUREMENTS AND MAIN RESULTS: During observations, urinary total nitrogen loss and 3-methylhistidine excretion were determined daily. When the rats were killed, mesenteric lymph nodes (MLNs), spleen, and liver were aseptically removed and cultured. Colonies identified as translocated E. coli were counted in each organ. Intracellular amino acid free pools were measured in extensor digitorum longus and anterior tibialis. Endotoxin induces bacterial translocation of bacteria from gut lumen to MLNs (100% vs. 59% in the lipopolysaccharide-untreated control group; p < .05) and dissemination to spleen and liver (65% and 45% of positive cultures after endotoxemia, respectively, vs. 6% and 12% in the control groups). No translocation occurred in the reference group. Evidence for the hypermetabolic response was seen in lipopolysaccharide-treated and infected rats, but protein catabolism was more closely related to the occurrence of bacterial dissemination to spleen and liver than to translocation alone (e.g., the cumulative 3-methylhistidine excretion during the observation period was 4.07+/-0.18 micromol in uninfected rats, 4.48+/-0.29 in rats with positive MLN cultures alone and 6.17+/-0.30 in MLN, spleen, or liver infected rats; 1 vs. 2, NS; 3 vs. 1, and 3 vs. 2, p < .05). CONCLUSIONS: Gut barrier failure is associated with a deep excessive catabolic response in the host. The mechanism by which the metabolic state affects the resistance to infection apparently involves amino acid metabolism.
Animals↗
Antimicrobial susceptibilities and serogroups of clinical strains of Clostridium difficile isolated in France in 1991 and 1997.
Glycopeptides (vancomycin and teicoplanin) and metronidazole are the drugs of choice for the treatment of Clostridium difficile infections, but trends in susceptibility patterns have not been assessed in the past few years. The objective was to study the MICs of glycopeptides and metronidazole for unrelated C. difficile strains isolated in 1991 (n = 100) and in 1997 (n = 98) by the agar macrodilution, the E-test, and the disk diffusion methods. Strain susceptibilities to erythromycin, clindamycin, tetracycline, rifampin, and chloramphenicol were also determined by the ATB ANA gallery (bioMérieux, La Balme-les-Grottes, France). The MICs at which 50% of isolates are inhibited (MIC(50)s) and MIC(90)s of glycopeptides and metronidazole remained stable between 1991 and 1997. All the strains were inhibited by concentrations that did not exceed 2 microgram/ml for vancomycin and 1 microg/ml for teicoplanin. Comparison of MICs determined by the agar dilution method recommended by the National Committee for Clinical Laboratory Standards and the E test showed correlations (+/-2 dilutions) of 86. 6, 95.9, and 99% for metronidazole, vancomycin, and teicoplanin, respectively. The E test always underestimated the MICs. Strains with decreased susceptibility to metronidazole (MICs, >/=8 microgram/ml) were isolated from six patients (n = 4 in 1991 and n = 2 in 1997). These strains were also detected by the disk diffusion method (zone inhibition diameter, </=21 mm); they belonged to nontoxigenic serogroup D (n = 5) and toxigenic serogroup H (n = 1). Decreased susceptibility to erythromycin (MICs, >/=1 microgram/ml), clindamycin (MICs, >/=2 microgram/ml), tetracycline (MICs, >/=8 microgram/ml), rifampin (MICs, >/=4 microgram/ml), and chloramphenicol (MICs, >/=16 microgram/ml) was observed in 64.2, 80.3, 23.7, 22.7, and 14.6% of strains, respectively. Strains isolated in 1997 were more susceptible than those isolated in 1991, and this trend was correlated to a major change in serogroup distribution. Periodic studies are needed in order to detect changes in serogroups and the emergence of strains with decreased susceptibility to therapeutic drugs.
Adult↗
Clostridium difficile-associated diarrhea in HIV-infected patients: epidemiology and risk factors.
A retrospective analysis of all the cases of Clostridium difficile-associated diarrhea (CDAD) in hospitalized patients infected with HIV was performed over a 52-month period to assess the incidence, epidemiology, and risk factors of CDAD. A case of CDAD was defined as a patient with diarrhea and a positive stool cytotoxin B assay. Sixty-seven cases of CDAD were recorded in HIV-infected patients between January 1991 and April 1995. The annual incidence of CDAD ranged from 1.7 to 6.4 per 100 HIV-infected patients discharged from hospital. The 67 CDAD cases included 48 (72%) first episodes and 19 (28%) relapses. Serogroup C accounted for 69% of strains from initial episodes of CDAD. To identify risk factors for CDAD, 34 HIV-infected patients with a first episode were compared with 66 HIV-infected controls matched for the length of hospital stay. Three independent factors remained significantly associated with CDAD among HIV-infected patients: CD4+ cell counts <50/mm3 (OR = 5.2; 95% CI = 1.4-19.3; p = 0.01), clindamycin use (OR = 5.0; 95% CI = 1.3-18.3; p = 0.02) and penicillin use (OR = 4.6; 95% CI = 1.1-18.8; p = 0.03). C. difficile is a common enteric pathogen responsible for nosocomial diarrhea in HIV-infected patients. Clinicians should keep this pathogen in mind when searching for the cause of diarrhea in these patients, especially those who are severely immunocompromised or have received clindamycin or penicillin.
Adult↗
[Prospective study of pathogenic agents isolated from feces of patients with HIV infections].
OBJECTIVE: Determine the frequency of enteropathogenic agents isolated in diarrheic feces of patients with HIV infection and to compare findings with a control group (HIV + without diarrhea) in order to identify risk factors. PATIENTS AND METHODS: All HIV seropositive inpatients and outpatients seropositive for HIV, with or without diarrhea, seen between 1 November 1994 and 30 April 1995 were included. Samples of feces were obtained for culture, virology examination, parasite examination and search for Clostridium difficile. The same samples were obtained in case of diarrhea during the course of hospitalization. RESULTS: There were 113 samples. Analyses demonstrated a pathogenic agent in 73.6% of the samples in patients with diarrhea and in 31.6% of those without diarrhea. Clostridium difficile and parasites were the most frequently identified agents. An infectious agent was identified in one-fourth of the patients without clinical signs of diarrhea, and in one-fourth of those with diarrhea no pathogen could be demonstrated. No factor of risk for finding a particular microorganism in feces of patients with diarrhea could be identified. DISCUSSION: The exact pathogenic roles of Pseudomonas aeuriginosa, yeast, and adenovirus remain to be determined. It is hypothesized that the HIV has a direct effect on the host digestive tract.
AIDS-Related Opportunistic Infections↗
[New gram-positive opportunistic bacteria: pathogenic role and treatment].
NOVEL BACTERIA: The appearance of novel bacterial species among Gram positive microorganisms is mainly related to progress in bacterial taxonomy justifying such nomen species, i.e. C. jeikeium, C. urealyticum or R. equi. Another feature of such emergence of "Novel" bacteria is related to the rise in the number of clinical observations mediated by some well-known species described elsewhere such as in food bacteriology. PREDISPOSING FACTORS: Among Gram positive microorganisms, emergence for some species and renaissance or rebirth for others is mainly explained by natural resistance to widely used antibiotics including beta-lactams such as third generation cephalosporins, aminoglycosides, or more recently glycopeptides and the combined effect of several predisposing factors (hospitalized patients, underlying disease or prematurity, interruption of the normal integumentary defense via intravascular catheters). Clinical features depend on the bacterial species. Bacteriological diagnosis is easily obtained in terms of isolation and identification. Nevertheless, as for any opportunistic pathogen, a distinction must be made between colonization and infection. Finally successful treatment regimens depend on the bacterial species and may include surgery.
Drug Resistance, Microbial↗
[Central venous catheters. Prospective surveillance of a hospital].
OBJECTIVES: All the central venous catheters (CVC) inserted at the Saint-Antoine Hospital between December 5, 1994 and June 6, 1995 were prospectively studied in order to better define practices in the management of CVC and to determine the rate of catheter-related infections. METHODS: The following data were recorded for each CVC: insertion procedure, clinical data, catheter dressings, removal, catheter-related infections, bacteriological findings. Catheter-related infections were distinguished from probably catheter-related infections and localized skin infections. RESULTS: Among 325 patients, a total of 414 catheters were inserted. At the end of the surveillance period, 350 (85%) had been removed, 43 (10%) were still in place and 21 (5%) were lost to follow-up. Analysis of procedures such as cutaneous disinfection, routine replacement of the i.v. sets or changes of dressings showed wide variations between care units and within the same unit. The overall incidence of catheter-related infections was 0.24 per 100 days of catheterization. Infections occurred 29 +/- 34 days after insertion. Microorganisms responsible for catheter-related bacteremia were mostly Gram positive (84%) and Gram negative (16%). Sixty-two infections (15%) were clinically suspected by physicians, leading to the catheter removal in 84% of cases. Out of the 43 CVC sent to the laboratory, 29 (67%) were negative (i.e., "sterile") in quantitative culture of the tips as described by Brun-Buisson, suggesting that the CVC was unnecessarily removed. Bacteriological analysis ordered by physicians were not always relevant. For example, 76% of CVC received by the laboratory were systematically sent although they were not suspected of infections. Conversely, only 61% of exsudate formation at the insertion site were collected and analyzed. CONCLUSION: This study was designed to recall good guidelines to the hospital staff. Results will lead to the development of a better use of antiseptics and to the implementation of appropriate and standardized procedures to reduce risk infection.
Adult↗
Nosocomial outbreak of Clostridium difficile diarrhea in a pediatric service.
An outbreak of nosocomial diarrhea that occurred in a pediatric orthopedic service between 1 December 1993 and 15 April 1994 is reported. A total of 37 patients (mean age, 9.6 years; range, 2 months-19.3 years) were involved in the outbreak, including six patients with bacteriologically documented Clostridium difficile infection. A multivariate analysis identified lincomycin treatment for at least three days as the only significant risk factor. Stool samples from four asymptomatic patients were also positive for Clostridium difficile and its cytotoxins. Isolates from all patients belonged to serogroup C, were highly resistant to lincomycin, and exhibited the same restriction pattern by pulsed-field gel electrophoresis. The outbreak ended after treatment with lincomycin was discontinued and hygiene control measures were implemented.
Adolescent↗
Arbitrary primed PCR rules out Clostridium difficile cross-infection among patients in a haematology unit.
Eight out of 20 (40%) patients with haematological malignancies hospitalized in the same unit of our hospital from 24 January to 24 April 1995, suffered from diarrhoea due to Clostridium difficile. The C. difficile isolates were characterized by serotyping and by arbitrary primed polymerase chain reaction (AP-PCR) using three different 10-mer oligonucleotides. It was found by serotyping that five patients had non-typeable isolates and three had serogroup H isolates. The AP-PCR typed all the isolates and yielded various patterns suggesting that there had been no cross-transmission between the patients. Control faecal sample cultures showed that two patients were still carrying the same isolates after specific treatment with vancomycin or metronidazole, and that one patient had acquired an isolate with a new AP-PCR type. AP-PCR was found to be a rapid, effective discriminative method for the immediate epidemiological tracking of hospital-acquired infections due to C difficile.
Adult↗
Prevalence and pathogenicity of Clostridium difficile in hospitalized patients. A French multicenter study.
BACKGROUND: Although Clostridium difficile is the main agent responsible for nosocomial diarrhea in adults, its prevalence in stool cultures sent to hospital microbiology laboratories is not clearly established. OBJECTIVES: To determine the prevalence of C difficile in inpatient stools sent to hospital microbiology laboratories and to assess the relationship between serotypes and toxigenicity of the strains isolated and the clinical data. METHODS: From January 18, 1993, to July 31, 1993, the presence of C difficile was systematically investigated in a case-control study on 3921 stool samples sent for stool culture to 11 French hospital microbiology laboratories. The prevalence of C difficile in this population (cases) was compared with that of a group of 229 random hospital controls matched for age, department, and length of stay (controls). Stool culture from controls was requested by the laboratory although not prescribed by the clinical staff. Serotype and toxigenesis of the strains isolated were compared. RESULTS: The overall prevalence of C difficile in the cases was twice the prevalence in the controls (9.7% vs 4.8%; P < .001) and was approximately 4 times as high in diarrheal stools (ie, soft or liquid) as in normally formed stools from controls (11.5% vs 3.3%; P < .001). The strains isolated from diarrheal stools were more frequently toxigenic than those isolated from normally formed stools. Serogroup D was never toxigenic, and its proportion was statistically greater in the controls than in the cases (45% vs 18%; chi 2 = 5.2; P < .05). Conversely, serogroup C was isolated only from the cases. Clostridium difficile was mainly found in older patients ( > 65 years), suffering from a severe disabling disease, who had been treated with antibiotics and hospitalized for more than 1 week in long-stay wards or in intensive care. CONCLUSIONS: This multicenter period prevalence study clearly supports the hypothesis of a common role of C difficile in infectious diarrhea in hospitalized patients. Disease associated with C difficile should therefore be systematically evaluated in diarrheal stools from inpatients.
Anti-Bacterial Agents↗
Risk factors for isolation of Streptococcus pneumoniae with decreased susceptibility to penicillin G from patients infected with human immunodeficiency virus.
We conducted a retrospective study of all hospitalized human immunodeficiency virus (HIV)-infected patients from whom a strain of Streptococcus pneumoniae was isolated (n = 45) between January 1992 and September 1994, in order to determine the clinical manifestations and outcome of and risk factors for infection by S. pneumoniae with decreased susceptibility to penicillin G. Such strains were isolated from 14 patients (31%), of whom 8 had pneumonia, 2 had bronchial superinfection, 2 had sinusitis, and 2 were colonized. All infected patients made a clinical recovery regardless of the MIC of the isolate. Indexes of HIV disease stage (CD4+ cell count and p24 antigenemia), antiretroviral treatment, and hospital admission in the previous 3 months did not influence the susceptibility of the isolates. For HIV-infected patients, treatment with antibacterial agents--particularly trimethoprim-sulfamethoxazole--in the previous 3 months is associated with an increased risk for isolation of S. pneumoniae with decreased susceptibility to penicillin G (relative risk, 5.0; 95% confidence interval, 1.9-13.3).
AIDS-Related Opportunistic Infections↗
Value of routine stool cultures in hospitalized patients with diarrhea.
In a prospective study conducted over a six-month period, the relative yield of 721 routine cultures of stool from adult inpatients as a function of the time after hospital admission was assessed. Salmonella, Campylobacter, Shigella or Yersinia spp. were recovered from 10.9% (41/377) of patients within three days of hospitalization and from only 1.5% (5/344) after three days. However, a review of these patients' charts did not suggest nosocomial transmission but rather a delay in stool collection or asymptomatic carriage. Clostridium difficile was isolated with a high frequency in patients both within and after three days of hospitalization (10.3% and 10.2%, respectively). Thus, stool specimens from adults hospitalized for more than three days should not be cultured except for Clostridium difficile unless there are plausible clinical or epidemiological reasons to do so.
Adult↗