D. Christmann

Role of comorbidity in mortality related to Staphylococcus aureus bacteremia: a prospective study using the Charlson weighted index of comorbidity.

OBJECTIVE : To demonstrate the effectiveness of the Charlson weighted index of comorbidity (WIC) for controlling comorbidity in prospective studies focusing on mortality in patients with Staphylococcus aureus bacteremia (SAB). DESIGN: Cohort study. SETTING: Two tertiary-care, university-affiliated hospitals in France. PATIENTS: One hundred sixty-six inpatients 18 years or older consecutively diagnosed with SAB from May 15, 2001, to May 15, 2002. METHODS: Patients were prospectively assessed and cases were followed by the infectious diseases consult service at least 3 months after effective antibiotic therapy completion. The Charlson WIC was computed and dichotomized into scores of fewer than 3 points and 3 or more points. Bacteremia source, acute complication due to SAB acquisition in the ICU, and inappropriate empiric antibiotic therapy were recorded. The endpoint was death due to SAB and overall mortality. RESULTS: In univariate analysis, the Charlson WIC was able to predict overall mortality and S. aureus-related death. The following variables were found to be independently predictive of mortality due to SAB using the Cox model: an acute complication due to S. aureus (OR, 8.9; CI 95 , 4 to 19.7; P <.001), a Charlson WIC score of 3 or more (OR, 3; CI 95 , 1.3 to 5.5; P =.006), and age (OR, 1.04; CI 95 , 1.009 to 1.07; P <.01). CONCLUSIONS: Comorbidity contributes to death in patients with SAB. The Charlson WIC is a good predictor of mortality in this population and may be a useful instrument to control comorbidity in studies aiming to investigate risk factors for death due to bacteremia.

Diagnosis of Cat Scratch Disease with Detection of Bartonella henselae by PCR: a Study of Patients with Lymph Node Enlargement

ABSTRACT Cat scratch disease (CSD) is mostly due to Bartonella henselae after inoculation of the organism through a skin injury. Since the causative bacteria cannot be easily cultured from human lymph node samples, the diagnosis usually relies on epidemiological, clinical, histological, and serological criteria (classical criteria). A study was performed to determine the diagnostic value of PCR analysis for the detection of B. henselae for the diagnosis of CSD and its place in the diagnostic strategy alongside the classical criteria. Over a 7-year period, lymph node biopsy specimens or cytopunctures from 70 patients were systematically tested by PCR for the presence of B. henselae DNA (htrA gene) in the Bacteriology Laboratory of the Hôpitaux Universitaires de Strasbourg. Serological testing by an immunofluorescence assay for B. henselae antibodies was also performed for each patient, and clinical, epidemiological, and histological data were collected. The patients were then divided into two groups according to the number of positive diagnostic criteria for CSD: 29 patients with definite CSD (two or more classical criteria) and 15 patients with possible CSD (less than two classical criteria). The remaining 26 patients for whom another diagnosis was retained were used as a control group. Among all criteria, PCR analysis had the best specificity (100%). The PCR assay for B. henselae was positive for 22 (76%; 95% confidence interval [CI95], 56.5 to 89.7%) of the 29 definite CSD patients and 3 (20%; CI95, 4.3 to 48.1%) of the 15 possible CSD patients. We then studied combinations of diagnostic criteria, including B. henselae PCR analysis. The best diagnostic performance was observed if at least two criteria were present among serologic, epidemiologic, histological, and molecular criteria.

Healthcare-associated Staphylococcus aureus bacteremia and the risk for methicillin resistance: is the Centers for Disease Control and Prevention definition for community-acquired bacteremia still appropriate?

OBJECTIVE To evaluate a new classification for bloodstream infections that differentiates hospital acquired, healthcare associated, and community acquired in patients with blood cultures positive for Staphylococcus aureus. DESIGN Prospective, observational study. SETTING Three tertiary-care, university-affiliated hospitals in Dublin, Ireland, and Strasbourg, France. PATIENTS Two hundred thirty consecutive patients older than 18 years with blood cultures positive for S. aureus. METHODS S. aureus bacteremia (SAB) was defined as hospital acquired if the first positive blood culture was performed more than 48 hours after admission. Other SABs were classified as healthcare associated or community acquired according to the definition proposed by Friedman et al. When available, strains of methicillin-resistant Staphylococcus aureus (MRSA) were analyzed by pulsed-field gel electrophoresis (PFGE). RESULTS Eighty-two patients were considered as having community-acquired bacteremia according to the Centers for Disease Control and Prevention (CDC) classification. Of these 82 patients, 56% (46) had healthcare-associated SAB. MRSA prevalence was similar in patients with hospital-acquired and healthcare-associated SAB (41% vs 33%; P > .05), but significantly lower in the group with community-acquired SAB (11%; P < .03). PFGE of MRSA strains showed that most community-acquired and healthcare-associated MRSA strains were similar to hospital-acquired MRSA strains. On multivariate analysis, Friedmans classification was more effective than the CDC classification for predicting MRSA. CONCLUSION These results support the call for a new classification for community-acquired bacteremia that would account for healthcare received outside the hospital by patients with SAB.

Babesiosis in Immunocompetent Patients, Europe

We report 2 cases of babesiosis in immunocompetent patients in France. A severe influenza-like disease developed in both patients 2 weeks after they had been bitten by ticks. Diagnosis was obtained from blood smears, and Babesia divergens was identified by PCR in 1 case. Babesiosis in Europe occurs in healthy patients, not only in splenectomized patients.

Introduction of SARS in France, March–April, 2003

We describe severe acute respiratory syndrome (SARS) in France. Patients meeting the World Health Organization definition of a suspected case underwent a clinical, radiologic, and biologic assessment at the closest university-affiliated infectious disease ward. Suspected cases were immediately reported to the Institut de Veille Sanitaire. Probable case-patients were isolated, their contacts quarantined at home, and were followed for 10 days after exposure. Five probable cases occurred from March through April 2003; four were confirmed as SARS coronavirus by reverse transcription–polymerase chain reaction, serologic testing, or both. The index case-patient (patient A), who had worked in the French hospital of Hanoi, Vietnam, was the most probable source of transmission for the three other confirmed cases; two had been exposed to patient A while on the Hanoi-Paris flight of March 22–23. Timely detection, isolation of probable cases, and quarantine of their contacts appear to have been effective in preventing the secondary spread of SARS in France.

Impact of malnutrition and social determinants on survival of HIV-infected adults starting antiretroviral therapy in resource-limited settings.

Objectives:Determining the impact of malnutrition, anaemia and social determinants on survival once starting antiretroviral therapy (ART) in a cohort of HIV-infected adults in a rural HIV care centre in Sihanoukville, Cambodia. Methods:Retrospective and descriptive cohort study of adults starting ART between December 2004 and July 2009. We used the Kaplan–Meier and Cox regression survival analyses to identify predictors of death. Results:Out of 1002 patients, 49.7% were men; median age was 40; median time of follow-up was 2.4 years and 10.4% died during the follow-up. At baseline, median CD4 cell count was 83 cells/&mgr;l, 79.9% were at WHO stage III or IV. In multivariate analysis, malnutrition appeared to be a strong and independent risk factor of death; 11.2% had a BMI less than 16 kg/m2 and hazard ratio was 6.97 [95% confidence interval (CI), 3.51–13.89], 21.5% had a BMI between 16 and 18 kg/m2 and hazard ratio was 2.88 (95% CI, 1.42–5.82), 30.8% had a BMI between 18 and 20 kg/m2 and hazard ratio was 2.18 (95% CI, 1.09–4.36). Severe anaemia (haemoglobin ⩽8.4 g/dl) and CD4 cell count below 100 cells/&mgr;l also predicted mortality, hazard ratio were 2.25 (95% CI, 1.02–4.34) and 2.29 (95% CI, 1.01–2.97), respectively. Social determinants were not significantly associated with death in univariate analysis. Conclusion:Malnutrition and anaemia are strong and independent prognostic factors at the time of starting ART. Nutritional cares are essential for the clinical success of HIV programs started in developing countries.

Risk factors for metastatic infection in patients with Staphylococcus aureus bacteremia with and without endocarditis

Background: Staphylococcus aureus bacteremia (SAB) may be complicated by endocarditis or metastatic infection without evidence of endocarditis (MIWE). The aim of this study was to identify risk factors for MIWE and endocarditis in patients with SAB. METHODS: We performed a retrospective chart review to compare characteristics of patients with uncomplicated SAB and patients whose SAB course was complicated by MIWE or endocarditis. We reviewed the charts of patients with SAB diagnosed in our department from 1992 to 1999 for S. aureus portal of entry, secondary foci of infection, underlying conditions, previous valvular defects, and foreign material. Endocarditis was defined according to the Duke criteria. Patients were classified as having MIWE when the diagnosis of endocarditis was not definite according to the Duke criteria and when there was evidence of at least one secondary metastatic infection other than endocarditis. RESULTS: Some 109 patients had 111 episodes of SAB. Sixty-three patients had no evidence of metastatic infection and constituted the control group. Twenty-seven patients developed at least one episode of MIWE. A community-acquired SAB (CI 95% OR: 1.4-12.3, P<0.02), two or fewer underlying conditions (CI 95% OR: 1.2-83, P<0.04), and a non-severe portal of entry (CI 95% OR: 1.2-20, P<0.03) were independently predictive for MIWE. The characteristics of 21 patients with endocarditis were compared with those of the control group. Only a previous valvular defect was significantly associated with endocarditis. CONCLUSION: A previous valvular defect seems to be an important factor for developing endocarditis during SAB. Risk factors for having MIWE may differ from those found for patients with endocarditis.

Tick-borne encephalitis in eastern France.

Each y a few cases of TBE infection are described in Alsace, France which lies at the occidental limit of the endemic zone of tick-borne encephalitis (TBE). Hence we carried out a retrospective epidemiological and clinical study of TBE infection in Alsace. Data were collected from serological results sent to the Institut de Virologie (Université Louis Pasteur) in Strasbourg. All samples positive for specific IgM against TBE were retained. The physician in charge of each patient was asked to provide clinical, epidemiological and biological data and with his agreement the medical file was referred to us. Since 1968, 64 cases of TBE infection, occurring between April and November, had been described. In 56% of cases, flu-like symptoms preceded neurological symptoms. Most patients had meningitis (54%) or meningoencephalitis (34%). There was no death due to TBE. Two areas were more highly endemic for the disease: the Guebwiller valley in low mountain country and the Neuhof forest, near Strasbourg in the plain of Alsace. In the last 2 y of the study, a third zone seemed to emerge, in the Munster valley. This epidemiological survey revealed the existence in Alsace of 2 endemic zones of TBE with a third zone possibly emerging in the last few y. The survey must be continued to follow the evolution of the disease.

Unusual abdominal localization of cat scratch disease mimicking malignancy on F-18 FDG PET/CT examination.

Abstract: Because of its high diagnostic sensitivity in detection of unknown primary tumors, F-18 FDG PET/CT was used in the exploration of a 51-year-old woman presenting with multiple lymphadenopathy of the hepatic hilum and several hepatic and splenic hypodensities on radiologic examinations for which malignancy was suspected. Despite the morphofunctional malignant appearance, both histologic examination and PCR analysis revealed Bartonella henselae infection. Moreover, repeat F-18 FDG PET showed disease regression during focused antibiotic therapy.

Minocycline-induced hypersensitivity syndrome presenting with meningitis and brain edema: a case report

BackgroundHypersentivity Syndrome (HS) may be a life-threatening condition. It frequently presents with fever, rash, eosinophilia and systemic manifestations. Mortality can be as high as 10% and is primarily due to hepatic failure. We describe what we believe to be the first case of minocycline-induced HS with accompanying lymphocytic meningitis and cerebral edema reported in the literature.Case presentationA 31-year-old HIV-positive female of African origin presented with acute fever, lymphocytic meningitis, brain edema, rash, eosinophilia, and cytolytic hepatitis. She had been started on minocycline for inflammatory acne 21 days prior to the onset of symptoms. HS was diagnosed clinically and after exclusion of infectious causes. Minocycline was withdrawn and steroids were administered from the second day after presentation because of the severity of the symptoms. All signs resolved by the seventh day and steroids were tailed off over a period of 8 months.ConclusionClinicians should maintain a high index of suspicion for serious adverse reactions to minocycline including lymphocytic meningitis and cerebral edema among HIV-positive patients, especially if they are of African origin. Safer alternatives should be considered for treatment of acne vulgaris. Early recognition of the symptoms and prompt withdrawal of the drug are important to improve the outcome.