Daniel Floret

COMMUNITY-ACQUIRED METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS INFECTIONS IN FRANCE: EMERGENCE OF A SINGLE CLONE THAT PRODUCES PANTON-VALENTINE LEUKOCIDIN

To characterize the clinical and bacteriologic characteristics of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections, we reviewed 14 cases that were diagnosed in previously healthy patients during an 18-month period in France. Eleven patients had skin or soft-tissue infections. Two patients died of CA-MRSA necrotizing pneumonia. A case of pleurisy occurred in a child who acquired CA-MRSA from his mother, who had a breast abscess. The Panton-Valentine leukocidin genes and the lukE-lukD leukocidin genes were detected in all 14 isolates. The clonal origin of all of the isolates was demonstrated on the basis of their pulsotypes and antibiotic resistance profiles. All isolates had an agr3 allele. The combination of the Panton-Valentine leukocidin determinant (which encodes a virulence factor for primary skin infection and pneumonia) with the mecA gene (which confers antibiotic resistance and epidemicity) appears to have created a superadapted S. aureus strain that is spreading in the community.

Factors Predicting Mortality in Necrotizing Community-Acquired Pneumonia Caused by Staphylococcus aureus Containing Panton-Valentine Leukocidin

BACKGROUNDnNecrotizing pneumonia due to Panton-Valentine leukocidin-producing strains of Staphylococcus aureus is associated with a high mortality rate. We sought factors associated with vital outcome in 50 cases occurring from 1986 through 2005.nnnMETHODSnWe compared the clinical and biological characteristics of 50 patients according to their vital outcome and examined the characteristics of the corresponding S. aureus isolates.nnnRESULTSnThe overall mortality rate was 56%, and the median survival time was 10 days. All of the deaths were attributed to S. aureus infection and were secondary to refractory shock and/or respiratory failure. Fatal outcome was associated with classical severity factors, such as the need for mechanical ventilation or inotrope support, and with onset of the acute respiratory distress syndrome. Airway bleeding was strongly associated with fatal outcome (P=.002). Patients who had focal staphylococcal infection before the onset of pneumonia had a significantly lower mortality rate (P=.002). The main biological feature associated with death was leukopenia (P<.001). In multivariate analysis, leukopenia and erythroderma occurring within the first 24 h after admission to the hospital were independently associated with fatal outcome. Erythroderma was not associated with toxic shock syndrome toxin.nnnCONCLUSIONSnAirway bleeding, erythroderma, and leukopenia are associated with fatal outcome from Panton-Valentine leukocidin-positive S. aureus necrotizing pneumonia. More work is needed to develop more efficacious therapy against this highly lethal disease.

Non-invasive ventilation as primary ventilatory support for infants with severe bronchiolitis

ObjectiveTo report our experience of non-invasive ventilation (NIV) as primary ventilatory support strategy in infants admitted for severe bronchiolitis.Design and settingRetrospective study in a paediatric intensive care unit of an university hospital.PatientsInfants aged less than 12xa0months, admitted for bronchiolitis during 2003–2004 and 2004–2005 winter epidemics.InterventionNIV was used as the primary ventilatory support during the second winter (NIV period), whereas invasive ventilation (IV) was the only support employed during the first winter (IV period). NIV consisted in either continuous positive airway pressure (CPAP from 5 to 10xa0cmH2O) or bilevel positive airway pressure (inspiratory pressure from 12 to 18xa0cmH2O) with a nasal mask.ResultsDuring the IV period, 53 infants were included, compared to 27 during the NIV period. The two groups did not differ in age or in number of premature births. Children in NIV group had less apnoea on admission. The intubation rate was reduced during NIV period (pxa0<xa00.001). No children had ventilator-associated pneumonia (VAP) during NIV period compared to nine during IV period (pxa0<xa00.05). In the NIV group, 10 infants (37%) required supplemental oxygen for more than 8xa0days compared to 33 children (65%) in IV group (pxa0<xa00.05). The length of hospital stay and the duration of ventilation were similar.ConclusionsIn this retrospective study, the use of NIV decreased the rate of ventilator associated pneumonia and reduced the duration of oxygen requirement without prolonging the hospital stay.

Toxin involvement in staphylococcal scalded skin syndrome.

The production of staphylococcal exfoliative toxin A (ETA) and toxin B (ETB), toxic shock syndrome toxin (TSST-1), and enterotoxins A-E was analyzed in 60 Staphylococcus aureus strains isolated from children with scalded skin syndrome (15 with generalized exfoliative syndrome, 28 with bullous impetigo, and 17 with staphylococcal scarlet fever). All strains isolated from patients with generalized exfoliative syndrome or bullous impetigo produced ETA and/or ETB and caused a Nikolskys sign when injected subcutaneously into newborn mice. In contrast, exfoliative toxin was detected in an S. aureus strain from only one of 17 case of staphylococcal scarlet fever; the 16 other S. aureus strains produced TSST-1 and/or an enterotoxin. In conclusion, enterotoxins or TSST-1 are more frequently associated with staphylococcal scarlet fever than are exfoliative toxins. Hence staphylococcal scarlet fever may well represent an abortive form of toxic shock syndrome rather than a milder form of staphylococcal scalded skin syndrome.

Pragmatic management of Panton-Valentine leukocidin-associated staphylococcal diseases.

Panton-Valentine leukocidin (PVL)-producing Staphylococcus aureus is associated with a broad spectrum of diseases, ranging from common uncomplicated soft tissue infections to severe diseases such as complicated soft tissue infections, extensive bone and joint infections, and necrotising pneumonia. Specialised management of infection based on the presence of PVL may not be required for mild infections, whereas it could be lifesaving in other settings. Moreover, most severe PVL diseases are recently identified entities and a gold standard treatment from comparatives studies of different therapeutic options is lacking. Thus, recommendations are based on expert opinions, which are elaborated based on theory, in vitro data and analogies with other toxin-mediated diseases. In this review, we consider the potential need for specialised PVL-based management and, if required, which tools should be used to achieve optimal management.

Infections ostéoarticulaires à staphylocoques dorés sécréteurs de la leucocidine de Panton-Valentine

Panton-Valentine Leucocidin (PVL) is associated in the USA with community-acquired meticillin resistant strains of Staphylococcus aureus (CA-MRSA). Bone and joint infection due to such strains appears to be more severe, necessiting longer antibiotic course and various surgical procedure. Our study of 14 PVL positive bone and joint infection, performed in France where PVL is rarely (2/14) associated with meticillin resistance, demonstrates that severity is linked with PVL secretion more than with resistance. Considering PVL associated bone and joint infections as a toxin-mediated disease, prompt diagnosis is needed in order to start specific therapeutic procedures. PVL mediated infection could be evoked in front of severe acute osteomyelitis or arthritis, with radiological abnormalities present in the first days of evolution and with pejorative evolution despite antibiotic treatment. Evolution toward multifocal osteomyelitis and/or multiple abscesses seems to be a major characteristic of such infection. Therapeutic approach should use an association of parenteral antibiotics with at least one molecule active against protein synthesis like Clindamycin, associated with betalactams or Vancomycin in area of high incidence of CA-MRSA. Surgical procedure should be considered whenever focal abscesses of bones or adjacent tissue is detected and should be repeated in most cases.

Rat bite fever caused by Streptobacillus moniliformis in a child: human infection and rat carriage diagnosed by PCR

A child owning pet rats developed an eruptive fever with blisters, polyarthritis, and spectacular desquamation of the hands. Streptobacillus moniliformis was identified after culture of the child’s blister fluid and was detected in rat samples by molecular methods. Such detection in the pet of a human victim of rat bite fever has not been reported previously.

Pneumonies staphylococciques graves de l'enfant

Resume Entre 1986 et 1999, huit observations de pneumopathies severes liees a des souches de staphylocoque dore produisant la leucocidine de Panton et Valentine (PVL) ont ete adressees au Centre national de reference des toxemies a staphylocoque. Tous ces patients, sauf un etaient des enfants. Ceci a amene a conduire une etude prospective durant lannee 1999 destinee a definir les caracteristiques cliniques de ces pneumopathies. La pneumonie staphylococcique a ete definie selon les criteres usuels. La recherche du gene codant pour la PVL a ete pratiquee sur toutes les souches, les cas associes avec la production de PVL ont ete consideres comme le groupe detude. Les pneumopathies nosocomiales ont ete exclues. Cinquante-deux cas ont ete collectes et parmi ceux-ci 16 produisaient la PVL. Les pneumonies sont survenues chez des sujets plus jeunes (mediane dâge = 14,8 ans contre 70,1 ans), en bonne sante prealable alors que parmi le groupe controle 40 % avaient une maladie sous-jacente. Les elements notables etaient la presence dune infection virale les jours precedents (45 % contre 9 %), la frequence du choc (81 contre 53 %), de la detresse respiratoire (75 contre 50 %), des hemoptysies (38 contre 3 %). Une leucopenie etait presente dans 79 % des cas. La mortalite est plus elevee dans les groupes PVL (75 contre 47 %). La pneumonie staphylococcique severe associee a un choc, une leucopenie, une hemoptysie et un haut risque de mortalite avait deja ete decrite chez lenfant et ladulte jeune. Nous demontrons la relation entre ce syndrome et la production de PVL par Staphylococcus aureus . Il semble que linfection virale constitue le primum movens par une alteration de lepithelium respiratoire permettant secondairement linvasion par Staphylococcus aureus . Leffet necrosant de la PVL entraine une pneumopathie massive hemorragique et necrotique. La pneumonie staphylococcique necrosante est une nouvelle entite dont la frequence est probablement sous-estimee. Des etudes ulterieures sont necessaires pour determiner les facteurs de pronostic, le role du portage staphylococcique et de linfection virale. La description de ce nouveau syndrome pourrait amener a des modifications dans le traitement des pneumonies staphylococciques de lenfant.

Long-term critical issues in pediatric renal transplant recipients: a single-center experience

Data on long‐term outcomes after pediatric renal transplantation (Tx) are still limited. We report on a 20‐year single‐center experience. Medical charts of all consecutive pediatric Tx performed between 1987 and 2007 were reviewed. Data of patients who had been transferred to adult units were extracted from the French databases of renal replacement therapies. Outcomes were assessed using Kaplan–Meier and Cox models. Two hundred forty Tx were performed in 219 children (24.1% pre‐emptive and 17.5% living related donor Tx). Median age at Tx was 11.1 years and median follow‐up was 10.4 years. Patient survival was 94%, 92%, and 91% at 5, 10, and 15 years post‐Tx, respectively. Overall, transplant survival was 92%, 82%, 72%, and 59% at 1, 5, 10, and 15 years post‐Tx, respectively. The expected death‐censored graft half‐life was 20 years. Sixteen patients developed malignancies during follow‐up. Median height at 18 years of age was 166 cm in boys and 152 cm in girls with 68% of patients being in the normal range. The proportion of socially disadvantaged young people was higher than in general population. Excellent long‐term outcomes can be achieved in pediatric renal Tx, but specific problems such as malignancies, growth, and social outcome remain challenging.

Extracoronary echocardiographic findings as predictors of coronary artery lesions in the initial phase of Kawasaki disease

Objective To describe the significance of pericardial effusion (PE), mitral regurgitation (MR) and impaired systolic function in predicting coronary artery lesions (CAL) at diagnosis and follow-up in Kawasaki disease (KD). Design Echocardiographic records on admission, at 1–3u2005weeks of illness, and at 6–8u2005weeks of illness were retrospectively retrieved in children with acute KD treated by intravenous immunoglobulins. Setting, patients The study included 194 consecutive children (113 male; median age 2.1u2005years) in a paediatric cardiology tertiary care centre, from 1988 to 2007. Results Overall, children with CAL (64/194) were more likely to have PE (OR=3.00, CI 1.34 to 6.72) and MR (OR=2.51, CI 1.22 to 5.16) at diagnosis; PE was the sole echocardiographic abnormality associated with CAL in multivariable analysis. These abnormalities were predictive of the presence of CAL at the first echocardiography in the acute phase of the disease only. MR, systolic dysfunction and PE were not associated with persistence of CAL in the convalescent phase. Male gender, CAL size and resistance to immunoglobulin treatment were independent factors predictive of the persistence of CAL. Conclusions Children with MR or PE should undergo careful assessment of coronary status at diagnosis. However, PE or MR at diagnosis is not predictive of persistent CAL at follow-up.