Jean-Pierre Thys

Impact of Infectious Diseases Specialists and Microbiological Data on the Appropriateness of Antimicrobial Therapy for Bacteremia

Antimicrobial therapy for 428 episodes of bacteremia in an 850-bed university hospital was prospectively evaluated for 1 year to measure the impact of two factors--blood culture results and the therapy chosen by infectious diseases specialists (IDSs)--on quality of treatment and outcome. Initial shock, a simplified acute physiology score of >15, and inappropriateness of the empirical treatment were independently associated with increased mortality. Empirical treatment was appropriate in 63% of the episodes. This proportion reached 78% for the episodes treated by IDSs, compared with 54% for the others (P < .001). After availability of blood culture results, the proportion of appropriate treatments increased to 94%, with 97% for IDS-treated patients and 89% for other patients (P = .008). IDSs more frequently shifted to oral antibiotics and used fewer broad-spectrum drugs. This study underlines the impact of blood culture results and of IDSs on the prescription of appropriate treatment for bacteremia and on the better use of antimicrobial drugs.

Risk factors for septicemia following endoscopic biliary stenting

The purpose of this study was to identify patients who were more likely to experience septicemia after endoscopic biliary drainage. In an attempt to determine the relative importance of each risk factor and their possible interdependancy to more precisely identify high-risk patients and to deduce some guidelines for prevention, a discriminant regression analysis of risk factors for septicemia was used. Clinical, biological, and radiological data of 34 consecutive patients who experienced septicemia within 3 days after endoscopic biliary stenting were reviewed retrospectively and compared with data of a group of 71 patients without any septic complication. If only data available before the procedure were used in the discriminant analysis, prior cholangitis and leucocytosis appeared as significant risk factors, but the linear combination of these data could not predict septicemia in 50% of cases. When information concerning the quality of drainage after the procedure was introduced into the analysis, 91% of the septicemic patients were identified, and other expected risk factors such as the nature of the stricture, the type of drainage, or prior cholangitis and leukocytosis had no or marginal predictive values. Patients referred from centers where duodenoscopes might have been poorly disinfected appeared to be at higher risk for Pseudomonas aeruginosa septicemia. These results emphasize the crucial role of the quality of drainage as a risk for septicemia. Regarding the prevention of infection, it is concluded from this study that (a) pure diagnostic endoscopic retrograde cholangiopancreatography should be avoided in obstructed patients if drainage cannot be performed during the same procedure; (b) drainage should be as complete as possible; (c) antibiotics should be administered before ERCP to every patient with suspected obstructive jaundice and should cover P. aeruginosa if local epidemiological data suggest that there is a problem with disinfection of the endoscopes; and (d) the quality of drainage should guide the duration of antibiotic prophylaxis.

Fatal primary infection due to human herpesvirus 6 variant A in a renal transplant recipient.

We describe a fatal primary human herpesvirus 6 (HHV-6) variant A infection in a kidney transplanted adult woman. On day 20 post transplantation (TX), after rejection therapy, the patient presented an acute hemophagocytic syndrome with hepatitis and central nervous system involvement. HHV-6 IgG and IgM antibodies seroconversion was demonstrated. HHV-6 variant A was the sole pathogen detected by nested PCR and/or culture in blood, bone marrow aspiration, liver biopsy, cerebrospinal fluid and bronchoalveolar lavage. The graft was HHV-6 seropositive and the patient was not transfused before day 28 post TX, suggesting that the virus was transmitted by the graft. Despite immunoglobulins, ganciclovir and foscarnet therapy, the HHV-6 infection progressed and led to severe aplasia. The patient developed Aspergillus fumigatus pneumonia and died from fulminant candidemia. This case demonstrated for the first time that HHV-6 variant A primary infection can cause life-threatening disseminated infection in immunosuppressed patients.

Vancomycin Penetration of Uninfected Pleural Fluid Exudate after Continuous or Intermittent Infusion

ABSTRACT Blood and pleural exudate samples were obtained from 16 patients receiving intermittent or continuous infusions of vancomycin after lung surgery. The areas under the concentration-time curves for blood and pleural exudates were identical for both administration schedules, while continuous infusion allowed the concentrations in pleural exudates to be more sustained (mean concentration, 12 mg/liter).

Ceftazidime- and Imipenem-Induced Endotoxin Release During Treatment of Gram-Negative Infections

Abstract. To determine whether ceftazidime and imipenem, which target two different penicillin-binding proteins, result in different amounts of endotoxin and cytokine release in patients with gram-negative infection, plasma endotoxin, interleukin-6, and tumor necrosis factor alpha were measured during the first 24 h of antibiotic therapy in 27 patients with gram-negative infection who had been randomized to receive either ceftazidime 2 g t.i.d. (n=12) or imipenem/cilastatin 1 g t.i.d. (n=15). The source of infection was the digestive tract (n=13), the urinary tract (n=5), the respiratory tract (n=2), soft tissue (n=2), i.v. line (n=2), or other (n=3). After the first antibiotic injection, a significant increase in the median concentration of plasma interleukin-6 and plasma tumor necrosis factor alpha was noted, without significant differences related to the antibiotic administered. Antibiotic-induced endotoxemia was detectable in nine patients (including 7 with bacteremia). In conclusion, ceftazidime and imipenem had similar effects on endotoxin and cytokine release during the treatment of gram-negative infections.

Diagnosis and treatment of herpes encephalitis ☆: A multidisciplinary approach

Abstract Five cases of acute necrotizing encephalitis treated by IUdR are presented; 4 were also treated surgically. The aetiology of the disease was investigated by brain biopsy (in 4 cases), electron microscopy (in 3 cases) and virological studies (in 5 cases). Evidence of herpes virus infection was based upon electron microscopy (1 case), virus isolation (1 case) and the rise of complement-fixing antibodies and kinetic neutralizing antibodies (4 cases). This latter technique is specific for herpes virus hominis type 1. In 1 case, structures suggestive of incomplete viruses were seen by electron microscopy. In 2 cases, electrophoresis of the cerebrospinal fluid showed an abnormal pattern. Two patients died. The importance of a multidisciplinary approach is stressed. The problem of early diagnosis and the possible usefulness of chemotherapy are discussed.

Anti pseudomonas activity in bronchial secretions of patients receiving amikacin or tobramycin as a continuous infusion

The penetration of amikacin and tobramycin into bronchial secretions and the resulting anti-Pseudomonas activity were assessed in two groups of tracheostomized or intubated patients with tracheobronchial infection and purulent bronchial secretions. The aminoglycosides were administered as continuous, high-dose intravenous infusions. The mean drug concentrations in serum and bronchial secretions were 12.8 and 2.0 microgram/ml for amikacin and 3.6 and 0.7 microgram/ml for tobramycin. The bronchial secretion/serum ratios varied over a wide range: from 9.6 to 22.8% (average, 14.9%) for amikacin and from 3 to 39.3% (average, 17.5%) for tobramycin. Sustained anti-Pseudomonas activities in bronchial secretions were achieved only in patients with very high aminoglycoside levels in serum. In most patients, however, no anti-Pseudomonas activity could be detected within bronchial secretions despite therapeutic levels of amikacin and tobramycin and adequate bactericidal activities in serum.

Vascular graft infection caused by Aspergillus species: case report and review of the literature.

We report an unusual case of vascular graft infection caused by Aspergillus fumigatus that began with a false aneurysm, major arterial emboli, and septic arthritis. Successful treatment included resection of the infected graft, restoration of circulation by extraanatomic bypass, and administration of amphotericin B and itraconazole, a new antifungal agent. Graft infection in the case reported herein most likely occurred during surgery and took place during an insidious outbreak of postoperative infection.

Prevotella bivia as an unusual cause of endocarditis.

A case of monomicrobial endocarditis due toPrevotella bivia in a 60-year-old man without previous cardiac lesions is reported. The extremely indolent course with multiple systemic emboli as the only clinical manifestation occurring at least seven months before diagnosis and the persistently negative blood cultures were remarkable features of this case. The incidence, clinical characteristics, treatment and outcome of published cases of infective endocarditis due to anaerobic bacteria are briefly reviewed.

Erythromycin prophylaxis for Legionnaire's disease in immunosuppressed patients in a contaminated hospital environment

Between January 1 and June 30, 1983, immunosuppressive drugs were administered in 20 renal transplant recipients undergoing 23 rejection episodes and in 3 patients with renal failure secondary to systemic disease. Legionella pneumophila, serogroup 1, pneumonia was diagnosed on 12/26 (47%) occasions. In an attempt to decrease this high rate, a program of erythromycin prophylaxis was instituted for every new patient who received immunosuppressive chemotherapy until eradication of the organism from the water supply could be realized. From July 1, 1983 to April 30, 1984, erythromycin prophylaxis (1.5-3 g/day by mouth) was administered during 39 episodes of high-dose immunosuppression (20 kidney graft recipients and 4 patients with systemic diseases); no cases of Legionnaires disease were recorded. During the same period, erythromycin prophylaxis was withheld from 9 other high-dose immunosuppression episodes (7 kidney graft recipients and one patient with sarcoidosis); 5 cases of Legionnaires disease occurred (56%) in this group. We conclude that erythromycin effectively protects immunocompromised patients in an environment contaminated with L pneumophila.