NosoVeille aout 2010

NosoVeille – Bulletin de veille août 2010
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NosoVeille n°8
Août 2010
Rédacteurs : Nathalie Sanlaville, Sandrine Yvars, Annie Treyve
Ce bulletin de veille est une publication mensuelle qui recueille les publications
scientifiques publiées au cours du mois écoulé.
http://nosobase.chu-lyon.fr/
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Abonnement / Désabonnement
Sommaire de ce numéro
Acinetobacter baumannii
Antibiotique
Bactériémie
Chirurgie
Clostridium difficile
Endoscopie
Grippe
Hémodialyse
Hygiène des mains
Klebsiella pneumoniae
Maladie de Creutzfeldt-Jakob
Pédiatrie
Personne âgée/EHPAD
Personnel
Psychiatrie
Réanimation/Soins intensifs
Staphylococcus aureus
Surveillance
Transplantation
Ventilation assistée

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Acinetobacter baumannii
NosoBase n° 27907
Infections à Acinetobacter baumannii multirésistant aux antibiotiques : épidémiologie et prise en
charge
Garnacho-Montero J; Amaya-Villar R. Multiresistant Acinetobacter baumannii infections: epidemiology and
management. Current opinion in infectious diseases 2010/08; 23(4): 332-339.
Mots-clés : EPIDEMIOLOGIE; MULTIRESISTANCE; ACINETOBACTER BAUMANNII;
ANTIBIORESISTANCE; TRAITEMENT; QUALITE; CARBAPENEME; COLISTINE; TIGECYCLINE;
SULBACTAM; RIFAMPICINE; BIBLIOGRAPHIE
Purpose of review: We present recent data about epidemiology of Acinetobacter baumannii in the hospital
setting, major resistance mechanisms, and therapeutic options for infections caused by multidrug-resistant
strains.
Recent findings: A. baumannii has emerged as a major cause of healthcare-associated infections. It
commonly presents resistance to multiple antimicrobial agents, including carbapenems. These strains are
now ussually resistant to the rest of antipseudomonal beta-lactams and sulbactam, a beta-lactamase
inhibitor with bactericide activity against A. baumannii. Rifampicin has demonstrated its effectiveness
in animal models but can never be used in monotherapy because of the rapid development of resistance.
Colistin, an old antibiotic, has re-emerged as a valid alternative given its excellent in-vitro activity. Numerous
studies have confirmed its efficacy in serious infections, including ventilator-associated pneumonia and
nosocomial meningitis, with an acceptable safety profile. Tigecycline appears as a promising therapeutic
option for multidrug resistant A. baumannii, althogh more clinical data about its efficacy especially in
pulmonary infections are required. The role of combination therapy or the use or colistin in alternative routes
(nebulized or intrathecally) has not been established.
Summary: The optimal treatment for multidrug-resistant A. baumannii nosocomial infections has not been
established. Carbapenems are the mainstay of treatment in susceptible isolates. Colistin and tigecycline
retain good in-vitro activity and in many cases represent the only therapeutic options.
NosoBase n° 27845
Impact d'une antibiothérapie inappropriée sur l'évolution de patients hospitalisés présentant une
pneumonie nosocomiale à Acinetobacter baumannii
Joung MK; Kwon KT; Kang CI; Cheong HS; Rhee jy; Jung DS; et al. Impact of inappropriate antimicrobial
therapy on outcome in patients with hospital-acquired pneumonia caused by. Acinetobacter baumannii. The
Journal of infection 2010; in press: 20 pages.
Mots-clés : ACINETOBACTER BAUMANNII; ANTIBIOTIQUE; TRAITEMENT; PNEUMONIE; ETUDE
RETROSPECTIVE; MULTIRESISTANCE; MORTALITE
Objectives: The purpose of this study was to evaluate the impact of inappropriate antimicrobial therapy on
the outcome of patients with hospital-acquired pneumonia (HAP) caused by Acinetobacter baumannii.
Methods: All cases of HAP caused by A. baumannii from January 2000 to March 2006 at the Samsung
Medical Center (Seoul, Korea) were analyzed retrospectively.
Results: A total of 116 patients with clinically significant Acinetobacter HAP were enrolled. Among the A.
baumannii isolates, 60.3% showed multi-drug resistance (MDR), 16.4% were found to have imipenem
resistance, and 15.5% had pan-drug resistance (PDR). The mean APACHE II score of the patients was
22.3+/-7.9. The overall in-hospital and pneumonia-related mortality rates were 47.4% and 37.9%,
respectively. The univariate analysis showed that the factors associated with pneumonia-related mortality
were: MDR, PDR, high APACHE II score, inappropriate empirical antimicrobial therapy, and inappropriate
definitive antimicrobial treatment (All p<0.05). Among these, a high APACHE II score and inappropriate
definitive antimicrobial therapy were found to be independent factors associated with a high mortality, after
adjustment for other variables.
Conclusions: The appropriate definitive antimicrobial therapy should be provided in patients with
HAP caused by A. baumannii.

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NosoBase n° 27467
Contamination fréquente des gants, des blouses et des mains du personnel soignant à
Acinetobacter baumannii multirésistant
Morgan DJ; Liang SY; Smith CL; Johnson JK; Harris AD; Furuno JP; et al. Frequent multidrug-resistant
Acinetobacter baumannii contamination of gloves, gowns, and hands of healthcare workers. Infection control
and hospital epidemiology 2010/07; 31(7): 716-721.
Mots-clés : ACINETOBACTER BAUMANNII; PSEUDOMONAS AERUGINOSA; MULTIRESISTANCE;
INCIDENCE; MAIN; GANT; BLOUSE; CONTAMINATION; ETUDE PROSPECTIVE; SOIN INTENSIF;
FACTEUR DE RISQUE; TRANSMISSION SOIGNE-SOIGNANT; MEDECIN; INFIRMIER; CHAMBRE;
PANSEMENT; SOIN RESPIRATOIRE; AUDIT
Background: Multidrug-resistant (MDR) gram-negative bacilli are important nosocomial pathogens.
Objective: To determine the incidence of transmission of MDR Acinetobacter baumannii and Pseudomonas
aeruginosa from patients to healthcare workers (HCWs) during routine patient care.
Design: Prospective cohort study.
Setting: Medical and surgical intensive care units.
Methods: We observed HCWs who entered the rooms of patients colonized with MDR A. baumannii or
colonized with both MDR A. baumannii and MDR P. aeruginosa. We examined their hands before room
entry, their disposable gloves and/or gowns upon completion of patient care, and their hands after removal
of gloves and/or gowns and before hand hygiene.
Results: Sixty-five interactions occurred with patients colonized with MDR A. baumannii and 134 with
patients colonized with both MDR A. baumannii and MDR P. aeruginosa. Of 199 interactions between
HCWs and patients colonized with MDR A. baumannii, 77 (38.7% [95% confidence interval {CI}, 31.9%-
45.5%]) resulted in HCW contamination of gloves and/or gowns, and 9 (4.5% [95% CI, 1.6%-7.4%]) resulted
in contamination of HCW hands after glove removal before hand hygiene. Of 134 interactions with patients
colonized with MDR P. aeruginosa, 11 (8.2% [95% CI, 3.6%-12.9%]) resulted in HCW contamination of
gloves and/or gowns, and 1 resulted in HCW contamination of hands. Independent risk factors for
contamination with MDR A. baumannii were manipulation of wound dressing (adjusted odds ratio [aOR],
25.9 [95% CI, 3.1-208.8]), manipulation of artificial airway (aOR, 2.1 [95% CI, 1.1-4.0]), time in room longer
than 5 minutes (aOR, 4.3 [95% CI, 2.0-9.1]), being a physician or nurse practitioner (aOR, 7.4 [95% CI, 1.6-
35.2]), and being a nurse (aOR, 2.3 [95% CI, 1.1-4.8]).
Conclusions: Gowns, gloves, and unwashed hands of HCWs were frequently contaminated with MDR A.
baumannii. MDR A. baumannii appears to be more easily transmitted than MDR P. aeruginosa and perhaps
more easily transmitted than previously studied methicillin-resistant Staphylococcus aureus or vancomycin-
resistant Enterococcus. This ease of transmission may help explain the emergence of MDR A. baumannii.
Antibiotique
NosoBase n° 27906
Comment endiguer le flux d'enterobactéries qui produisent des carbapénèmases : stratégies
proactives ou réactives ?
Bilavsky E; Schwaber MJ; Carmeli Y. How to stem the tide of carbapenemase-producing
enterobacteriaceae? proactive versus reactive strategies. Current opinion in infectious diseases 2010/08;
23(4): 327-331.
Mots-clés : ENTEROBACTERIE; CARBAPENEME; ANTIBIORESISTANCE; INCIDENCE;
RECOMMANDATION; CONTROLE; PREVENTION; ESCHERICHIA COLI; KLEBSIELLA;
ENTEROBACTER; BIBLIOGRAPHIE
Purpose of review: The spread of carbapenem-resistant Enterobacteriaceae (CRE) or carbapenemase-
producing Enterobacteriaceae in healthcare settings is an important medical problem and a major public
health threat. Infections with CRE are associated with high rates of morbidity and mortality, and are
spreading rapidly across the globe. The medical community can either observe the natural course of this
epidemic or act proactively and take adequate preventive measures to contain the spread of these bacteria.
The purpose of this review is to highlight the impact of these problematic pathogens and to examine
infection control policies needed in order to limit their spread.

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Recent findings: The incidence of CRE is on the rise in several parts of the world; however, data regarding
proper infection control methods on this issue are scarce. Great variability exists in infection control
measures taken to confront CRE in various settings. Recently, two sets of guidelines to control CRE have
been issued, one by the US Centers for Disease Control and Prevention and the other by an expert group
under the auspices of the European Society of Clinical Microbiology and Infectious Diseases. These
guidelines have many similarities but also considerable differences.
Summary: Whereas clinical information regarding how to contain infections by CRE pathogens is still limited,
it is obvious that it relies on a multifaceted approach and implementation of strict infection control measures.
Since it has been observed that lack of adequate and timely reaction is common and associated with great
morbidity and mortality, preparation plans should be evaluated and implemented locally, regionally,
nationally and even on an international level.
NosoBase n° 27834
Evaluation prospective de la pertinence des associations d'antibiotiques en médecine interne
Caruba T; Sabatier B; Matta M; Arlet JB; Ranque B; Capron L; et al. Prospective evaluation of the relevance
of prescribing antibiotic combinations in an internal medicine department. La Revue de médecine interne
2010/07; 31(7): 469-475.
Mots-clés : EVALUATION; ANTIBIOTIQUE; MEDECINE INTERNE; ETUDE PROSPECTIVE ;
CENTRE HOSPITALIER UNIVERSITAIRE
Propos : Évaluer la conformité des associations d'antibiotiques, définie par l'adéquation entre l'association
prescrite et l'ensemble des recommandations disponibles.
Méthodes : Étude prospective monocentrique réalisée pendant 12 mois dans un service hospitalo-
universitaire de médecine interne.Toutes les associations d'antibiotiques ont été évaluées en tenant compte
du site de l'infection, de la bactérie, des antibiotiques, des doses prescrites et des durées de traitement. Un
comité scientifique a classé chaque association comme : (1) conforme aux recommandations existantes ;
(2) conforme à l'antibiogramme en l'absence de recommandation ; (3) non conforme (NC) sans
conséquence clinique ; (4) NC avec conséquence clinique.
Résultats : Quatre-vingt-sept associations d'antibiotiques ont été analysées. Le taux de conformité était de
77 % (67cas). Les associations NC, avec et sans conséquence clinique, étaient respectivement de 7 % (six
cas) et 16 % (14 cas). Les motifs de non-conformité étaient : (1) monothérapie suffisante ou aucun
antibiotique nécessaire (14 cas) ; (2) antibiotique prescrit ne correspondant pas à l'antibiogramme (trois cas)
; (3) antibiotique prescrit inefficace sur les principales espèces bactériennes habituellement rencontrées
(traitement probabiliste) (trois cas). Pour 52 % des prescriptions, l'avis de l'unité mobile de microbiologie
clinique avait été demandé ; le taux de conformité après avis était de 96 % contre 57 % en l'absence d'avis
(p < 0,001).
Conclusion : Soixante-dix-sept pourcent des associations sont conformes aux recommandations et le
conseil auprès d'une structure référente améliore significativement ce pourcentage.
NosoBase n° 27983
Traitement par le linezolide des infections bactériennes à pathogènes à Gram positif chez des
nouveau-nés prématurés : revue systématique
Kocher S; Muller W; Resch B. Linezolid treatment of nosocomial bacterial infection with multiresistant gram-
positive pathogens in preterm infants: a systematic review. International journal of antimicrobial agents
2010/08; 36(2): 106-110.
Mots-clés : LINEZOLIDE; TRAITEMENT; MULTIRESISTANCE; PREMATURE; NEONATALOGIE;
VANCOMYCINE; TOLERANCE; BACTERIE A GRAM POSITIF
Linezolid is an antibiotic of the oxazolidinone class that has bacteriostatic and bactericidal activity against a
broad range of Gram-positive bacteria, including multiresistant pathogens. Owing to increasing resistance of
Gram-positive pathogens to traditional antibiotics such as vancomycin, the oxazolidinones were introduced
into therapy. The aim of this review was to summarise actual data on the pharmacokinetics, safety and
clinical use of linezolid in preterm infants. The Medline and EMBASE databases were searched using the
term 'linezolid' combined with 'newborn', 'neonate', 'preterm' and 'premature' for papers published between
January 1987 and June 2009. Studies reporting on a population including preterm infants and other age
groups as well as case reports on preterm infants only were acceptable for analysis. Five studies and eight
case reports were identified evaluating linezolid in preterm infants. A dosage regimen of 10mg/kg body

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weight given either orally or intravenously every 8h in infants aged >or=1 week and the same dose given
every 12h in infants <1 week was shown to be safe and effective with a mean treatment duration of 10-28
days. In summary, linezolid was shown to be a safe and effective alternative to vancomycin in the treatment
of infections with multiresistant Gram-positive pathogens in preterm infants.
NosoBase n° 27804
Résumé du consensus sur l'administration d'antibiotiques par aérosol
Le J; Ashley ED; Neuhauser MM; Brown J; Gentry C; Klepser ME; et al. Consensus summary of
aerosolized antimicrobial agents: application of guideline criteria. Pharmacotherapy 2010/06; 30(6): 562-
584.
Mots-clés : ANTIBIOTIQUE; CONSENSUS; AEROSOL; RECOMMANDATION; PHARMACIEN; APPAREIL
RESPIRATOIRE; EFFICACITE; TOLERANCE; PREVENTION; TRAITEMENT; PNEUMONIE;
MUCOVISCIDOSE; ANTIFONGIQUE; TOBRAMYCINE; COLISTINE; ANTIBIOTIQUE; AMINOSIDE
Aerosolized delivery of antimicrobial agents is an attractive option for management of pulmonary infections,
as this is an ideal method of providing high local drug concentrations while minimizing systemic exposure.
With the paucity of consensus regarding the safety, efficacy, and means with which to use aerosolized
antimicrobials, a task force was created by the Society of Infectious Diseases Pharmacists to critically
review and evaluate the literature on the use of aerosolized antiinfective agents. This article summarizes key
findings and statements for preventing or treating a variety of infectious diseases, including cystic fibrosis,
bronchiecstasis, hospital-acquired pneumonia, fungal infections, nontuberculosis mycobacterial infection,
and Pneumocystis jiroveci pneumonia. Our intention was to provide guidance for clinicians on the use of
aerosolized antibiotics through evidence-based pharmacotherapy. Further research with well-designed
clinical trials is necessary to elucidate the optimal dosage and duration of therapy and, of equal importance,
to appreciate the true risks associated with the use of aerosolized delivery systems.
NosoBase n° 27905
Escherichia coli producteur de bêta-lactamases à spectre élargi : changements d'épidémiologie et
impact clinique
Oteo J; Perez-Vazquez M; Campos J. Extended-spectrum beta-lactamase producing Escherichia coli:
changing epidemiology and clinical impact. Current opinion in infectious diseases 2010/08; 23(4): 320-326.
Mots-clés : EPIDEMIOLOGIE; ESCHERICHIA COLI; BETA-LACTAMASE A SPECTRE ELARGI;
BIBLIOGRAPHIE; FACTEUR DE RISQUE; MORTALITE; ANTIBIOTIQUE; TRAITEMENT; INFECTION
URINAIRE; BIOLOGIE MOLECULAIRE; ANTIBIORESISTANCE; COLONISATION DIGESTIVE;
INFECTION COMMUNAUTAIRE
Purpose of review: This review discusses the recent findings (July 2008-January 2010) on extended-
spectrum [beta]-lactamase (ESBL)-producing Escherichia coli, mainly focussed on the epidemiology and
clinical impact of infections owing to this pathogen.
Recent findings: CTX-M-producing E. coli, mainly the CTX-M-15 producers, has emerged and disseminated
worldwide as an important cause of both nosocomial and community-onset infections. The clonal spread of
the ST131 epidemic E. coli strain is linked not only to the CTX-M-15 pandemia but also to other ESBLs
types. The most commonly reported risk factors for community-onset ESBL-producing E. coli infections are
contact with healthcare centres, recent use of antimicrobial agents, and presence of comorbidities. But
infections owing to ESBL-producing E. coli in patients without obvious risk factors can occur, probably
related to the increase of healthy carriers colonized with this pathogen. The main significant predictor of
mortality caused by ESBL-producing E. coli is inadequate initial antimicrobial therapy. Alternatives of
treatment of severe ESBL-producing E. coli infections included carbapenems, amikacin, tigecycline, and
[beta]-lactam/[beta]-lactamase inhibitor combinations; with some of them enough clinical evidence is lacking
(tigecycline, [beta]-lactam/[beta]-lactamase inhibitor combinations). For urinary tract infections, fosfomycin
and nitrofurantoin could be useful.
Summary: The worldwide emergence of multiresistant ESBL-producing E. coli raises key therapeutic
problems; interventions addressed to their quick detection and early appropriate antibiotic treatment and
prevention are urgently needed.