NosoVeille Août 2011

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NosoVeille n°8
Août 2012
Rédacteurs : Nathalie Sanlaville, Sandrine Yvars, Annie Treyve
Secrétariat de rédaction : Nathalie Vincent
Ce bulletin de veille est une publication mensuelle qui recueille les publications scientifiques publiées au
cours du mois écoulé.
Il est disponible sur le site de NosoBase à l’adresse suivante :
http://nosobase.chu-lyon.fr/RevuesBiblio/sommaire_biblio.html
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Abonnement / Désabonnement
Sommaire de ce numéro
Acinetobacter baumannii
Antibiotique
Bactériémie
Cathéter
Chirurgie
Clostridium difficile
EHPAD / Personne âgée
Endoscopie
Epidémie
Epidémiologie
Gale
Gestion des risques
Grippe
Hépatite
Hygiène des mains
Infection urinaire
Législation
Maladies émergentes
Norovirus
Odontologie
Pédiatrie
Personnel
Prévention
Réanimation
Responsabilité
Staphylococcus aureus
Travaux hospitaliers
Vaccination

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Acinetobacter baumannii
NosoBase n° 34531
Contrôle d'une épidémie d'infections à Acinetobacter baumannii à l'aide de vapeur de peroxyde
d'hydrogène
Chmielarczyyk A; Higgins PG; Wojkowska-Mach J; Synowiec E; Zander E; Romaniszyn D; et al. Control of an
outbreak of Acinetobacter baumannii infections using vaporized hydrogen peroxide. The Journal of hospital
infection 2012/08; 81(4): 239-245.
Mots-clés : ACINETOBACTER BAUMANNII; EPIDEMIE; CONTROLE; VAPEUR; PEROXYDE
D'HYDROGENE; EPIDEMIOLOGIE; ANTIBIORESISTANCE; CARBAPENEME; EFFICACITE; PCR;
DESINFECTION; SOIN INTENSIF; TYPAGE; CONTROLE; ENVIRONNEMENT
Background: Multidrug-resistant Acinetobacter baumannii (MRAB) is a serious nosocomial pathogen
characterized by its survival on inanimate surfaces for long periods, making control of outbreaks difficult.
Aim: To analyse two hospital outbreaks caused by MRAB, determine their epidemiology, carbapenem-
resistance mechanisms and assess the effectiveness of surface disinfection by vaporized hydrogen peroxide
(VHP).
Methods: MRAB strains were isolated from patients in two intensive care units (ICUs). Antimicrobial
susceptibility testing was performed by E-test. Polymerase chain reaction (PCR) was used to detect the
presence of the most common A. baumannii carbapenemases. Epidemiological typing was performed by rep-
PCR (DiversiLab) and pulsed-field gel electrophoresis. VHP was used to decontaminate the affected ICUs.
Findings: MRAB was isolated from 28 patients between January 2009 and September 2010. All isolates were
resistant to ciprofloxacin and gentamicin. Twenty-one were also resistant to carbapenems. Carbapenem
resistance was associated primarily with the acquired OXA-23-like enzyme. Genotyping revealed three
clones; the predominant clone corresponded to the international clone (IC) 2. Typing of the isolates pointed to
a multifocal outbreak without a single source of infection, with horizontal spread of the dominating clone
among ICU patients. A combination of rigorous infection control measures including strict isolation, education
of staff, hand hygiene and surface decontamination using VHP halted the outbreak.
Conclusion: The results of this study confirm the importance of rigorous infection prevention and control
measures, combined with VHP decontamination in controlling an outbreak of MRAB.
NosoBase n° 34622
Bactériémies récurrentes à Acinetobacter calcoaceticus - Acinetobacter baumannii complex
Lai CC; Hsu HL; Tan CK; Tsai HY; Cheng A; Liu CY; et al. Recurrent bacteremia caused by Acinetobacter
calcoaceticus - Acinetobacter baumannii complex. Journal of clinical microbiology 2012; in press: 24 pages.
Mots-clés : ACINETOBACTER BAUMANNII; BACTERIEMIE; INFECTION RECURRENTE;
ACINETOBACTER; ENQUETE; BIOLOGIE MOLECULAIRE; MORTALITE; CATHETER
This study is to investigate the clinical and microbiological characteristics of patients with recurrent
bacteremia caused by Acinetobacter calcoaceticus-Acinetobacter baumannii complex (ACB complex) at a
medical center. All ACB complex isolates associated with recurrent bacteremia were identified to the genomic
species level using a 16S-23S rRNA gene intergenic spacer sequence-based method. Genotypes were
determined by the random amplified polymorphic DNA patterns generated by arbitrarily primed PCR and by
pulsotypes generated by pulsed-field gel electrophoresis. Relapse of infection was defined when the
genotype of the recurrent isolate was identical to that of the original infecting strain. Reinfection was defined
when the genospecies or genotype of the recurrent isolate differed from that of the original isolate. From 2006
to 2008, 446 patients had ACB complex bacteremia and 25 (5.6%) had recurrent bacteremia caused by ACB
complex. Among the 25 patients, 12 (48%) had relapse of bacteremia caused by A. nosocomialis (n=7) or A.
baumannii (n=5). Among the 13 patients with reinfection, 5 (38.5%) had reinfection caused by different
genospecies of ACB complex. Most of the patients were immunocompromised and most of the infection foci
were catheter-related bloodstream infections. The overall in-hospital mortality rate was 33.3%. A. baumannii
isolates had lower antimicrobial susceptibility rates than A. nosocomialis and A. pittii isolates. In conclusion,
relapse of ACB complex bacteremia can develop in immunocompromised patients, especially those with
central venous catheters. Molecular methods to identify ACB complex to the genospecies level are essential
for differentiating between reinfection and relapse of bacteremia caused by ACB complex.

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NosoBase n° 33467
Impact d'une antibiothérapie appropriée sur la mortalité associée aux bactériémies à Acinetobacter :
mise en relation avec la sévérité de l'infection
Lee YT; Kuo SC; Yang SP; Lin YT; Tseng FC; Chen TL; et al. Impact of appropriate antimicrobial therapy on
mortality associated with Acinetobacter baumannii bacteremia: relation to severity of infection. Clinical
infectious diseases 2012/07/15; 55(2): 209-215.
Mots-clés : BACTERIEMIE; ACINETOBACTER BAUMANNII; MORTALITE; ETUDE RETROSPECTIVE;
ANTIBIOTIQUE; SCORE
Background: The efficacy of antimicrobial therapy for Acinetobacter baumannii bacteremia has been difficult
to establish because of confounding by underlying diseases, severity of infection, and differences in the
pathogenicity of Acinetobacter species. This retrospective study was conducted to evaluate the effect of
appropriate antimicrobial therapy on 14-day mortality after adjustment for multiple risk factors.
Methods: The population consisted of 252 patients with monomicrobial A. baumannii bacteremia admitted to
a large teaching hospital in Taiwan. The isolates were identified to species level using reference molecular
methods. Predictors of 14-day mortality were determined by logistic regression analysis. The influence of
severity of infection, determined by Acute Physiology and Chronic Health Evaluation (APACHE) II score, on
the impact of appropriate use of antimicrobials on 14-day mortality was assessed by including an interaction
term.
Results: The overall 14-day mortality rate was 29.8% (75 of 252 patients). The unadjusted mortality rate for
appropriate antimicrobial therapy was 13.2% (12 of 91 patients). Appropriate therapy was independently
associated with reduced mortality (odds ratio [OR], 0.22; 95% confidence interval [CI], .01-.50; P<.001), and
the effect was influenced by APACHE II score (OR for interaction term, 0.90; 95% CI, .82-.98; P=.02). A
subgroup analysis revealed that the benefit of appropriate therapy was limited to patients with high APACHE
II scores (OR for patients with scores >25 and =35, 0.16 [95% CI, .07-.37]; OR for those with scores >35,
0.06; 95% CI, .01-.25).
Conclusions: Appropriate antimicrobial therapy significantly reduced 14-day mortality for A. baumannii
bacteremia in severely ill patients.
NosoBase n° 34689
Signalement des infections nosocomiales à Acinetobacter baumannii résistant à l'imipénème, France,
août 2011 – mai 2011
Vaux S; Nguyen E; Alleaume S; Blanckaert K; Galas M; Poujol I; et al. Reporting of nosocomial imipenem-
resistant Acinetobacter baumannii infections, France, august 2011 - may 2011. Bulletin épidémiologique
hebdomadaire 2012/07/24: 31-32 : 355-360.
Mots-clés : ACINETOBACTER BAUMANNII; SIGNALEMENT; ANTIBIORESISTANCE; SURVEILLANCE;
EPIDEMIE; EPIDEMIOLOGIE; APPAREIL RESPIRATOIRE; BACTERIEMIE; SEPTICEMIE; INFECTION
URINAIRE
Bactérie pathogène opportuniste, Acinetobacter baumannii (AB) peut être responsable d'infections sévères,
en particulier chez des patients fragilisés. Naturellement résistant à de nombreux antibiotiques, AB est
capable d'acquérir des mécanismes de résistance aux carbapénèmes, dont l'imipénème, conduisant à des
difficultés thérapeutiques. Les infections/colonisations à AB résistant à l'imipénème (ABRI) peuvent être
signalées à l'Agence régionale de santé et au Centre de coordination de la lutte contre les infections
nosocomiales dans le cadre du signalement réglementaire des infections nosocomiales (SIN). L'analyse
rétrospective des SIN reçus à l'Institut de veille sanitaire entre le 01/08/2001 et le 31/05/2011 montre une
nette augmentation du nombre annuel de signalements pour ABRI. Sur 10 288 signalements reçus sur la
période, 343 (3,3 %) impliquaient des ABRI. Les signalements pour ABRI représentaient entre 2 et 3% de
l'ensemble des SIN reçus de 2003 à 2008, 3,2 % en 2009, 5,1 % en 2010 et 11,1 % sur les cinq premiers
mois de 2011. Les sites les plus fréquemment rapportés étaient les infections respiratoires (37 %), les
bactériémies/septicémies (18,9 %) ou les infections urinaires (12,6 %). La description de deux épidémies
dans le Nord-Pas-de-Calais et au CHU de Fort-de-France illustre leurs modalités d'investigation et de
prévention.

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Antibiotique
NosoBase n° 33458
La vancomycine pour l'antibioprophylaxie chirurgicale
Crawford T; Rodvold KA; Solomkin JS. Vancomycin for surgical prophylaxis? Clinical infectious diseases
2012/05/15; 54(10): 1474-1479.
Mots-clés : ANTIBIORESISTANCE; METICILLINO-RESISTANCE; ANTIBIOPROPHYLAXIE; CHIRURGIE;
SITE OPERATOIRE; PREVENTION; VANCOMYCINE
The increasing prevalence of methicillin-resistant Staphylococcus aureus (MRSA) has resulted in a
reevaluation of the role of vancomycin for surgical prophylaxis. Two systematic reviews of randomized control
studies have concluded that cephalosporins are as effective as vancomycin for the prevention of surgical site
infections (SSIs). However, most of these studies were conducted more than 10 years ago and cannot be
generalized to the current rates of MRSA. Several time-series analyses have recently evaluated the
effectiveness of vancomycin for surgical prophylaxis in institutions with a high prevalence of MRSA. Decision
analysis models have also been used to estimate thresholds of MRSA prevalence for which vancomycin
would minimize the incidence and cost of SSIs. Combination therapy and the emergence of resistant
pathogens following vancomycin prophylaxis are reviewed. Vancomycin is not recommended for routine use
in surgical prophylaxis but may be considered as a component of a MRSA prevention bundle for SSIs in
selective circumstances.
NosoBase n° 34308
Approche prospective pour gérer une pénurie d'antibiotiques
Griffith MM; Patel JA; Sutton SH; Bolon MK; Esterly JS; Gross AE; et al. Prospective approach to managing
antimicrobial drug shortages. Infection control and hospital epidemiology 2012/07; 33(7):745-752.
Mots-clés : INFECTION; ANTIBIOTIQUE; PRESCRIPTION; RECOMMANDATION
Antimicrobial drug shortages continue to increase, with few new therapeutic options available. Nationally,
proposals have been offered to alleviate drug shortages; however, these recommendations are unlikely to
effect change in the near future. Thus, antimicrobial stewardship leaders in acute care hospitals must develop
a prospective management strategy to lessen the impact of these shortages on patient care. Herein, we
describe several resources available to aid professionals in antimicrobial stewardship and healthcare
epidemiology to manage drug shortages. An effective approach should include prospectively tracking
shortages and maximizing inventory by appropriately managing usage. Several tenets should underpin this
management. Alternative agents should be rationally chosen before the inventory of the primary agent has
reached zero, ethical considerations should be taken into account, and timely notification and communication
with key stakeholders should occur throughout the prescribing and dispensing process.
NosoBase n° 34628
Corrélation entre consommation de carbapénèmes et résistance aux carbapénèmes parmi des isolats
d'entérobactéries recueillies chez des patients présentant des infections intra-abdominales dans cinq
centres hospitaliers de Taiwan, 2006-2010
Ho CM; Ho MW; Liu YC; Toh HS; Lee YL; Liu YM; et al. Correlation between carbapenem consumption and
resistance to carbapenems among Enterobacteriaceae isolates collected from patients with intra-abdominal
infections at five medical centers in Taiwan, 2006-2010. International journal of antimicrobial agents 2012;
40(Supplément 1): S24-S28.
Mots-clés : ANTIBIOTIQUE; CONSOMMATION; CARBAPENEME; ANTIBIORESISTANCE;
ENTEROBACTERIE; ABDOMEN; ESCHERICHIA COLI; KLEBSIELLA; ENTEROBACTER; TAUX
We investigated the trend in resistance to carbapenems among isolates of Enterobacteriaceae that had been
collected from patients with intra-abdominal infections at five medical centers in Taiwan from 2006 to 2010
and evaluated the correlation between resistance to carbapenems and consumption of said agents as part of
the Study for Monitoring Antimicrobial Resistance Trends (SMART). During the study period, the usage of

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ertapenem and that of total carbapenems (ertapenem, imipenem, and meropenem) increased significantly
from 6.13 to 13.38 defined daily doses per 1000 patient-days for ertapenem and from 20.43 to 34.25 defined
daily doses per 1000 patient-days for total carbapenems. The most common species were Escherichia coli
(n=1095), Klebsiella spp. (n=663), and Enterobacter spp. (n=202). The susceptibility of all isolates to
ertapenem and to imipenem varied during the study period. For ertapenem, the rates of nonsusceptibility
ranged from 3.5% to 10.3% and those for imipenem ranged from 3.5% to 10.7%. Although the use of
carbapenems increased during the study period, there was no marked increase in resistance to
carbapenems. Continuous monitoring of resistance trends is necessary so that antimicrobial prescription
policies can be adjusted and infection control intervention programs can be implemented.
NosoBase n° 34596
Antibiorésistance des entérobactéries, incluant la caractérisation moléculaire des espèces
productrices de bêta-lactamases à spectre étendu dans des isolats urinaires provenant de patients
hospilalisés en Amérique du Nord et en Europe : résultats de l'étude SMART 2009-2010
Hoban DJ; Lascols C; Nicolle LE; Badal R; Bouchillon S; Hackel M; et al. Antimicrobial susceptibility of
enterobacteriaceae, including molecular characterization of extended-spectrum beta-lactamase-producing
species, in urinary tract isolates from hospitalized patients in North America and Europe: results from the
SMART study 2009-2010. Diagnostic microbiology and infectious disease 2012; in press: 6 pages.
Mots-clés : ENTEROBACTERIE; ANTIBIORESISTANCE; INFECTION URINAIRE; BETA-LACTAMASE A
SPECTRE ELARGI; ESCHERICHIA COLI; KLEBSIELLA PNEUMONIAE; CARBAPENEME; IMIPENEME;
BIOLOGIE MOLECULAIRE; AMERIQUE DU NORD; EUROPE; SURVEILLANCE
In 2009-2010, 3646 urinary tract isolates of Enterobacteriaceae spp. were isolated from hospitalized patients
in North America and Europe. Extended-spectrum beta-lactamase (ESBL) production was detected in 8.5%
and 8.8% of Escherichia coli and Klebsiella pneumoniae, respectively, in North America and in 17.6% and
38.9% for Europe, respectively. The carbapenems (ertapenem and imipenem) were the most active agents in
vitro, with ampicillin-sulbactam the least active. Molecular characterization of about 50% of ESBL-positive
isolates identified the presence of bla(CTX-M) genes in over 90% of Escherichia coli from both continents.
bla(KPC) was more common in North American isolates of K. pneumoniae than in European isolates (21.4%
versus 6.9%). bla(TEM) and AmpC genes were infrequent. Enterobacteriaceae spp. isolated from
hospitalized patients with urinary tract infections in both North America and Europe are often resistant to
commonly used antimicrobials with bla(CTX-M) genes common in both Escherichia coli and K. pneumoniae.
NosoBase n° 34646
Benchmarking (comparaison de performance) des traitements antibiotiques empiriques inappropriés
Kariv G; Paul M; Shani V; Muchtar E; Leibovici L. Benchmarking inappropriate empirical antibiotic treatment.
Clinical microbiology and infection 2012; in press: 13 pages.
Mots-clés : ANTIBIOTIQUE; TRAITEMENT; ANTIBIORESISTANCE; MORTALITE; TAUX; ETUDE
PROSPECTIVE; COHORTE; PRESCRIPTION; BIBLIOGRAPHIE
Inappropriate empirical antibiotic treatment for severe infections is associated with increased mortality.
Superfluous treatment is associated with resistance induction. We aimed to define acceptable rates of
inappropriate empirical antibiotic treatment. We included all prospective cohort studies published between
1975 and 2009 reporting the proportion of appropriate and inappropriate empirical antibiotic treatment of
microbiologically documented infections. Studies were identified in PubMed and in reference lists of included
studies. Funnel plots were drawn using the proportion of inappropriate empirical treatment as the effect size.
A pooled estimate of inappropriate empirical antibiotic treatment was calculated using a ß-binomial model.
Control limits were calculated with the overdispersion factor technique and 20% winsorized data.
Heterogeneity was assessed through subgroup analysis for categorical moderators and meta-regression for
continuous variables. Eighty-seven studies, comprising 92 study groups, with 27 628 patients met inclusion
criteria. The pooled rate of inappropriate empirical antibiotic treatment was 28.6% (95% CI 25.4-31.8). Funnel
plot analysis yielded a dispersed graph with only 37 (40%) studies falling within the control limits. Using the
overdispersion factor technique with 20% winsorizing, 79 (86%) studies fell within the control limits. None of
the clinical or methodological factors could explain the large heterogeneity observed. The funnel plot
presented can be used to benchmark rates of inappropriate empirical antibiotic treatment. Based on the
control limits found, at least 500 patients should be evaluated before establishing a local rate. Lower and
higher than expected rates might indicate overly aggressive treatment or poor performance, respectively.