Laurence Armand-Lefevre

Paris Diderot University, Lutetia Parisorum, Île-de-France, France

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Publications (54)204.72 Total impact

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    Clinical Infectious Diseases 08/2015; DOI:10.1093/cid/civ705 · 9.42 Impact Factor
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    ABSTRACT: Infective endocarditis (IE) due to gram-negative bacilli (GNB) is rare. However, several studies described a change in the epidemiological profile of patients within the past few years. We reviewed all cases diagnosed and followed in the infectious diseases ward of a French teaching hospital in Paris between 2009 and 2014, inclusive. Among the 17 patients with definite GNB-IE (11 male, mean age 54 years), 12 (70%) were due to non-HACEK GNB and 5 (30%) to HACEK group GNB. A prosthetic valve was involved in 10 cases (8 in non-HACEK and 2 in HACEK group). Escherichia coli (4/12 patients) and Pseudomonas aeruginosa (3/12 patients) were the most common pathogens in the first group; all the pathogens in the second group were Haemophilus spp. One-third of the patients with non-HACEK GNB had nosocomial IE, whereas injection drug use-related infections were rare (2/12). All patients with HACEK infection had at least one complication (intracardiac abscess, stroke or other systemic embolization). All patients were treated by antibiotic combination therapy during a median time of 42 days (interquartile range (IQR) = 42-42) and 10 (59%) underwent cardiac surgery. One death at 9 months was observed in the non-HACEK group. Regarding HACEK IE, this report supports the frequent association with vascular complications. Regarding non-HACEK GNB IE, this report supports the increasing proportion of nosocomial infections. We reported a high proportion of surgery in the therapeutic management of both HACEK and non-HACEK groups associated with no in-hospital mortality.
    08/2015;
  • J J Parienti · J C Lucet · A Lefort · L Armand-Lefèvre · M Wolff · F Caron · V Cattoir · Y Yazdanpanah
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    ABSTRACT: Poor outcomes occur when patients with serious infections receive antibiotics to which the organisms are resistant. Decision trees simulated in-hospital mortality, costs, incremental cost-effectiveness ratio per life year saved, and carbapenem resistance according to 3 empirical antibiotic strategies among adults hospitalized for community-acquired (CA) upper urinary tract infections (UTIs): ceftriaxone (CRO) plus gentamicin (GM) in the intensive care unit (ICU), imipenem (IMP), and individualized choice (IMP or CRO) based on clinical risk factors for CA- extended-spectrum β-lactamase (ESBL). The estimated prevalence of CA-ESBL on admission was 5% (range, 1.3%-17.6%); 3% and 97% were admitted to the ICU and medical ward (MW), respectively. In the ICU, CRO plus GM was dominated; IMP was cost-effective (incremental cost-effectiveness ratio: €4,400 per life year saved compared with individualized choice). In the MW, IMP had no impact on mortality and was less costly (-€142 per patient vs CRO, -€38 vs individualized choice). The dominance of IMP was consistent in sensitivity analyses. Compared with CRO, colonization by carbapenem-resistant pathogens increased by an odds ratio of 4.5 in the IMP strategy. Among the ICU patients, empirical IMP therapy reduces mortality at an acceptable cost. Among MW patients, individualized choice or CRO is preferred to limit carbapenem resistance at a reasonable cost. Copyright © 2015 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
    American journal of infection control 07/2015; DOI:10.1016/j.ajic.2015.05.033 · 2.33 Impact Factor
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    ABSTRACT: Emerging resistance to antibiotics shows no signs of decline. At the same time, few new antibacterials are being discovered. There is a worldwide recognition regarding the danger of this situation. The urgency of the situation and the conviction that practices should change led the Société de Réanimation de Langue Française (SRLF) and the Société Française d'Anesthésie et de Réanimation (SFAR) to set up a panel of experts from various disciplines. These experts met for the first time at the end of 2012 and have since met regularly to issue the following 67 recommendations, according to the rigorous GRADE methodology. Five fields were explored: i) the link between the resistance of bacteria and the use of antibiotics in intensive care; ii) which microbiological data and how to use them to reduce antibiotic consumption; iii) how should antibiotic therapy be chosen to limit consumption of antibiotics; iv) how can antibiotic administration be optimized; v) review and duration of antibiotic treatments. In each institution, the appropriation of these recommendations should arouse multidisciplinary discussions resulting in better knowledge of local epidemiology, rate of antibiotic use, and finally protocols for improving the stewardship of antibiotics. These efforts should contribute to limit the emergence of resistant bacteria.
    Intensive Care Medicine 06/2015; DOI:10.1007/s00134-015-3853-7 · 7.21 Impact Factor
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    ABSTRACT: The emergence of extended-spectrum beta-lactamase (ESBL) producing Enterobacteriaceae has resulted in the increase of carbapenem prescriptions. The objective of our study was to determine the appropriateness of carbapenem prescriptions from initiation to reassessment of treatment, between 2009 and 2011. A questionnaire drafted by infectious diseases specialists (IDS) and microbiologists was used to collect clinical and microbiological data concerning carbapenem prescriptions in 2009 and 2011. An IDS then compared the results to assess carbapenem prescription compliance with our hospital's local recommendations. Seventy-one prescriptions were included in 2009 and 32 in 2011. The carbapenem treatment had been most frequently probabilistic to treat nosocomial infections. The microbiological data revealed that the number of multidrug-resistant (MDR) infections had increased between 2009 and 2011, especially infections involving ESBL-producing Enterobacteriaceae. At treatment reassessment, in 2009 and 2011, 15 (21%) and 12 (38%) carbapenem prescriptions were appropriate and continued. Overall, when comparing the 2 periods, prescriptions complied with local guidelines from initiation to reassessment of treatment without any statistically significant difference (68% in 2009 and 75% in 2011). Our study results showed that MDR infections had increased and especially infections due to ESBL-producing Enterobacteriaceae; this was consistent with epidemiological data. We also proved that most carbapenem prescriptions were compliant with recommendations. The increased mobile IDS interventions in medical and surgical departments helped reach this rate of compliance. Carbapenem stewardship may be promoted even in a difficult epidemiological context, especially with IDS interventions for the duration of treatment or at treatment reassessment. Copyright © 2015 Elsevier Masson SAS. All rights reserved.
    Médecine et Maladies Infectieuses 06/2015; DOI:10.1016/j.medmal.2015.04.008 · 0.91 Impact Factor
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    ABSTRACT: Background. Multidrug-resistant Enterobacteriaceae (MRE) are widespread in the community, especially in tropical regions. Travelers are at risk of acquiring MRE in these regions, but the precise extent of the problem is not known. Methods. From February 2012 to April 2013, travelers attending 6 international vaccination centers in the Paris area prior to traveling to tropical regions were asked to provide a fecal sample before and after their trip. Those found to have acquired MRE were asked to send fecal samples 1, 2, 3, 6, and 12 months after their return, or until MRE was no longer detected. The fecal relative abundance of MRE among all Enterobacteriaceae was determined in each carrier. Results. Among 824 participating travelers, 574 provided fecal samples before and after travel and were not MRE carriers before departure. Of these, 292 (50.9%) acquired an average of 1.8 MRE. Three travelers (0.5%) acquired carbapenemase-producing Enterobacteriaceae. The acquisition rate was higher in Asia (142/196 [72.4%]) than in sub-Saharan Africa (93/195 [47.7%]) or Latin America (57/183 [31.1%]). MRE acquisition was associated with the type of travel, diarrhea, and exposure to β-lactams during the travel. Three months after return, 4.7% of the travelers carried MRE. Carriage lasted longer in travelers returning from Asia and in travelers with a high relative abundance of MRE at return. Conclusions. MRE acquisition is very frequent among travelers to tropical regions. Travel to these regions should be considered a risk factor of MRE carriage during the first 3 months after return, but not beyond. Clinical Trials Registration. NCT01526187.
    Clinical Infectious Diseases 04/2015; DOI:10.1093/cid/civ333 · 9.42 Impact Factor
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    ABSTRACT: The incidence of surgical site infection (SSI) after cardiac surgery depends on the definition used. A distinction is generally made between mediastinitis, as defined by the Centers for Disease Control (CDC), and superficial SSI. Our objective was to decipher these entities in terms of presentation and risk factors. We performed a 7-year single center analysis of prospective surveillance of patients with cardiac surgery via median sternotomy. SSI was defined as the need for reoperation due to infection. Among 7,170 patients, 292 (4.1%) developed SSI, including 145 CDC-defined mediastinitis (CDC+ SSI, 2.0%) and 147 superficial SSI without associated bloodstream infection (CDC- SSI, 2.1%). Median time to reoperation for CDC- SSI was 18 days (IQR, 14-26) and 16 (IQR, 11-24) for CDC+ SSI (p= 0.02). Microorganisms associated with CDC- SSI were mainly skin commensals (62/147, 41%) or originated in the digestive tract (62/147, 42%) and only 6 Staphylococcus aureus (4%), while CDC+ SSI were mostly due to S.aureus (52/145, 36%) and germs from the digestive tract (52/145: 36%). Risk factors for SSI were older age, obesity, chronic obstructive bronchopneumonia, diabetes mellitus, critical pre-operative state, post-operative vasopressive support, transfusion or prolonged ventilation and coronary artery bypass grafting, especially if using both internal thoracic arteries (ITA) in female patients. The number of ITA used and factors affecting wound healing were primarily associated with CDC- SSI, whereas co-morbidities and peri-operative complications were mainly associated with CDC+ SSI. These 2 entities differed in time to revision surgery, bacteriology and risk factors, suggesting a differing pathophysiology. Copyright © 2015. Published by Elsevier Ltd.
    Clinical Microbiology and Infection 04/2015; 21(7). DOI:10.1016/j.cmi.2015.03.025 · 5.20 Impact Factor
  • C Bonnal · G Birgand · I Lolom · S Diamantis · C Dumortier · F L'Heriteau · L Armand-Lefevre · J C Lucet
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    ABSTRACT: Surveillance of preventable healthcare associated infections and feedback of the results to clinicians is central in the efforts to improve performance. We assessed Staphylococcus aureus healthcare associated bloodstream infection (HA-BSI) as an indicator of healthcare quality. Between 2002 and 2012, we carried out a ten-year prospective bedside surveillance of S. aureus healthcare associated bacteraemia in a 940-bed university hospital using standard definitions. Overall, 2784 HA-BSI were identified during the study period, among which 573 (18%) were due to S. aureus. Among these 573 S. aureus bacteraemias, 189 originated from intravascular catheters (32.8%) of which 84% (158/189) in patients outside intensive care units. The proportion of catheter related HA-BSI due to S. aureus was 56% (61/109) in PVC-related HA-BSI and 34% (103/301) in CVC-related HA-BSI. A sharp decrease of PVC-related HA-BSI from 20 to 7 per year was obtained during the same period. In our experience, S. aureus HA-BSI is a simple and useful indicator of catheter associated infections, and therefore of healthcare quality, especially in units not covered by other type of surveillance. Copyright © 2015 Elsevier Masson SAS. All rights reserved.
    Médecine et Maladies Infectieuses 02/2015; 45(3). DOI:10.1016/j.medmal.2015.01.002 · 0.91 Impact Factor
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    ABSTRACT: Despite recent advances, antibiotic therapy of ventilator-associated pneumonia (VAP) in ICU patients is still challenging. We assessed the impact of imipenem and amikacin pharmacokinetic and pharmacodynamic parameters on microbiological outcome in these patients. Patients with Gram-negative bacilli (GNB) VAP were prospectively included. Blood samples for pharmacokinetic analysis were collected after empirical administration of a combination of imipenem three times daily and one single dose of amikacin. MICs were estimated for each GNB obtained from respiratory samples. Microbiological success was defined as a ≥10(3) cfu/mL decrease in bacterial count in quantitative cultures between baseline and the third day of treatment. Thirty-nine patients [median (min-max) age = 60 years (28-84) and median SAPS2 at inclusion = 40 (19-73)] were included. Median MICs of imipenem and amikacin were 0.25 mg/L (0.094-16) and 2 mg/L (1-32), respectively. Median times over MIC and over 5× MIC for imipenem were 100% (8-100) and 74% (3-100), respectively. The median C1/MIC ratio for amikacin was 23 (1-76); 34 patients (87%) achieved a C1/MIC ≥10. Microbiological success occurred in 29 patients (74%). No imipenem pharmacodynamic parameter was significantly associated with the microbiological success. For amikacin, C1/MIC was significantly higher in the microbiological success group: 26 (1-76) versus 11 (3-26) (P = 0.004). In ICU patients with VAP, classic imipenem pharmacodynamic targets are easily reached with usual dosing regimens. In this context, for amikacin, a higher C1/MIC ratio than previously described might be necessary. © The Author 2015. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.
    Journal of Antimicrobial Chemotherapy 01/2015; 70(5). DOI:10.1093/jac/dku569 · 5.44 Impact Factor
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    ABSTRACT: Inappropriate antibiotic therapy in ventilator-associated pneumonia (VAP) is associated with increased mortality. Using broad-spectrum antibiotics for 48 h until the results of conventional cultures and antimicrobial susceptibility testing (AST) are available, may promote the emergence of drug-resistant bacteria. Performing AST directly on clinical respiratory samples would hasten the process by at least 24 h. Here, we analysed the diagnostic performance of a rapid method combining mass spectrometry and direct AST (DAST), and compared it with the conventional method (mass spectrometry with conventional AST (CAST)). Additionally, we assessed its potential impact on antimicrobial use in patients. Over a period of 18 months, the two methods were performed on 85 bronchoalveolar lavages obtained from intensive care unit patients with suspected VAP, and in which Gram-negative bacilli were observed on direct examination. Only the CAST results were reported to the clinicians. DAST produced useable results in 85.9% of the patients. The sensitivity and negative predictive values of DAST were 100% for all antibiotics tested, except gentamicin (97.1%, (95% CI 93.3-101) and 97.4% (93.7-101), respectively) and amikacin (88.9% (81.7-96.1) and 96.4% (92.1-100.7), respectively), compared with CAST. Specificity and positive predictive values ranged from 82.9 (74.2-91.5) to 100%, and from 86.4 (78.5-94.2) to 100%, respectively. If the DAST results had been reported to the clinicians, treatment could have been optimized 24 h earlier in 35/85 (41.2%) patients, with 17 carbapenem patient-days saved. Overall, routine use of the DAST method could help optimize earlier antibiotic treatment in patients with suspected VAP. Copyright © 2014 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
    Clinical Microbiology and Infection 12/2014; 21(5). DOI:10.1016/j.cmi.2014.12.007 · 5.20 Impact Factor
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    Infection Control and Hospital Epidemiology 11/2014; 35(11):1427-9. DOI:10.1086/678425 · 3.94 Impact Factor
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    ABSTRACT: A 65 year-old woman was admitted for acute heart failure and severe sepsis revealing definite mitral infective endocarditis with severe regurgitation, complicated by multiple embolisms. Three blood cultures yielded a group G Streptococcus canis strain. Urgent surgery was performed with bioprosthetic valve replacement. Polymerase chain reaction analysis of the valve found S canis DNA. Amoxicillin and gentamicin were given for 2 weeks followed by 4 weeks of amoxicillin alone. She reported contact with a dog without bite. S canis has been reported to cause zoonotic septicemia but to our knowledge, this is the first human case of native valve infective endocarditis. Copyright © 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
    The Canadian journal of cardiology 11/2014; 30(11):1462.e1-2. DOI:10.1016/j.cjca.2014.07.013 · 3.94 Impact Factor
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    ABSTRACT: Aims Modifications of antimicrobials’ pharmacokinetic parameters have been reported in critically ill patients, resulting in a risk of treatment failure. We characterized amikacin pharmacokinetic variability in critically ill patients with ventilator-associated pneumonia (VAP) and evaluated several dosing regimens. Methods We conducted a prospective multicenter study in critically ill patients with presumptive diagnosis of Gram-negative bacilli (GNB) VAP. Patients empirically received imipenem and a single-dose of amikacin, which was administered as a 30-min infusion (20 mg/kg). Concentrations were measured 0.5, 1, 8, 16, and 24 h after beginning of infusion. Pharmacokinetic parameters were estimated using a population approach. Main pharmacodynamic target was a ratio ≥10 between the concentration achieved 1 h after beginning of infusion (C 1h) and the minimal inhibitory concentration of the liable bacteria (MIC). We simulated individual C 1h for several dosing regimens by Monte Carlo method and computed C 1h/MIC ratios for MICs from 0.5 to 64 mg/L. Results Sixty patients (47 males), median (range) age, and body weight, 61.5 years (28–84) and 78 kg (45–126), respectively, were included. Amikacin median C 1h was 45 mg/L (22–87). Mean value (between-patients variability) for CL, V1, Q, and V2 were 4.3 L/h (31 %), 15.9 L (22 %), 12.1 L/h (27 %), and 21.4 L (47 %), respectively. CL increased with CrCL (p
    European Journal of Clinical Pharmacology 10/2014; DOI:10.1007/s00228-014-1766-y · 2.70 Impact Factor
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    ABSTRACT: AimsSignificant alterations in the pharmacokinetics (PK) of antimicrobials have been reported in critically ill patients. We describe PK parameters of imipenem in intensive care unit (ICU) patients with suspected ventilator-associated pneumonia and evaluate several dosage regimens. Methods This French multicentre, prospective, open-label study was conducted in ICU patients with a presumptive diagnosis of ventilator-associated pneumonia caused by Gram-negative bacilli, who empirically received imipenem intravenously every 8h. Plasma imipenem concentrations were measured during the fourth imipenem infusion using six samples (trough, 0.5, 1, 2, 5 and 8h). Data were analysed with a population approach using the stochastic approximation expectation maximization algorithm in Monolix4.2. A Monte Carlo simulation was performed to evaluate the following six dosage regimens: 500, 750 or 1000mg with administration every 6 or 8h. The pharmacodynamic target was defined as the probability of achieving a fractional time above the minimal inhibitory concentration (MIC) of >40%. ResultsFifty-one patients were included in the PK analysis. Imipenem concentration data were best described by a two-compartment model with three covariates (creatinine clearance, total bodyweight and serum albumin). Estimated clearance (between-subject variability) was 13.2lh(-1) (38%) and estimated central volume 20.4l (31%). At an MIC of 4gml(-1), the probability of achieving 40% fractional time > MIC was 91.8% for 0.5h infusions of 750mg every 6h, 86.0% for 1000mg every 8h and 96.9% for 1000mg every 6h. Conclusions This population PK model accurately estimated imipenem concentrations in ICU patients. The simulation showed that for these patients, the best dosage regimen of imipenem is 750mg every 6h and not 1000mg every 8h.
    British Journal of Clinical Pharmacology 06/2014; 78(5). DOI:10.1111/bcp.12435 · 3.69 Impact Factor
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    Eurosurveillance: bulletin europeen sur les maladies transmissibles = European communicable disease bulletin 04/2014; 19(14). DOI:10.2807/1560-7917.ES2014.19.14.20768 · 4.66 Impact Factor
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    ABSTRACT: We describe the prevalence of carriage and variables associated with introduction of highly drug-resistant microorganisms (HDRMO) into a French hospital via patients repatriated or recently hospitalized in a foreign country. The prevalence of HDRMO was 11% (15/132), with nine carbapenamase-producing Enterobacteria-ceae, nine carbapenem-resistant Acinetobacter baumannii and six glycopeptide-resistant enterococci. Half of the admitted patients (63/132, 48%) were colonized with extended spectrum beta-lac-tamase-producing Enterobacteriaceae (ESBLPE). Among the four episodes with secondary cases, three involved A. baumannii.
    Clinical Microbiology and Infection 04/2014; 20(11). DOI:10.1111/1469-0691.12604 · 5.20 Impact Factor
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    ABSTRACT: We retrospectively studied daptomycin use during 2010 at the Bichat-Claude-Bernard teaching-hospital (Paris) to observe the evolution of daptomycin prescriptions. Twenty-one patients were included and several parameters were documented: site of infection, bacterial species involved, reason for daptomycin use, dose and clinical outcome. Ninety-five percent of daptomycin prescritions were off-label and most did not comply with local guidelines. Fifteen of the 21 patients were cured (71%), including 9 patients of the 12 with off-label and off-local recommendation prescriptions (75%). Osteitis and Enterococcus spp endocarditis were the new indications. Daptomycin was increasingly used at higher doses: 52% of our patients were given doses above 6mg/kg. Staphylococcus spp. was the most frequent pathogen responsible for infection is our patients, followed by Enterococcus spp. Daptomycin use is likely to evolve because of its effectiveness in the treatment of osteitis, left-sided and Enterococcus spp. infective endocarditis. It is generally used at higher doses, which are well tolerated. However, therapeutic monitoring needs to be developed. The antibiotic commission of our hospital gave new recommendations for daptomycin use in 2011.
    Médecine et Maladies Infectieuses 12/2013; DOI:10.1016/j.medmal.2013.11.002 · 0.91 Impact Factor
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    C Neulier · G Birgand · E Ruppé · L Armand-Lefèvre · I Lolom · Y Yazdanpanah · J-C Lucet · A Andremont
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    ABSTRACT: The increasing prevalence of extended spectrum beta-lactamase producing enterobacteriaceae (ESBLPE) requires defining the use of carbapenems in first intention. We analyzed the associations between enterobacteriaceae bacteremia (EbBact) and ESBLPE carriage during 10 years in a 950-bed teaching hospital. We analyzed a 10-year (July 2001 to June 2011) prospective collection of bacteremia cases including 2 databases: (1) EbBact and (2) a computerized database of patients carrying EBLSE. Only one episode of EbBact was analyzed per patient and hospital stay. Factors associated with ESBLPE bacteremia were assessed by univariate and multivariate logistic regression analysis. Overall, 2355 cases of EbBact were identified, among which 135 (5.7%) were ESBLPE (2001-05: 1.4%, 2006-09: 7.6%, 2010-11: 14.2%). ESBLPE bacteremia was observed in 52 of the 88 (59%) patients carrying ESBLPE and in 83/2267 (3.7%) patients not known to be colonized with ESBLPE. Factors associated with ESBLPE bacteremia in patients not known to be colonized were: female gender (ORa=0.56, CI95% [0.34-0.91]), hospitalization in the ICU (ORa=2.51 [1.27-5.05]) or medical/surgical wards (ORa=1.83 [1.04-3.38]), the period (2006-09, ORa=4.08 [2.21-8.16]; 2010-11, ORa=8.17 [4.14-17.06] compared to 2001-05), and history of EbBact (ORa=2.29 [0.97-4.79]). In case of EbBact, patients known to be colonized with ESBLPE present with ESBLPE bacteremia in more than half of the cases, requiring carbapenems as empirical antibiotic treatment. The global prevalence of ESBLPE among patients presenting with EbBact not known to be colonized with ESBLPE was 3.7%.
    Médecine et Maladies Infectieuses 12/2013; DOI:10.1016/j.medmal.2013.11.003 · 0.91 Impact Factor
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    ABSTRACT: According to French national recommendations, the detection of a patient colonized with glycopeptide-resistant enterococci (GRE) leads to interruption of new admissions and transfer of contact patients (CPs) to another unit or healthcare facility, with weekly screening of CPs. We evaluated the medical and economic impact of a pragmatic adaptation of national guidelines associated with a real-time PCR (RTP) (Cepheid XpertTM vanA/vanB) as part of the strategy for controlling GRE spread in two medical wards. Screening was previously performed using chromogenic selective medium (CSM). Turn around time (TAT), costs of tests and cost of missed patient days were prospectively collected. In February 2012, the identification of GRE in one patient in the diabetology ward led to the screening of 31 CPs using CSM; one secondary case was identified in a CP already transferred to the Nephrology ward. Awaiting the results of SCM (median TAT, 70.5 h), 41 potential patient days were missed, due to interruption of admissions. The overall cost (screening tests + missing patient.days) was estimated at 14, 302.20 [euro sign]. The secondary case led to screening of 22 CPs in the Nephrology ward using RTP. Because of a short median TAT of 4.6 h, we did not interrupt admissions and patients' transfers. Among 22 CPs, 19 (86%) were negative for vanA, 2 were positive for vanB and 3 had invalid results needing CSM. The overall cost of the strategy was estimated at 870.40 [euro sign] (cost of screening tests only), without missing patient days. The rapid PCR test for vanA-positive GRE detection both allowed rapid decision about the best infection control strategy and prevented loss of income due to discontinuation of patient transfers and admissions.
    11/2013; 2(1):30. DOI:10.1186/2047-2994-2-30

Publication Stats

869 Citations
204.72 Total Impact Points

Institutions

  • 2007–2015
    • Paris Diderot University
      Lutetia Parisorum, Île-de-France, France
  • 2004–2015
    • Assistance Publique – Hôpitaux de Paris
      Lutetia Parisorum, Île-de-France, France
  • 2003–2015
    • Hôpital Bichat - Claude-Bernard (Hôpitaux Universitaires Paris Nord Val de Seine)
      • Service des Maladies Infectieuses et Tropicales
      Lutetia Parisorum, Île-de-France, France
  • 2014
    • Université Paris-Sorbonne - Paris IV
      Lutetia Parisorum, Île-de-France, France
  • 2011
    • Harvard Medical School
      • Department of Medicine
      Boston, MA, United States
  • 2009
    • National Scientific and Practical Centre for Preventive Medicine, Chisinau
      Kischinew, Chişinău, Moldova