Bacillus cereus bacteraemia: comparison between haematologic and nonhaematologic patients.

Bacillus cereus bacteraemia can be severe, especially among patients with haematologic malignancy. We retrospectively reviewed first episodes of true B. cereus bacteraemia (more than one positive bottle plus signs of infection) at our institution between 1997 and 2013 with the aim to compare haematologic versus nonhaematologic patients and analyse episodes with complicated outcome. Among 56 episodes of positive-blood cultures for B. cereus, 21 were considered significant. Median age was 54 years (range 23-82 years). Ten patients (48%) had a haematologic malignancy; all were neutropenic at the time of B. cereus bacteraemia. Nonhaematologic patients were either intravenous drug users (n = 3, 14%), polytraumatized (n = 3, 14%) or had multiple chronic comorbidities (n = 5, 24%). Most episodes were hospital acquired (15, 71%). Sources of bacteraemia were intravascular catheter (n = 11, 52%), digestive tract (n = 6, 29%), drug injection (n = 3, 14%) and wound (n = 1, 5%). Adequate antibiotic therapy was provided to 18 patients (86%) during a median of 17 days (range 2-253 days). The intravascular catheter was removed in eight cases (42%). Three haematologic patients had a complicated course with neurologic complications (meningoencephalitis and cerebral abscesses). Complications appeared to be associated with catheter infection (100% of complicated cases vs. 29% of noncomplicated cases). In conclusion, B. cereus bacteraemia can have a complicated course in a subset of patients, mainly those with haematologic malignancy. Catheter infection may be associated with a worse outcome with frequent neurologic complications

Low sensitivity of qSOFA, SIRS criteria and sepsis definition to identify infected patients at risk of complication in the prehospital setting and at the emergency department triage.

Sepsis is defined as life-threatening organ dysfunction caused by a host response to infection. The quick SOFA (qSOFA) score has been recently proposed as a new bedside clinical score to identify patients with suspected infection at risk of complication (intensive care unit (ICU) admission, in-hospital mortality). The aim of this study was to measure the sensitivity of the qSOFA score, SIRS criteria and sepsis definitions to identify the most serious sepsis cases in the prehospital setting and at the emergency department (ED) triage. We performed a retrospective study of all patients transported by emergency medical services (EMS) to the Lausanne University Hospital (CHUV) over twelve months. All patients with a suspected or proven infection after the ED workup were included. We retrospectively analysed the sensitivity of the qSOFA score (≥2 criteria), SIRS criteria (≥2 clinical criteria) and sepsis definition (SIRS criteria + one sign of organ dysfunction or hypoperfusion) in the pre-hospital setting and at the ED triage as predictors of ICU admission, ICU stay of ≥3 days and early (i.e. 48 h) mortality. No direct comparison between the three tools was attempted. Among 11,411 patients transported to the University hospital, 886 (7.8%) were included. In the pre-hospital setting, the sensitivity of qSOFA reached 36.3% for ICU admission, 17.4% for ICU stay of three days or more and 68.0% for 48 h mortality. The sensitivity of SIRS criteria reached 68.8% for ICU admission, 74.6% for ICU stay of three days or more and 64.0% for 48 h mortality. The sensitivity of sepsis definition did not reach 60% for any outcome. At ED triage, the sensitivity of qSOFA reached 31.2% for ICU admission, 30.5% for ICU stay of ≥3 days and 60.0% for mortality at 48 h. The sensitivity of SIRS criteria reached 58.8% for ICU admission, 57.6% for ICU stay of ≥3 days 80.0% for mortality at 48 h. The sensitivity of sepsis definition reached 60.0% for 48 h mortality. Incidence of sepsis in the ED among patients transported by ambulance was 3.8 percent. This rate, associated to the mortality of sepsis, confirms the necessity to dispose of a test to early identify those patients. The sensitivity performance of all three tools was suboptimal. The qSOFA score, SIRS criteria and sepsis definition have low identification sensitivity in selecting septic patients in the pre-hospital setting or upon arrival in the ED at risk of complication

Bacillus cereus bacteremia with central nervous system involvement: A neuropathological study.

<i>Bacillus cereus</i> is a widely-distributed, gram-positive or variable, rod-shaped bacterium frequently considered a contaminant in clinical specimens. It is recognized as a potential pathogen inducing self-limiting emetic or diarrheal food poisoning or localized infection in immunocompetent patients. True <italic>B. cereus</italic> bacteremia is uncommon and mainly observed in fragile patients, notably in immunocompromised individuals. We report clinical, radiological, and pathological findings of a 64-year-old patient with a history of acute myeloid leukemia who initially presented a fever while neutropenic after the induction of a second cycle of chemotherapy. He developed <italic>B. cereus</italic> bacteremia with invasive infection and a fatal outcome. The clinical and radiological data of this case are compared to a previously-published series of 21 patients from our institution with <italic>B. cereus</italic> bacteremia. This study highlights the clinical challenge to diagnose <italic>B. cereus</italic> and the importance of the delay between the detection of <italic>B. cereus</italic> and the initiation of an effective targeted antibiotic therapy. This case presented an aggressive evolution with multiple necrotic and hemorrhagic foci in the brain. Upon histological examination, <italic>B. cereus</italic> virulence was notably reflected by the dissection of blood vessel walls by the bacilli and luminal occlusion, a pattern that has not been yet reported.


National Early Warning Score (NEWS) Outperforms Quick Sepsis-Related Organ Failure (qSOFA) Score for Early Detection of Sepsis in the Emergency Department.

Prompt recognition of sepsis is critical to improving patients' outcomes. We compared the performance of NEWS and qSOFA scores as sepsis detection tools in patients admitted to the emergency department (ED) with suspicion of sepsis. A single-center 12-month retrospective study comparing NEWS using the recommended cut-off of ≥5 and qSOFA as sepsis screening tools in a cohort of patients transported by emergency medical services (EMS) to the Lausanne University Hospital (LUH). We used the Sepsis-3 consensus definition. The primary study endpoint was the detection of sepsis. Secondary endpoints were ICU admission and 28-day all-cause mortality. Among 886 patients admitted to ED by EMS for suspected infection, 556 (63%) had a complete set of vital parameters panel enabling the calculation of NEWS and qSOFA scores, of whom 300 (54%) had sepsis. For the detection of sepsis, the sensitivity of NEWS > 5 was 86% and that of qSOFA ≥ 2 was 34%. Likewise, the sensitivities of NEWS ≥ 5 for predicting ICU admission and 28-day mortality were higher than those of qSOFA ≥ 2 (82% versus 33% and 88% versus 37%). Conversely, the specificity of qSOFA ≥ 2 for sepsis detection was higher than that of NEWS ≥ 5 (90% versus 55%). The negative predictive value of NEWS > 5 was higher than that of qSOFA ≥ 2 (77% versus 54%), while the positive predictive value of qSOFA ≥ 2 was higher than that of NEWS ≥ 5 (80% versus 69%). Finally, the accuracy of NEWS ≥ 5 was higher than that of qSOFA ≥ 2 (72% versus 60%). The sensitivity of NEWS ≥ 5 was superior to that of qSOFA ≥ 2 to identify patients with sepsis in the ED and predict ICU admission and 28-day mortality. In contrast, qSOFA ≥ 2 had higher specificity and positive predictive values than NEWS ≥ 5 for these three endpoints

L'année 2014 mise en perspective par les internistes hospitaliers [What is new in 2014 for the specialist in hospital internal medicine? The point of view of university hospital chief residents].

The year 2014 was rich in significant advances in all areas of internal medicine. Many of them have an impact on our daily practice and on the way we manage one problem or another. From the use of the ultrasound for the diagnosis of pneumonia to the choice of the site of venous access and the type of line, and the increasing complexity of choosing an oral anticoagulant agent, this selection offers to the readers a brief overview of the major advances. The chief residents in the Service of internal medicine of the Lausanne University hospital are pleased to share their readings