Search

Propionibacterium acnes belongs to the cutaneous flora of humans and is rarely considered a pathogen in human diseases. It is a frequent contaminant in blood cultures; however, in some patients it has been identified as the causative agent of life-threatening infections. Within the last years we have observed an abrupt increase in severe P. acnes infections which prompted us to study in detail the clinical and microbiological features, risk factors, and outcomes of these cases. In a retrospective review of microbiological records of 905 Propionibacterium isolates from a five-year period (1990-95), 70 were identified from 20 patients with clinical and microbiological evidence of a P. acnes infection. The clinical syndromes included endocarditis (7 patients), post-craniotomy infections (6 patients), arthritis and spondylodiscitis (4 patients), endophthalmitis (2 patients) and pansinusitis (1 patient). The predominant predisposing conditions were previous surgery preceding the infection from 2 weeks to 4 years and implantation of foreign bodies such as prosthetic heart valves, intraocular lenses and ventriculo-peritoneal shunts. Therapy consisted of intravenous antibiotics in all cases and surgical procedures to remove infected tissue in eighteen patients. The outcome was favorable in sixteen patients (80 percent) who had a complete recovery. These data confirm the pathogenic potential of P. acnes in late post-surgical infections, in particular after implantation of a foreign body, and suggest a combined therapeutic approach with intravenous antibiotics and surgical removal of the infected tissue.

Infections with varicella zoster virus (VZV) are common viral infections associated with significant morbidity. Diagnosis and management are complex, particularly in immunocompromised patients and during pregnancy. The present recommendations have been established by a multidisciplinary panel of specialists and endorsed by numerous Swiss medical societies involved in the medical care of such patients (Appendix). The aim was to improve the care of affected patients and to reduce complications.

A panel of infectious disease specialists, clinical microbiologists and hospital epidemiologists of the five Swiss university hospitals reviewed the current literature on the treatment of invasive fungal infections in adults and formulated guidelines for the management of patients in Switzerland. For empirical therapy of Candida bloodstream infection, fluconazole is the drug of choice in non-neutropenic patients with no severe sepsis or septic shock or recent exposure to azoles. Amphotericin B deoxycholate or caspofungin would be the treatment option for patients with previous azole exposure. In neutropenic patients, empirical therapy with amphotericin B deoxycholate is considered first choice. In patients with severe sepsis and septic shock, caspofungin is the drug of first choice. For therapy of microbiologically-documented Candida infection, fluconazole is the drug of choice for infections due to C. albicans, C. tropicalis or C. parapsilosis. When infections are caused by C. glabrata or by C. krusei, caspofungin or amphotericin B deoxycholate are first line therapies. Treatment guidelines for invasive aspergillosis (IA) were stratified into primary therapy, salvage therapy and combination therapy in critically ill patients. Voriconazole is recommended for primary (ie upfront) therapy. Caspofungin, voriconazole (if not used for primary therapy) or liposomal amphotericin B are recommended for salvage therapy for refractory disease. Combination therapy with caspofungin plus voriconazole or liposomal amphotericin B should be considered in critically ill patients. Amphotericin B deoxycholate is recommended as initial therapy for the empirical therapy in patients with neutropenia and persistent fever with close monitoring of adverse events.

Candida species are among the most common bloodstream pathogens in the United States, where the emergence of azole-resistant Candida glabrata and Candida krusei are major concerns. Recent comprehensive longitudinal data from Europe are lacking. We conducted a nationwide survey of candidemia during 1991-2000 in 17 university and university-affiliated hospitals representing 79% of all tertiary care hospital beds in Switzerland. The number of transplantations and bloodstream infections increased significantly (P

The incidence of nosocomial infections is one of the most important quality indicators in health care. It increases the economical burden, augments morbidity, lengthens hospital stay, and is associated with a high mortality rate. Infection control programs are designed to minimize such adverse events. An effective infection control program can reduce the incidence of nosocomial infections by over 30%. It is regarded as among the most cost-efficient medical interventions available in modern public health. The national law for health insurance (KVG) makes quality in health care also a legal issue. This law enforces quality assurance on a scientific basis. In Switzerland there are no national guidelines to define the nature and extent of infection control in health care institutions as in many other European countries. In the United States quality standards are part of accreditation of any health care institution. Evaluating scientific evidence and international experience this article provides the rationale for a quality standard for infection control in Swiss hospitals. It features three general rules and five elements of structural quality. The recommendations are: (1) Every hospital must have a system to control nosocomial infection in patients, care givers and visitors. (2) This program consists of defined elements of structural quality. (3) The program is permanently being improved in its quality. The basic elements are: (1) infection control committee, (2) infection control team, (3) guidelines, (4) surveillance, (5) infrastructure. The feasability and impact of this standard has to be evaluated.

The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) among hospitalized patients is relatively high in many European countries. Many patients are still colonized at the time of discharge and contribute to the growing reservoir of MRSA carriers both inside and outside of hospitals and other healthcare facilities such as nursing homes or rehabilitation hospitals, or even population groups in the community [1]. In order to fight the spread of MRSA, some European countries apply the Dutch “search and destroy” policy. This includes the screening of certain risk groups (search) for MRSA colonization and the eradication of MRSA carriage (destroy) by the application of a decolonization protocol [2]. Typically, such a decolonization protocol includes the application of topical mupirocin ointment to both nares and total body washings with chlorhexidine. The success rate of a decolonization cycle is variable and may be quite low in the presence of wound or lower respiratory tract colonization. Many experts agree that the ideal strategy for MRSA decolonization has not yet been found. Some colleagues even argue that decolonization attempts are a waste of time and resources. Thus, the question whether and how to decolonize MRSA carriers currently awaits a definitive answer. The discussion on the topic of MRSA decolonization is now broadened by the study of Wenisch et al. [3], which we publish in this issue of INFECTION. Under the label of “a holistic approach,” the colleagues from Vienna have lined up all the big and little guns to fight MRSA in critically ill patients with MRSA pneumonia and colonization of the respiratory tract and other body sites. Treatment included systemic linezolid and rifampicin, jet-ventilation with vancomycin, body washing with chlorhexidine, nose treatment with mupirocin, care of the tracheostoma exit site, central venous catheter exit site with polyvidoniodide. The study was conducted in a prospective but non-controlled fashion and included 21 patients. Due to the death of seven patients, only 14 were evaluable, including a follow-up of 2 months. Interestingly, all 14 patients were successfully decolonized and remained free of MRSA at the time of follow-up. Obviously, the uncontrolled nature of the study precludes any definitive conclusions. However, these preliminary data should raise the question, whether a more aggressive approach is needed in patients with infection and/or colonization of the respiratory tract. The study may at least be a starting point for a lively discussion of the topic of MRSA decolonization. Maybe, it will also trigger the inception and design of a prospective-controlled study in a subset of critically ill patients with MRSA infection and colonization.

The prevalence of nosocomial infections is higher in intensive care units (ICUs) than in general hospital wards. Catheter-related bloodstream infections, ventilator-associated pneumonias, and surgical site infections cause the majority of these infections, which result in a considerable increase of morbidity, mortality, and cost. Overall length of stay, stay in the ICU, and duration of mechanical ventilation are prolonged among surviving patients. Several studies have shown that the utilization of invasive devices such as venous and urinary catheters, endotracheal tubes, and intracranial pressure monitoring devices is a major risk factor for the development of nosocomial infections in ICU patients. Thus, the incidence of such infections is expressed as number of infections per 1,000 device-utilization days. Early removal of such invasive devices will eliminate the risk of such a device-associated infection. However, the critical condition of many ICU patients often requires the continued use of these catheters, tubes, and drains. Adherence to preventive measures by ICU staff is therefore crucial for a successful risk reduction strategy. It has been shown that teaching the proper technique of catheter insertion and care results in a significant reduction in the incidence of catheter-related bloodstream infections. Implementation of evidence-based infection control measures should be the basis for all additional measures, which could be useful for the prevention of nosocomial infections in the ICU. New technologies such as the coating of catheters and tubes with antibiotics or antiseptics, the use of bacterial filters in breathing circuits, or the use of selective decontamination of the digestive tract might be applied in addition to the standard measures, but should not be used as an excuse for poor compliance with these measures. Intensive care units should receive priority attention from hospital epidemiology units. In addition to good practical advice, surveillance of nosocomial infections allows the quantification of the burden of nosocomial infections in individual units, as well as the discovery and monitoring of antibiotic resistance. This has been nicely demonstrated in two articles that appear in this issue of INFECTION [1, 2]. Continued research efforts will be needed to address the persistent, great problem of nosocomial infections in the ICU, which pose a significant threat to the health of our patients.

Background The increasing incidence of candidemia and emergence of drug-resistant Candida species are major concerns worldwide. Long-term surveillance studies are needed. Methods The Fungal Infection Network of Switzerland (FUNGINOS) conducted a 15-year (2004–2018), nationwide, epidemiological study of candidemia. Hospital-based incidence of candidemia, Candida species distribution, antifungal susceptibility, and consumption were stratified in 3 periods (2004–2008, 2009–2013, 2014–2018). Population-based incidence over the period 2009–2018 derived from the Swiss Antibiotic Resistance Surveillance System (ANRESIS). Results A total of 2273 Candida blood isolates were studied. Population and hospital-based annual incidence of candidemia increased from 2.96 to 4.20/100 000 inhabitants (P = .022) and 0.86 to 0.99/10 000 patient-days (P = .124), respectively. The proportion of Candida albicans decreased significantly from 60% to 53% (P = .0023), whereas Candida glabrata increased from 18% to 27% (P < .0001). Other non-albicans Candida species remained stable. Candida glabrata bloodstream infections occurred predominantly in the age group 18–40 and above 65 years. A higher proportional increase of C glabrata was recorded in wards (18% to 29%, P < .0001) versus intensive care units (19% to 24%, P = .22). According to Clinical and Laboratory Standards Institute, nonsusceptibility to fluconazole in C albicans was observed in 1% of isolates, and anidulafungin and micafungin nonsusceptibility was observed in 2% of C albicans and C glabrata. Fluconazole consumption, the most frequently used antifungal, remained stable, whereas use of mold-active triazoles and echinocandins increased significantly in the last decade (P < .0001). Conclusions Over the 15-year period, the incidence of candidemia increased. A species shift toward C glabrata was recently observed, concurring with increased consumption of mold-active triazoles., The incidence of candidemia increased in Switzerland from 2004 to 2018. A species shift toward C glabrata was observed after 2013, now accounting for one fourth of all candidemia, concurring with increased consumption of mold-active triazoles.

This nation-wide survey on the epidemiology of vancomycin-resistant enterococci (VRE) included 142 healthcare institutions and showed an increasing number of VRE colonizations and infections in Switzerland, probably for the most part due to nosocomial dissemination. The introduction and spread of a new clone, gaps in VRE screening policies as well as heterogeneity regarding the management of VRE clusters may be possible explanations. Electronic supplementary material The online version of this article (10.1186/s13756-019-0466-x) contains supplementary material, which is available to authorized users.

The harmonisation of training programmes for infection control and hospital hygiene (IC/HH) professionals in Europe is a requirement of the Council recommendation on patient safety. The European Centre for Disease Prevention and Control commissioned the ‘Training Infection Control in Europe’ project to develop a consensus on core competencies for IC/HH professionals in the European Union (EU). Core competencies were drafted on the basis of the Improving Patient Safety in Europe (IPSE) project’s core curriculum (CC), evaluated by questionnaire and approved by National Representatives (NRs) for IC/HH training. NRs also re-assessed the status of IC/HH training in European countries in 2010 in comparison with the situation before the IPSE CC in 2006. The IPSE CC had been used to develop or update 28 of 51 IC/HH courses. Only 10 of 33 countries offered training and qualification for IC/ HH doctors and nurses. The proposed core competencies are structured in four areas and 16 professional tasks at junior and senior level. They form a reference for standardisation of IC/HH professional competencies and support recognition of training initiatives., peer-reviewed

We describe an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) among injection drug users (IDUs). From August 1994 through December 1999, we registered 31 IDUs with MRSA infections (12 with soft-tissue infection, 7 with pneumonia [fatal in 1], 7 with endocarditis [fatal in 1], 2 with osteomyelitis, 2 with septic arthritis, and 1 with ulcerative tonsillitis), with a marked increase in the number of IDUs registered during 1998 and 1999. Of 31 patients, 15 (48%) were infected with human immunodeficiency virus. A point-prevalence study among IDUs who frequented outpatient facilities in Zurich revealed an MRSA carriage rate of 10.3% (range, 0%-28.6%) in various facilities. In all but 1 case, pulsed-field gel electrophoresis banding patterns of isolates obtained from these patients were indistinguishable from isolates of the initial 31 IDUs registered. Risk factors for MRSA carriage were disability and prior hospitalization in a hospice. In summary, MRSA became endemic in IDUs in Zurich as a result of the spread of a single clone. This clone caused major morbidity and was responsible for a lethal outcome in 2 cases.

Several community-acquired infections, such as pneumonia, urinary tract infection, and diarrhea, may be associated with bacteremia in a minority of patients. Bacteremia is considered to be a normal variation of the clinical presentation of such infections and, as such, it generally does not change the physician’s approach to therapeutic managment of the infection. However, experienced physicians are clearly aware of the possibility that bacteremia may lead to secondary metastatic complications, such as bacterial arthritis, spondylodiscitis, or endocarditis. Certain pathogens, such as pneumococci, are more frequently associated with such complications than others, such as, for example, Escherichia coli. Good clinical management of these infections requires that the patient be examined at frequent intervals to control the development of such complications and to ensure that the duration of antibiotic therapy is carefully tailored to the clinical course of the specific infection. Although all experienced infectious disease physicians have been confronted earlier or later in their medical career with infections that have taken a lethal course, a significant risk of a lethal outcome is usually not associated with community-acquired bacteremia within our current conceptual framework of these types of infections. The study by Laupland et al. [1] in this issue of Infection provides the reader with a very interesting insight into shortand longterm mortality associated with community-onset bacteremia. The study is based on data on the Calgary Zone complied in the electronic surveillance system database of the Alberta Health Services System. Analysis of this database by the authors revealed that 12% of 2,448 patients died within 28 days following the diagnosis of communityacquired bacteremia and that one quarter of the patients had died by 1 year post-diagnosis. While these rates reflect all-cause case fatality, they seem to be higher than those most clinicians would expect to experience in their daily practice. Not unexpectedly, older age and significant co-morbidities were independently associated with late mortality. In contrast, bacteremia caused by Streptococcus pneumoniae was not associated with late mortality. While this study does not answer the question of whether early appropriate antibiotic therapy reduces both shortand longterm mortality, the data are nevertheless interesting, showing that patients with bacteremia may have an increased risk of dying within 1 year, especially if underlying diseases, older age, prolonged hospitalization, and polymicrobial infection are present as risk factors. These data will most likely not change our diagnostic and therapeutic approach to managing patients with suspected bacteremia, but they will help us to have a more sober outlook regarding the prognosis of patients with community-acquired bacteremia, especially when risk factors are present.

The prescription of antibiotics is a daily occurrence in the outpatient setting and also in hospitals. Ideally, antibiotics are prescribed for bacterial infections that have been definitely diagnosed. Treatment should be based on established guidelines. However, daily practice is far from this ideal. In many instances, an infection is suspected, but not proven and the prescription of an antibiotic is purely empiric. Many times, the decision to prescribe an antibiotic is not a decision of the physician alone. This is particularly the case for situations, which contain a certain measure of uncertainty regarding the etiology and also the severity of symptoms. In such situations, verbalized or non-verbalized expectations of the patients may influence the decision of the physician to prescribe an antibiotic. This interaction between patient and physician is wellknown but not examined in detail. In order to arrive at an informed decision regarding the prescription of antibiotics, physicians should be aware of patient expectations and their potential impact on his or her decision to prescribe an antibiotic. In this issue of INFECTION, You and colleagues report the results of a survey among more than thousand respondents in Hong Kong regarding their knowledge, attitude and behavior regarding antibiotic use [1]. It was interesting to note, that the expectation to receive an antibiotic is particularly prevalent regarding the treatment of symptomatic upper respiratory tract infections. Almost 80% of the respondents reported having received an antibiotic for the treatment of such an infection prior to the survey. Another interesting finding is that 8% of the respondents would share antibiotics with family members. The authors go on to investigate the variables, which may be predictors of a certain behavior or expectation regarding antibiotic use. Overall, this interesting study does shed some light onto the issue of antibiotic prescription and the expectation of patients. The findings are not completely surprising. While they where generated in a geographically distinct area, one would not be surprised to read similar results in a study performed in Europe. The question now is, what to do with these results? If we want to improve the use of antibiotics especially in the treatment of upper respiratory tract infections, it will be crucial to better inform the public about the etiology of these infections, which is mostly viral, and about the lack of a benefit and the potential harm of antibiotic use in these situations.

Zusammenfassung: Mittels Gelenkprothese kann bei Patienten mit arthrotisch oder arthritisch destruierten Gelenken (Hüfte, Knie, Schulter und Ellenbogen) Schmerzfreiheit erreicht und gleichzeitig die Mobilität gesteigert werden. Die Gelenkprotheseninfektion gilt als schwerwiegende, implantatassoziierte Komplikation, welche mit erhöhter Morbidität und Gesundheitskosten einhergeht. Pathogenetisch handelt es sich bei der Gelenkprotheseninfektion um eine Fremdkörperinfektion mit Ausbildung eines Biofilms, was die Diagnose und Therapie erschwert. Low-grade-Infektionen einer Gelenkprothese manifestieren sich häufig in Form einer frühen Prothesenlockerung mit oder ohne persistierende Schmerzen. Klinisch ist somit ein Low-grade-Infekt kaum von einem aseptischen Prothesenversagen zu unterscheiden. Die definitive Diagnose einer Gelenkprotheseninfektion kann meistens erst durch die Kombination verschiedener prä- und intraoperativer Untersuchungen gestellt werden. Durch rheumatologische Grundkrankheiten kann das periprothetische Gewebe entzündlich verändert sein, sodass nur der kulturelle Nachweis des Mikroorganismus eine definitive Diagnose erlaubt. Der Therapieerfolg ist einerseits von einer adäquaten chirurgischen Intervention und andererseits von einer antibiotischen Langzeittherapie abhängig. Letztere sollte eine biofilmaktive Substanz enthalten. In diesem Artikel werden Pathogenese, Epidemiologie, Diagnostik und Therapie einer Gelenkprotheseninfektion diskutiert. Dabei wird der Schwerpunkt auf die diagnostische Abklärung gelegt, zumal diese bei rheumatologischer Grundkrankheit erschwert sein kann

Zusammenfassung: Eine 74-jährige, polymorbide Patientin mit einer rheumatoiden Arthritis erlitt unter Therapie mit Methotrexat und Prednison eine Pneumocystis-jiroveci-Pneumonie (PcP). Eine Therapie mit Bactrim wurde eingeleitet. Trotz nicht mehr nachweisbaren Pneumozysten in einer Bronchiallavage verstarb die Patientin. Die genaue Todesursache blieb unklar. Wie dieses Beispiel zeigt, muss bei immunkompromittierten rheumatologischen Patienten an die Differenzialdiagnose einer PcP gedacht werden. Der typische Verlauf, Diagnose, Prophylaxe und Therapie der PcP bei dieser Patientengruppe werden diskutiert

Staphylococcus aureus with resistance to glycopeptide antibiotics has been considered to be a rare cause of clinically relevant infections. A review of the current literature shows that this is indeed the case for infections caused by S. aureus with high-level resistance to vancomycin (VRSA), as only isolated cases have been reported. VRSA develops following the insertion of the vanA gene, which is transferred from enterococci with vancomycin resistance. On the other hand, infections caused by S. aureus with intermediate resistance to glycopeptides (VISA), or heterogeneously expressed intermediate level glycopeptide resistance (hVISA), are more common. These infections are associated with clinical failure of glycopeptide therapy. While the biochemical and phenotypic features including a thickened cell wall of hVISA and VISA are well known, the genetic basis of these phenotypes remains unknown. Certain genetic regulatory elements such as agr II are associated with reduced susceptibility of S. aureus to glycopeptides. Available data suggest that certain infections might be successfully treated using higher doses of vancomycin. However, as treatment failure is particularly common in infections with a high bacterial load, it may be necessary to resort to other antibiotics such as linezolid, often combined with surgical intervention, in order to successfully treat these infections. Open questions regarding diagnosis, pathogenesis, epidemiology, and treatment of glycopeptide resistance in S. aureus are addressed in this review. Clinicians should be aware of these aspects, since S. aureus remains one of the most important bacteria in modern medicine