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Experts as well as national and international public health organizations or government agencies are agreeing on their prognosis that an influenza pandemic is likely to occur in the near future. As the majority of patients will need to be treated as outpatients, physicians in primary care will play an essential role in dealing with the health impact of such a pandemic in Switzerland. It will be necessary, that patients with influenza-like illnesses will be diagnosed and treated in a standardized fashion during this pandemic. The influenza pandemic preparedness plan of the federal office of public health provides important information in that regard. In addition to the standardized clinical management of patients, the implementation of infection control measures in the physician's office will also be of major importance. The goal of these infection control measures is to protect other patients from contracting influenza while visiting the physician's office. Furthermore, healthcare workers as well as the owner of the physician's office must be protected. Infection control measures include the antiviral prophylaxis with oseltamivir during the duration of the pandemic, the use of appropriate face masks to prevent droplet transmission during patient contact and the targeted use of disinfection to prevent contact transmission of the influenza virus in the office of the general practitioner In order to implement both clinical and infection control measures during this predictable hectic time of the pandemic, it is advisable to prepare some of these measures in advance.

Antibiotic resistance of microorganisms that cause infections of the urogenital tract is a clinically relevant problem in obstetrics and gynecology. Due to methodological difficulties, resistance testing is rarely used for the management of these infections. Therefore, solid epidemiological data on resistance rates of most involved pathogens are scarce. Antibiotic resistance of several microorganisms appears to be increasing in various areas of the world, mainly Trichomonas vaginalis and Gardnerella vaginalis (metronidazole),Streptococcus agalactiae (macrolides, clindamycin), Mycoplasma hominis (tetracyclines, intrinsically macrolide resistant). In addition,isolated cases of clinical infections caused by multi-resistant Chlamydia trachomatis have been reported. The presence of antibiotic resistance should therefore be considered in patients with an unfavorable course despite adequate antibiotic therapy. In light of the growing problem of antibiotic resistance and the large gaps in our knowledge in this particular area, research efforts in the field of anti-biotic resistance in gynecological infections should be markedly intensified.

The management of patients with community-acquired pneumonia confronts the practicing physician with the requirement to make two principal decisions. The first decision is on the site of treatment of this infection. The options are to either treat the patient as an outpatient or to hospitalize the patient. The second decision concerns the selection of an appropriate antimicrobial agent. Over the course of the last five years, a prediction rule was developed and validated in the U.S., which allows to accurately identify those patients that carry a low risk for the development of complications of their infections. Hence, these patients can safely be managed as outpatients. On the other hand, patients with high scores (risk classes III-V) should be hospitalized and at least initially managed as inpatients. The calculation of this score requires the collection of a substantial number of parameters. However, good clinical practice requires the evaluation of most of this parameters. Therefore, the additional work resulting from the calculation of this score is moderate and certainly justifiable. Details of the prediction rule according to Fine et al. are presented in this article. Several guidelines exist for the empiric antibiotic treatment of patients with community-acquired pneumonia. Some key recommendations are influenced by the aggravating problem of antibiotic resistance in the U.S. The situation in Switzerland differs from the American situation and therefore recommendations in this article reflect this difference. In daily clinical practice it is somewhat rare to know the microbiological etiology of the individual episode of community-acquired pneumonia with certainty. Therefore, antibiotic treatment is started empirically and also continued empirically in most cases.

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 value of the PCR for CMV in the CSF was evaluated. 23 samples from 20 patients were examined for CMV DNA, of which 11 were positive and 12 were negative for CMV. The clinical spectrum of the patients with positive samples included encephalitis, encephalitis, and polyradiculopathy, or isolated polyradiculopathy. The main symptoms were fever, confusion, lethargy, cognitive disturbance, cranial neuropathy, weakness of the legs, and incontinence. The laboratory evaluation showed a low CD4 lymphocyte count, a slightly increased blood sedimentation rate and a large variation of CSF patterns. The CMV early antigen tests were negative in all cases. In 4 cases the neuroradiological examination was compatible with CMV infection. 8 patients were treated with ganciclovir or foscarnet. Improvement of symptoms was observed in 2 cases and stabilization in 2 others. However, the CMV infection was rapidly progressive and 9 out of 10 patients died after a mean of 53 days after diagnosis.

Case notes of 722 HIV-infected patients who had died between March 1986 and August 1993 were analysed to evaluate the prevention and characteristic features of sinusitis associated with HIV infection. In 73 patients (10%) sinusitis had been diagnosed at least once on the basis of radiological or clear-cut clinical criteria. In addition, 15 patients with sinusitis were identified among those attending an HIV out-patient clinic. There were altogether 126 episodes of sinusitis in 88 patients (62 men, 26 women; mean age 33 [19-69] years). In 62 patients the CD4 lymphocyte count was under 100/microliters. The most commonly affected site was the maxillary sinuses. Patients with mirror formation had a significantly longer duration of illness than those without (P = 0.021). In 58 patients the symptoms of fever, headache and rhinitis were predominantly caused by the sinusitis, in 49 only partially so, and in 19 sinusitis was a chance diagnosis. In 10 of 49 attacks of sinusitis the concurrent disease (e.g. cerebral toxoplasmosis, malignant non-Hodgkin lymphoma) had not been recognized by the referring doctor. There were 1-5 recurrences over an observation period of 11.8 (0-72) months in 23 patients.-These findings show that sinusitis frequently occurs in HIV-infected patients, takes a protracted course and is difficult to distinguish from concomitant diseases by its clinical presentation. If symptoms persist, possible concurrent respiratory infection or CNS involvement must be looked for. Sinus needle aspiration is of decisive importance to ascertain the causative organism.

Encephalitis is the result of focal or global inflammation of the brain caused by invasion of the brain parenchyma by viruses, bacteria, parasites or fungi. In addition, postinfectious encephalitis may result from immunological processes as a consequence of preceding viral infections such as measles. For most forms of viral encephalitis no specific therapy is available. Herpes simplex encephalitis may be diagnosed using modern laboratory techniques for detection of viral DNA without the need for brain biopsy. Herpes simplex encephalitis responds well to treatment with acyclovir, as does encephalitis caused by varicella-zoster virus, which typically occurs following cutaneous herpes zoster involving dermatomal distributions of the trigeminal nerve. In immunocompromised hosts many etiologies of encephalitis need to be considered. It is important to arrive at a precise diagnosis in order to choose appropriate therapeutic agents directed toward treatable pathogens such as Toxoplasma gondii and cytomegalovirus.

The clinical presentation of a 38-year-old female patient with acute onset of fever and decreased level of consciousness is described. The clinical reasoning concerning differential diagnosis, therapeutic options, workup of the patient and possible bacterial etiologies, which is usually part of the physician's initial encounter with the patient, is included in the case presentation. This summary of a workshop offers a concise review of clinical aspects of bacterial meningitis.

Multidrug-resistant M. tuberculosis in HIV-infected people has not yet been reported in Switzerland, and there have been no nosocomial epidemics as they have recently occurred in the USA. We present the case of a 38-ear-old HIV-infected man who developed disseminated tuberculosis as AIDS-defining disease. Initially he was treated with isoniazid, pyrazinamide and rifampin. Due to the emergence of resistance to isoniazid and streptomycin, ethambutol was added for one month. Later the therapy was changed back to the initial three drugs. The patient responded well to this therapy, but five months later developed a relapse. In addition to the originally diagnosed double-drug resistance, a reduced susceptibility to rifampin appeared. Ethambutol, ciprofloxacin and amikacin were added to the original three-drug regimen. This resulted in rapid clinical improvement, although sputum cultures remained positive for M. tuberculosis two months later. This isolate was resistant to pyrazinamide. For that reason pyrazinamide was replaced by clofazimine. 14 months after diagnosis the patient died of hepatic failure. Because there was a delay in isolation of one week, 37 potentially exposed health care workers were tested by the Mantoux skin test. No conversions were observed. This case report demonstrates that tuberculosis in HIV-infected patients in Switzerland may be caused by multidrug-resistant M. tuberculosis. We propose that until the results of a susceptibility assay are known, a four-drug combination should be used initially in this patient group.

Whereas the diagnosis of community-acquired pneumonia usually is straightforward, in many cases the exact etiology is difficult or impossible to determine. The clinician must have a management strategy for this illness which is not dependent upon precise microbiological diagnosis in each case. Therefore, understanding of the spectrum of community-acquired pneumonias and awareness of the possible pathogens in specific clinical settings is crucial for the choice of the most appropriate antimicrobial therapy. The factors influencing prognosis of community-acquired pneumonia are important for the decision as to which patients should be hospitalized.

Leukopenia or pancytopenia as a result of bone marrow dysfunction are manifestations of various diseases or complications of therapeutic regimens. The spectrum of diseases associated with leukopenia is wide and includes congenital as well as acquired neutropenias secondary to conditions such as myelodysplastic syndromes, AIDS, malignant tumors with or without chemotherapy-enhanced neutropenia, bone marrow transplantation or therapeutic or accidental radiation. The morbidity and mortality of infectious diseases is greatly enhanced during neutropenic phases. Over the last few years attempts have been made to shorten the duration and lessen the severity of neutropenia in patients with the above conditions by administration of Granulocyte Macrophage Colony Stimulating Factor (G-CSF). Both cytokines were successfully tested in phase I and II trials. Treatment with GM-CSF or G-CSF results in a dose-dependent increase of the neutrophil count. GM-CSF also increases the number of eosinophils and monocytes in peripheral blood. The effect of both cytokines on the neutrophil count is transient as long as the underlying disease persists. This prompted the institution of maintenance therapy, which has been successfully used with either cytokine. Long-term treatment is usually well tolerated and results in a reduction in the frequency of infections as well as in the duration of antibiotic treatments. Side effects of GM-CSF or G-CSF are usually mild and include fever, myalgia, bone pain, and erythema. A number of patients developed dyspnea, hypotension, sweating, flushing and erythema after the first dose of GM-CSF in each treatment cycle. This first-dose reaction occurs more frequently after intravenous than reactions were reported with G-CSF. Some patients with myelodysplastic syndrome progressed to acute myeloic leukemia during or after treatment with GM-CSF or G-CSF. Most of these patients presented with an increased fraction of blasts in the bone marrow, which preceded the treatment with the colony stimulating factors. Since GM-CSF and possibly G-CSF may increase the risk of developing acute leukemia in patients with myelodysplastic syndrome, it appears prudent to limit the use of these cytokines in patients with this disease. The subcutaneous route of administration appears to be preferable to intravenous administration, since the incidence and severity of side effects are reduced. While many questions concerning dosage, long-term therapy and combination therapy still remain unanswered, the information presented in this review concerning the clinical use of these cytokines warrants an optimistic outlook.

A case of Campylobacter jejuni meningitis with associated septicemia and positive stool culture in a normal host is presented. Clinical findings, course of the illness and serologic data are compared with data from the literature. The possibility of infection due to a serum-resistant strain of Campylobacter jejuni is raised. Retrospective analysis of immunity revealed normal humoral and cellular immunity in a healthy patient one year later.