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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

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.

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.

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

As the number of implanted joint prostheses of various joints increases, so does the number of episodes of postoperative prosthetic joint infections. The management of such infections is difficult and usually requires a combined approach involving surgical debridement and long-term antibiotic therapy. With this approach, it is possible to retain the prosthesis in many cases, especially in those patients with early diagnosis of the infection [1, 2]. If all goes well, antibiotic treatment can be stopped after 3 months for hip prostheses and 6 months for knee prostheses [1]. The C-reactive protein (CRP) level is routinely measured to assess the response to treatment in addition to clinical assessment. Typically, CRP values return to normal levels during antibiotic treatment. However, in some patients, CRP values may remain elevated. Such a situation usually raises concerns regarding the effectiveness of the chosen antibiotic treatment among treating clinicians. Concerns may even be large enough to result in either an exhaustive diagnostic investigation, at times involving several imaging methods, or the use of surgical exploration to rule out the persistence of infection. Whether or not an elevated CRP should result in an aggressive diagnostic workup is a matter of debate. Undoubtedly, elevated CRP values need a good clinical assessment of the patient, including good medical history and physical examination. In this issue of Infection, Piso and Elke publish their experience of 14 patients with prosthetic joint infections and persistently elevated CRP [3]. The authors adhered to the treatment protocol mentioned above, using surgical debridement and retention of the prosthesis in 11 patients, single-staged reimplantation in one patient, and two-staged reimplantation in two patients. They stopped the antibiotic treatment after the time points mentioned above, even if the CRP levels remained above the upper limit of normal. The patients were followed up for 2 years. Interestingly, in most patients, the CRP value was lower after 2 years than during the treatment phase, but it did not reach normal levels in some patients. In one patient, there was a relapse of infection 5 months after stopping antibiotic treatment. In this case, the second pathogen was not identical to the first isolate. In all other patients, no recurrence of infection occurred within 24 months. While this is a small study, the findings are, nevertheless, interesting. The study highlights that it is not justified launching a diagnostic workup in each patient with a persistently elevated CRP after an adequate duration of antimicrobial therapy if there are no other clinical signs for infection. Of course, this study does not provide the argument for abandoning CRP measurements or ignoring the results of such measurements. It just reminds us that CRP elevation may have a variety of causes, infection being only one of them.

The relatively low rate of adherence to the indications for hand hygiene, despite various efforts in hospitals, is puzzling. Lack of time is frequently cited as a reason not to perform hand hygiene. Another reason is the unavailability of hand disinfectant solution at the bedside of the patient. These issues have been addressed by promoting the use of alcoholic hand rub, which requires less time to apply than soap and water and can be provided at the bedside. Nevertheless, adherence rates are frequently reported to be less than 50%, especially among physicians. For several years now, the World Health Organization (WHO) has been promoting hand hygiene through its First Global Patient Safety Challenge of ‘‘Clean Care is Safer Care’’ [1]. In this issue of Infection, Tai et al. [2] report the results of a multi-center exploratory study in Hong Kong, which investigated the perceptions of nurses and physicians on the topic of healthcare-associated infections and hand hygiene. The study was conducted in four acute care hospitals and the results are based on a total of 1,022 questionnaires. The overall response rate was 59.3%. While knowledge about the importance of healthcareassociated infections and their impact is widespread, the known differences among nurses and physicians in hand hygiene adherence is also reflected in their answers to the questions on the importance of healthcare-associated infections and also on their assessment of the time needed to disinfect hands. Interestingly, nurses and physicians reported a low rate of hand hygiene before direct patient contact. This finding suggests that hand hygiene is more likely to be performed when self-protection is the goal. Variables that influence the attitude towards hand hygiene are the department in which the respondents work, their attitudes, their perceived behavioral control, and also subjective norms. Several other studies have also found that subjective norms are the most important cognitive factor with an influence on hand hygiene behavior. However, as other factors such as department assignment, attitudes, and perceived behavioral control are also important, a multi-module and multi-facet approach will be needed in order to be successful in improving the compliance of healthcare workers with hand hygiene. The study by Tai et al. provides useful and important information to better understand the issue. The best strategy to make a big leap forward on this issue still remains to be found.