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The article focuses on a study which investigated if procalcitonin (PCT) algorithm can reduce antibiotic exposure without increasing the risk for adverse events. The study included 1,359 patients, who were diagnosed with lower respiratory tract infections (LRTI) from the emergency departments of six tertiary care hospitals in Switzerland from October 2006 to March 2008. Study participants were randomly selected to receive antibiotics based on PCT algorithm or based on standard guidelines. The study found that PCT guidance offered lower rates of antibiotic exposure and adverse effects compared to standard guidance.

Background: Lower respiratory tract infections like acute bronchitis, exacerbated chronic obstructive pulmonary disease and community-acquired pneumonia are often unnecessarily treated with antibiotics, mainly because of physicians' difficulties to distinguish viral from bacterial cause and to estimate disease-severity. The goal of this trial is to compare medical outcomes, use of antibiotics and hospital resources in a strategy based on enforced evidence-based guidelines versus procalcitonin guided antibiotic therapy in patients with lower respiratory tract infections. Methods and design: We describe a prospective randomized controlled non-inferiority trial with an open intervention. We aim to randomize over a fixed recruitment period of 18 months a minimal number of 1002 patients from 6 hospitals in Switzerland. Patients must be >18 years of age with a lower respiratory tract infections <28 days of duration. Patients with no informed consent, not fluent in German, a previous hospital stay within 14 days, severe immunosuppression or chronic infection, intravenous drug use or a terminal condition are excluded. Randomization to either guidelines-enforced management or procalcitonin-guided antibiotic therapy is stratified by centre and type of lower respiratory tract infections. During hospitalization, all patients are reassessed at days 3, 5, 7 and at the day of discharge. After 30 and 180 days, structured phone interviews by blinded medical students are conducted. Depending on the randomization allocation, initiation and discontinuation of antibiotics is encouraged or discouraged based on evidence-based guidelines or procalcitonin cut off ranges, respectively. The primary endpoint is the risk of combined disease-specific failure after 30 days. Secondary outcomes are antibiotic exposure, side effects from antibiotics, rate and duration of hospitalization, time to clinical stability, disease activity scores and cost effectiveness. The study hypothesis is that procalcitonin-guidance is non-inferior (i.e., at worst a 7.5% higher combined failure rate) to the management with enforced guidelines, but is associated with a reduced total antibiotic use and length of hospital stay. Discussion: Use of and prolonged exposure to antibiotics in lower respiratory tract infections is high. The proposed trial investigates whether procalcitonin-guidance may safely reduce antibiotic consumption along with reductions in hospitalization costs and antibiotic resistance. It will additionally generate insights for improved prognostic assessment of patients with lower respiratory tract infections. [ABSTRACT FROM AUTHOR]

Tick-borne encephalitis (TBE) is a viral infection that may cause irreversible damage to the brain and even result in death. No specific therapy exists. Active immunization is of major importance in controlling the infection. Vaccination is recommended to all adults and children > 6 years who live in endemic areas. Two inactivated vaccines are available in Switzerland. The vaccination schedule includes a basic immunization composed of 3 injections followed by boosting every 10 years. The efficacy of the vaccines has never been investigated in controlled studies, however, from indirect evidence, the vaccines are thought to cause good protection and to be safe. Local reactions at the injections site may occur in one third and mild systemic side effects in one fifth of vaccinees. Anaphylactic reactions and severe central nervous side effects are very rare.

Principles: Reimbursement for inpatient treatment in Switzerland is in transition. While hospitals in some cantons already use Diagnosis Related Groups (DRG) based systems for hospital financing, others use fee-for-service (FFS) based systems, a situation that provides the opportunity to perform a head-to-head comparison between the two reimbursement systems. The aim of this analysis was to compare reimbursement systems with regard to length of hospital stay (LOS) and patient outcomes in a cohort of community-acquired pneumonia patients from a previous prospective multicentre study in Switzerland., Methods: This is a post-hoc analysis of 925 patients with community-acquired pneumonia from a previous randomised-controlled trial. We calculated multivariate regression models adjusted for age, gender, comorbidities and severity of illness (using the Pneumonia Severity Index) and accounting for clustering within hospitals to compare LOS and outcomes between FFS (n = 4) or DRG hospitals (n = 2)., Results: LOS in DRG hospitals was significantly shorter compared to FFS hospitals (8.4 vs 10.3 days, absolute difference 1.9 days [95%CI 0.8-3.1]). This was confirmed in multivariate adjusted Cox models (hazard ratio 1.2 [95% 1.1-1.3]). There were no differences in 30-day and 18-month mortality rates (adjusted odds ratio 1.7 [95% 0.9-3.2] and 1.3 [95% 0.9-1.9]) or recurrence rates within 30 days (adjusted odds ratio 0.8 [95% 0.4-1.7]). Also, no differences were found in the rate of still ongoing clinical symptoms at 30 days, satisfaction with the discharge process and quality of life measures at 30 days of follow-up., Conclusions: This study focusing on community-acquired pneumonia patients with different severities found a 20% shorter LOS in hospitals with DRG financing compared to FFS hospitals without apparent harmful effects on patient outcomes, satisfaction with care and different quality of life measures. Further studies are required to validate these findings for other medical and surgical patient populations.

We report the history of a religion teacher who was hospitalized in December 2009 during the H1N1 outbreak at our hospital. The 62-year-old man presented in the emergency room with malaise, high fevers and dyspnea. Relevant findings included rales over both lungs, an elevated CRP and a chest x-ray with bilateral interstitial infiltrates suggesting a H1N1 pneumonia. His comorbidities included coronary and hypertensive heart disease, diabetes mellitus Type 2 and chronic renal insufficiency. Although H1N1 virus was not detected by PCR in the nasopharyngeal swabs, Oseltamivir 2 × 75 mg/die was begun and continued for 4 days. His breathing and general condition improved markedly. However, a delirium with psychotic and paranoid symptoms developed which persisted after discharge at home. There, they almost led to a catastrophic event. Although the infection could have been the cause of the delirious state, we propose that it was caused by Oseltamivir. Neuropsychiatric symptoms have been reported in case reports with Oseltamivir, however, this side effect was not specifically investigated when the drug was evaluated.

Introduction: Measurement of prohormones representing different pathophysiological pathways could enhance risk stratification in patients with community-acquired pneumonia (CAP) and other lower respiratory tract infections (LRTI)., Methods: We assessed clinical parameters and five biomarkers, the precursor levels of adrenomedullin (ADM), endothelin-1 (ET1), atrial-natriuretic peptide (ANP), anti-diuretic hormone (copeptin), and procalcitonin in patients with LRTI and CAP enrolled in the multicenter ProHOSP study. We compared the prognostic accuracy of these biomarkers with the pneumonia severity index (PSI) and CURB65 (Confusion, Urea, Respiratory rate, Blood pressure, Age 65) score to predict serious complications defined as death, ICU admission and disease-specific complications using receiver operating curves (ROC) and reclassification methods., Results: During the 30 days of follow-up, 134 serious complications occurred in 925 (14.5%) patients with CAP. Both PSI and CURB65 overestimated the observed mortality (X2 goodness of fit test: P = 0.003 and 0.01). ProADM or proET1 alone had stronger discriminatory powers than the PSI or CURB65 score or any of either score components to predict serious complications. Adding proADM alone (or all five biomarkers jointly) to the PSI and CURB65 scores, significantly increased the area under the curve (AUC) for PSI from 0.69 to 0.75, and for CURB65 from 0.66 to 0.73 (P < 0.001, for both scores). Reclassification methods also established highly significant improvement (P < 0.001) for models with biomarkers if clinical covariates were more flexibly adjusted for. The developed prediction models with biomarkers extrapolated well if evaluated in 434 patients with non-CAP LRTIs., Conclusions: Five biomarkers from distinct biologic pathways were strong and specific predictors for short-term adverse outcome and improved clinical risk scores in CAP and non-pneumonic LRTI. Intervention studies are warranted to show whether an improved risk prognostication with biomarkers translates into a better clinical management and superior allocation of health care resources., Trial Registration: NCT00350987.

Background: Despite remarkable progress in modern laboratory testing and imaging technology in recent years, diagnostic errors still occur. To assess whether diagnostic performance in a primary referral hospital improves with new diagnostic tools and algorithms, autopsy reports were analyzed over a ten-year period to monitor diagnostic errors., Methods: Medical reports from 1997 to 2006 were compared retrospectively with autopsy reports. A diagnostic error was assumed when the main clinical diagnosis was missed, independently of whether this influenced the patient's survival or whether this error led to incorrect treatment without effect on survival. Two cardiovascular markers with high sensitivity, namely cardiac troponin T and D-dimer testing and two algorithms for thoracic pain and thromboembolic disease were introduced during the study period., Results: 970 cases were included; the autopsy rate was 50.1%. Cardiovascular diseases were misdiagnosed in 18.7%, followed by infectious diseases in 12.9%, oncological 3.6% and neurological diseases in 1.8%. The most commonly missed diagnoses were myocardial infarction, pulmonary embolism and aortic dissection; however, the rate of errors for cardiovascular diseases decreased over the 10 years (p<0.002). Overall diagnostic sensitivity and specificity rose from 67% to 87% and from 94% to 99%, respectively., Conclusion: Autopsy remains a valuable tool to measure diagnostic performance. Errors occur most frequently in cardiovascular events, whereas in malignant and neurological diseases they are rare. The significant improvement of diagnostic accuracy for cardiovascular diseases is associated with the introduction of new sensitive laboratory tests and algorithms for thoracic pain and thromboembolic diseases.