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Objective: To compare the management of invasive candidiasis between infectious disease and critical care specialists. Design and setting: Clinical case scenarios of invasive candidiasis were presented during interactive sessions at national specialty meetings. Participants responded to questions using an anonymous electronic voting system. Patients and participants: Sixty-five infectious disease and 51 critical care physicians in Switzerland. Results: Critical care specialists were more likely to ask advice from a colleague with expertise in the field of fungal infections to treat Candida glabrata (19.5% vs. 3.5%) and C. krusei (36.4% vs. 3.3%) candidemia. Most participants reported that they would change or remove a central venous catheter in the presence of candidemia, but 77.1% of critical care specialists would start concomitant antifungal treatment, compared to only 50% of infectious disease specialists. Similarly, more critical care specialists would start antifungal prophylaxis when Candida spp. are isolated from the peritonal fluid at time of surgery for peritonitis resulting from bowel perforation (22.2% vs. 7.2%). The two groups equally considered Candida spp. as pathogens in tertiary peritonitis, but critical care specialists would more frequently use amphotericin B than fluconazole, caspofungin, or voriconazole. In mechanically ventilated patients the isolation of 104 Candida spp. from a bronchoalveolar lavage was considered a colonizing organism by 94.9% of infectious disease, compared to 46.8% of critical care specialists, with a marked difference in the use of antifungal agents (5.1% vs. 51%). Conclusions: These data highlight differences between management approaches for candidiasis in two groups of specialists, particularly in the reported use of antifungals

Low-grade infection was systematically searched for in all revision shoulder surgeries by harvesting tissue samples. Ten consecutive patients were identified with a non-purulent low-grade infection of the shoulder. All of these patients suffered from pain and eight were stiff. Preoperative aspiration in eight patients yielded bacterial growth in only one case. Serum C-reactive protein levels were normal in seven out of 10 cases. Propionibacterium acnes was identified in seven, coagulase-negative Staphylococcus in two and Staphylococcus saccharolyticus in one case. The delay between harvesting the tissue samples and detection of bacterial growth averaged eight days (range, 2-17). After debridement and antibiotic treatment for a mean of 4.5 months, tissue samples were repeatedly harvested in nine patients due to persistent pain. The infection was microbiologically eradicated in six out of nine cases that had a repeated biopsy. However, nine out of 10 patients continued to suffer from moderate to severe pain. Low-grade infection of the shoulder can be a cause of persistent pain and stiffness. The results of antibiotic treatment are disappointing. Further studies are necessary to analyse this difficult pathology

Background: Antimicrobial resistance may compromise the efficacy of antibiotic prophylaxis before surgery. The aim of this study was to measure susceptibility and clonal distribution of coagulase-negative staphylococci (CoNS) colonizing the skin around the surgery access site before and after the procedure. Methods: From March to September 2004, a series of 140 patients undergoing elective major abdominal surgery were screened for CoNS colonization at admission and 5days after surgery. All isolates were tested for antibiotic susceptibility and genotyped by pulsed-field gel electrophoresis (PFGE). Results: Colonization rates with CoNS at admission and after surgery were 85% and 55%, respectively. The methicillin-resistant CoNS rate increased from 20% at admission to 47% after surgery (P=0.001). The PFGE pattern after surgery revealed more patients colonized with identical clones: 8/140 patients (8/119 strains) and 26/140 patients (26/77 strains), respectively (P<0.001). Conclusions: Our results suggest rapid recolonization of disinfected skin by resistant nosocomial CoNS. Larger studies, preferably among orthopedic or cardiovascular patients, are required to clarify whether standard antibiotic prophylaxis with first- or second-generation cephalosporins for CoNS infections may be compromised if the patient requires an additional intervention 5days or more after the initial surgery

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 < .001). A total of 1137 episodes of candidemia were observed: Candida species ranked seventh among etiologic agents (2.9% of all bloodstream isolates). The incidence of candidemia was stable over a 10-year period. C. albicans remained the predominant Candida species recovered (66%), followed by C. glabrata (15%). Candida tropicalis emerged (9%), the incidence of Candida parapsilosis decreased (1%), and recovery of C. krusei remained rare (2%). Fluconazole consumption increased significantly (P < .001). Despite increasing high-risk activities, the incidence of candidemia remained unchanged, and no shift to resistant species occurred

Background To compare the quantitative antibiotic use between hospitals or hospital units and to explore differences, adjustment for severity of illness of hospitalized patients is essential. The case mix index (CMI) is an economic surrogate marker (i.e. the total cost weights of all inpatients per a defined time period divided by the number of admissions) to describe the average patients' morbidity of individual hospitals. We aimed to investigate the correlation between CMI and hospital antibiotic use. Methods We used weighted linear regression analysis to evaluate the correlation between in-hospital antibiotic use in 2006 and CMI of 18 departments of the tertiary care University Hospital Zurich and of 10 primary and 2 secondary acute care hospitals in the Canton of Zurich in Switzerland. Results Antibiotic use varied substantially between different departments of the university hospital [defined daily doses (DDD)/100 bed-days, 68.04; range, 20.97-323.37] and between primary and secondary care hospitals (range of DDD/100 bed-days, 15.45-57.05). Antibiotic use of university hospital departments and the different hospitals, respectively, correlated with CMI when calculated in DDD/100 bed-days [coefficient of determination (R2), 0.57 (P = 0.0002) and 0.46 (P = 0.0065)], as well as when calculated in DDD/100 admissions [R2, 0.48 (P = 0.0008) and 0.85 (P < 0.0001), respectively]. Conclusions Antibiotic use correlated with CMI across various specialties of a university hospital and across different acute care hospitals. For benchmarking antibiotic use within and across hospitals, adjustment for CMI may be a useful tool in order to take into account the differences in hospital category and patients' morbidities

Objective: To determine the prevalence and risk factors for nosocomial infections (NIs) in four Swiss university hospitals. Design and Setting: A 1-week period-prevalence survey conducted in May 1996 in medical, surgical, and intensive-care wards of four Swiss university hospitals (900-1,500 beds). Centers for Disease Control and Prevention definitions were used, except that asymptomatic bacteriuria was not categorized as NI. Study variables included patient demographics, primary diagnosis, comorbidities, exposure to medical and surgical risk factors, and use of antimicrobials. Risk factors for NIs were determined using logistic regression with adjustment for length of hospital stay, study center, device use, and patients' comorbidities. Results: 176 NI were recorded in 156 of 1,349 screened patients (11.6%; interhospital range, 9.8%-13.5%). The most frequent NI was surgical-site infection (53; 30%), followed by urinary tract infection (39; 22%), lower respiratory tract infection (27; 15%), and bloodstream infection (23; 13%). Prevalence of NI was higher in critical-care units (25%) than in medical (9%) and surgical wards (12%). Overall, 65% of NIs were culture-proven; the leading pathogens were Enterobacteriaceae (44; 28%), Staphylococcus aureus (20; 13%), Pseudomonas aeruginosa (17; 11%), and Candida species (16; 10%). Independent risk factors for NI were central venous catheter (CVC) use (odds ratio [OR], 3.35; 95% confidence interval [CI95], 2.91-3.80), admission to intensive care (OR, 1.75; CI95, 1.30-2.21), emergency admission (OR, 1.57; CI95, 1.15-2.00), impaired functional status (Karnofsky index 1-4: OR, 2.56; CI95, 1.95-3.17), and McCabe classification of ultimately fatal (OR, 2.50; CI95, 2.04-2.96) or rapidly fatal (OR 2.25; CI95,1.52-2.98) underlying condition. Conclusions: According to the results of this survey, NIs are frequent in Swiss university hospitals. This investigation confirms the importance of CVCs as a major risk factor for NI. Pat

We analyzed surgically resected endocardial specimens from 49 patients by broad-range PCR. PCR results were compared with (1) results of previous blood cultures, (2) results of culture and Gram staining of resected specimens, and (3) clinical data (Duke criteria). Molecular analyses of resected specimens and previous blood cultures showed good overall agreement. However, in 18% of patients with sterile blood cultures, bacterial DNA was found in the resected materials. When data from patients with definite or rejected cases of infective endocarditis (IE) were included, the sensitivity, specificity, and positive and negative predictive values of broad-range PCR were 82.6%, 100%, 100%, and 76.5%, respectively, overall, and 94.1%, 100%, 100%, and 90%, for cases of native valve endocarditis. The sensitivity, specificity, and positive and negative predictive values of culture of resected specimens from patients with native valve endocarditis were 17.6%, 88.9%, 75%, and 36.4%. We recommend broad-range PCR of surgically resected endocardial material in cases of possible IE, in cases of suspected IE in which blood cultures are sterile, and in cases in which organisms grow in blood cultures but only Duke minor criteria are met. We propose to add molecular techniques to the pathologic criteria of the Duke classification scheme

Objective: Assessment of the distribution of tasks and consultations provided by the hospital epidemiologist (HE) at University Hospital of Zurich (UHZ). Design: Prospective collection of data on hospital epidemiology consultations over a 3-year period (1995-1997). Time spent per consultation and activities of infection control practitioners were not recorded. Setting: A 1,040-bed tertiary-care university hospital in Zurich, Switzerland. Results: Between January 1, 1995, and December 31, 1997, the HE received 1,660 requests for consultation. Advice or action was sought in the following areas: epidemiology (27.5% of requests); quality assurance, including antibiotic utilization and technology assessment (24.8%); infection control and practice guidelines (22.5%); disinfection and sterilization (11.6%); clinical infectious diseases (13.4%). During 1997, 35% of epidemiology consults were related to methicillin-resistant Staphylococcus aureus and 5.8% to tuberculosis. Public or private hospitals not affiliated with UHZ requested 40% of all consults. Conclusions: This study shows that HEs are involved in many different activities. Only 27.5% of hospital epidemiology consultations were directly related to issues of epidemiology. Practical knowledge of the methodologies for continuous quality improvement and assessment of various new technologies is important for HEs. The results of this study may be useful in discussions between HEs and administrators about allocation of resources or issues of reimbursement

Background Empirical antibiotic therapy is based on patients' characteristics and antimicrobial susceptibility data. Hospital-wide cumulative antibiograms may not sufficiently support informed decision-making for optimal treatment of hospitalized patients. Methods We studied different approaches to analysing antimicrobial susceptibility rates (SRs) of all diagnostic bacterial isolates collected from patients hospitalized between July 2005 and June 2007 at the University Hospital in Zurich, Switzerland. We compared stratification for unit-specific, specimen type-specific (blood, urinary, respiratory versus all specimens) and isolate sequence-specific (first, follow-up versus all isolates) data with hospital-wide cumulative antibiograms, and studied changes of mean SR during the course of hospitalization. Results A total of 16 281 isolates (7965 first, 1201 follow-up and 7115 repeat isolates) were tested. We found relevant differences in SRs across different hospital departments. Mean SRs of Escherichia coli to ciprofloxacin ranged between 64.5% and 95.1% in various departments, and mean SRs of Pseudomonas aeruginosa to imipenem and meropenem ranged from 54.2% to 100% and 80.4% to 100%, respectively. Compared with hospital cumulative antibiograms, lower SRs were observed in intensive care unit specimens, follow-up isolates and isolates causing nosocomial infections (except for Staphylococcus aureus). Decreasing SRs were observed in first isolates of coagulase-negative staphylococci with increasing interval between hospital admission and specimen collection. Isolates from different anatomical sites showed variations in SRs. Conclusions We recommend the reporting of unit-specific rather than hospital-wide cumulative antibiograms. Decreasing antimicrobial susceptibility during hospitalization and variations in SRs in isolates from different anatomical sites should be taken into account when selecting empirical antibiotic treatment

Background Clostridium difficile infection (CDI) remains a major health problem worldwide. Antibiotic use, in general, and clindamycin and ciprofloxacin, in particular, have been implicated in the pathogenesis of CDI. Here, we hypothesized that antibiotics that are highly active in vitro against C. difficile are less frequently associated with CDI than others. The primary goals of our study were to determine if antibiotic susceptibility and CDI are associated and whether the antimicrobial susceptibility of C. difficile changed over the years.Methods and resultsWe examined a large panel of C. difficile strains collected in 2006¿2008 at the University Hospital of Zurich. We found that the antimicrobial susceptibilities to amoxicillin/clavulanate, piperacillin/tazobactam, meropenem, clindamycin, ciprofloxacin, ceftriaxone, metronidazole and vancomycin were similar to those reported in the literature and that they are similar to those reported in other populations over the last two decades. Antibiotic activity did not prevent CDI. For example, thre use of meropenem, which is highly active against all strains tested, was a clear risk factor for CDI. Most of the antibiotics tested also showed a higher minimum inhibitory concentration distribution than that of EUCAST. All strains were susceptible to metronidazole. One strain was resistant to vancomycin.ConclusionsAntibiotic susceptibilities of the collection of C. difficile from the University Hospital of Zurich are similar to those reported by others since the 1980. Patients treated with carbapenems and cephalosporins had the highest risk of developing CDI irrespective of the antimicrobial activity of carbapenems.