Development of primary malignant melanoma during treatment with a TNF-α antagonist for severe Crohn's disease: a case report and review of the hypothetical association between TNF-α blockers and cancer.

It is recognized that immunosuppression may lead to reduced immune surveillance and tumor formation. Because of the immunosuppressive properties of tumor necrosis factor (TNF)-alpha (TNF-α) antagonists, it is plausible that these biologics may increase the risk of the occurrence of malignancies or the reactivation of latent malignancies. TNF-α antagonists have gained momentum in the field of dermatology for treating rheumatoid arthritis and psoriasis, and they have revolutionized the treatment of other inflammatory autoimmune diseases such as refractory Crohn's disease. However, there is accumulating evidence that TNF-α inhibitors slightly increase the risk of cancer, including malignant melanoma (MM). The authors herein report the case of a 54-year-old female patient who developed a primary MM during treatment with adalimumab for severe Crohn's disease resistant to successive medical therapies. The patient had been receiving this TNF-α blocker therapy for 3 years before the occurrence of MM. After wide surgical excision of the lesion and staging (based on Breslow thickness and Clark level), evaluation with a whole-body computed tomography scan was negative for metastatic disease. The long duration of the adalimumab therapy and the patient's lack of a predisposition to skin cancer suggest an association between anti-TNF-α drugs and melanocytic proliferation. The authors also review the literature on the potential association between anti-TNF regimens and the occurrence of malignancies such as melanocytic proliferations. There is a substantial hypothetical link between anti-TNF-α regimens such as adalimumab and the potential for cancers such as melanoma. However, the risk of malignancy with biological therapy remains to be established, and most of the relevant studies have lacked the statistical power and randomization required for large clinical trials. Further long-term controlled clinical trials and registries are required to investigate this potentially serious association.

Primary umbilical endometrioma: a rare case of spontaneous abdominal wall endometriosis.

Umbilical endometrioma is a rare condition, with an estimated incidence of 0.5%-1% in all patients with endometrial ectopia. Spontaneous abdominal wall endometriosis is an even rarer and more unusual condition with unclear pathogenetic mechanisms. A 44-year-old parous woman presented with an umbilical skin lesion, and no history of bleeding from the umbilical mass or swelling in the umbilical area. The initial clinical diagnosis was granuloma, and excision was planned. Pathology examination revealed endometrial glands with mucinous-type metaplasia surrounded by a disintegrating mantle of endometrial stroma. Clinical examination and magnetic resonance imaging did not reveal pelvic endometriosis lesions, and given that the umbilical endometrioma was totally excised, no further treatment with hormonal therapy was proposed for the patient. Three years after excision, she was free of disease and no recurrence has been observed. Complete excision and histology is highly recommended for obtaining a definitive diagnosis and optimal treatment in spontaneous abdominal wall endometriosis.

Benign post-radiation rectal stricture treated with endoscopic balloon dilation and intralesional triamcinolone injection.

Post-radiation stricture is a rare complication after pelvis irradiation, but must be in the mind of the clinician evaluating a lower gastrointestinal obstruction. Endoscopy has gained an important role in chronic radiation proctitis with several therapeutic options for management of intestinal strictures. The treatment of rectal strictures has been limited to surgery with high morbidity and mortality. Therefore, a less invasive therapeutic approach for benign rectal strictures, endoscopic balloon dilation with or without intralesional steroid injection, has become a common treatment modality. We present a case of benign post-radiation rectal stricture treated successfully with balloon dilation and adjuvant intralesional triamcinolone injection. A 70-year-old woman presented to the emergency room complaining for 2 weeks of diarrhea and meteorism, 11 years after radiation of the pelvis due to adenocarcinoma of the uterus. Colonoscopy revealed a stricture at the rectum and multiple endoscopic biopsies were obtained from the stricture. The stricture was treated with endoscopic balloon dilation and intralesional triamcinolone injection. The procedure appears to have a high success rate and a very low complication rate. Histologic examination of the biopsies revealed non-specific inflammatory changes of the rectal mucosa and no specific changes of the mucosa due to radiation. All biopsies were negative for malignancy. The patient is stricture-free 12 months post-treatment.

The histological and immunohistochemical aspects of bile reflux in patients with gastroesophageal reflux disease.

Introduction. The pathogenesis of GERD is strongly related with mixed acid and bile reflux. Benign and malignant esophageal and gastric lesions have been associated with synergetic activity between those parameters. Bile reflux causes reactive gastropathy evaluated with Bile Reflux Index (BRI). The aim was to investigate if the sequence: bile reflux-intestinal metaplasia-GERD-esophagitis, is associated with apoptotic/oncogenetic disturbances. Materials/Methods. Fifteen asymptomatic subjects and 53 GERD patients underwent gastroscopy with biopsies. The specimens examined histologically and immunohistochemically for p53, Ki-67, Bax, and Bcl-2. Results. Elevated BRI score detected in 47% (25/53) of patients with GERD and in 13% (2/15) of controls (P = 0.02). Severe esophageal lesions were significantly more common in BRI (+) patients (14/25) compared to BRI (-) ones (P = 0.0049). Immunohistochemical analysis did not show associations between BRI score and biomarker expression. Conclusions. Bile reflux gastropathy is associated with GERD severity, but not with oncogene expression or apoptotic discrepancies of the upper GI mucosa.

Endoscopic treatment of a gastrocutaneous fistula using the over-the-scope-clip system: a case report.

The over-the-scope-clip (OTSC; Ovesco Endoscopy GmbH, Tuebingen, Germany) system is a newly designed method for the mechanical compression of large areas in the gastrointestinal tract. So far, indications for OTSC application are hemostasis of primary or postinterventional bleeding, closure of iatrogenic full-thickness or covered perforations. Recently closure of gastrointestinal tract fistulas using this device has been described. A 44-year-old man developed a gastrocutaneous fistula after surgical treatment for a perforated gastric ulcer. We describe the successful endoscopic closure of the fistula using the OTSC system. The patient's clinical followup was uneventful. Fistula closure was successfully implemented as it was documented by imaging and endoscopic examinations performed on the 2nd day and 6th week after the application of the clip. Endoscopic application of the OTSC device was safe and effective for the treatment of a gastrocutaneous fistula.

Adalimumab - an effective and promising treatment for patients with fistulizing Crohn's disease: a case series.

INTRODUCTION: Crohn's disease is a chronic inflammatory bowel disease of unknown etiology which may affect any part of the bowel. Fistulas are a common and often serious complication of Crohn's disease. The treatment for fistulizing Crohn's disease can be medical, surgical or a combination of the two. Recently, adalimumab, a fully human anti-tumor necrosis factor monoclonal antibody, has been suggested as a safe and effective treatment for the induction and maintenance of remission in adult patients with moderate to severe Crohn's disease, who are refractory to conventional therapy or intolerant to infliximab. However, large studies focusing on evaluating the efficacy of adalimumab in fistulizing Crohn's disease have not yet been published. CASE PRESENTATION: We report the cases of three patients, of European Caucasian ethnicity and Greek nationality, with active luminal and fistulizing Crohn's disease. All of the cases were treated successfully with adalimumab. Patient 1 (a 44-year-old man) and patient 2 (an 18-year-old woman) developed early post-surgical enterocutaneous fistulas, while patient 3 (a 20-year-old woman) had peri-anal fistulizing Crohn's disease. Adalimumab treatment (160 mg subcutaneously at week zero, 80 mg at week two, and 40 mg every other week) was used for three different indications: (1) after the failure of other conservative medical treatments for Crohn's disease (patient 1); (2) as a monotherapy in treating a naive patient (patient 2); (3) after an intolerance to infliximab (patient 3). A remission of the active luminal and fistulizing disease was achieved soon after the initiation of adalimumab and sustained thereafter with maintenance doses. No further surgical intervention was required and no adverse effects were observed in any of the cases. CONCLUSIONS: Fistulizing Crohn's disease remains a challenge in clinical practice. Adalimumab seems to be an effective, well-tolerated and safe treatment option for the induction and maintenance of remission in patients with moderate to severe peri-anal fistulizing Crohn's disease. Furthermore, adalimumab seems to be a promising treatment option for patients with moderate to severe fistulizing Crohn's disease with enterocutaneous fistulas. However, this clinical observation needs to be investigated in further clinical trials.

Spontaneous bowel perforation complicating ventriculoperitoneal shunt: a case report.

Ventriculoperitoneal shunt placement is an effective treatment of hydrocephalus diverting the cerebrospinal fluid into the peritoneal cavity. Unfortunately, the shunt devices have a high incidence of malfunction mainly due to catheter obstruction or infection and are associated with various complications, 25% of which are abdominal. Spontaneous bowel perforation is a rare potentially fatal complication of ventriculoperitoneal shunt occurring anytime, few weeks to several years, after the placement of the ventriculoperitoneal shunt device. A 54-year-old Greek man with spontaneous perforation of sigmoid colon as a complication of distal ventriculoperitoneal shunt migration was treated successfully by antibiotic prophylaxis and abdominal surgery. Clinicians managing patients with ventriculoperitoneal shunt must be familiar with its possible complications and be aware for early recognition of them.

Massive intestinal ischemia, a rare complication of oral contraceptive-induced mesenteric venous thrombosis: a case report and review of literature.

Intestinal necrosis and perforation is a clinical and pathological presentation of the infrequently seen mesenteric venous thrombosis in women using oral contraceptives.We report a case of a previously healthy 31-year-old female patient, who presented with a 3-day history of abdominal pain.Although chest and abdomen radiographs showed small bowel obstruction, conservative treatment failed and the patient developed peritonism. Contrast-enhanced Tomography of the abdomen revealed free air associated with dilated and thickened small bowel. A laparotomy was performed and segmental resection of both small and large bowel was required. The pathological examination showed intestinal ischemia and mesenteric venous thrombosis. There were no further predisposing factors and mesenteric venous thrombosis was ascribed to oral contraceptives.

The significance of histological evidence of bile reflux gastropathy in patients with gastro-esophageal reflux disease.

BACKGROUND: Synergetic activity between acid and bile has been associated with extensive esophageal mucosal damage in patients with gastro-esophageal reflux disease (GERD). Reflux of bile causes injury to gastric mucosa evaluated with an established histological index (bile reflux index, BRI). The aim of the study was to investigate the role of bile reflux in patients with GERD using the BRI. MATERIAL/METHODS: Fifteen asymptomatic subjects and 53 patients with GERD underwent upper gastrointestinal endoscopy with biopsies taken from the gastric antrum, body, cardia, and lower esophagus. The updated Sidney system was used for histological examination and BRI was calculated according to the findings in the antrum. RESULTS: BRI was elevated in 25/53 GERD patients (47%) and in 2/15 15 controls (13%) (OR: 5.8, 95%CI: 1.2-28.3). Elevated BRI was noted in 72% (13/18) of the patients with severe esophagitis (grade B or C) or Barrett's esophagus, whereas it was present in 34% (12/35) of those with mild or no lesions (OR: 5, 95%CI: 1.4-17.3). Additionally, 5 of the 6 patients detected with intestinal metaplasia (IM) at the cardia (83%) and 9 of the 12 patients with IM of the antrum (75%) had elevated BRI. CONCLUSIONS: Bile reflux gastropathy is present in a significant proportion of patients with GERD and associated with disease severity. The elevated BRI in such patients highlights the role of duodeno-gastro-esophageal reflux as an additional factor in the pathogenesis of GERD.

Obestatin/ghrelin ratio: a new activity index in inflammatory bowel diseases.

BACKGROUND: The aim was to determine obestatin and ghrelin serum levels and their ratio in inflammatory bowel disease (IBD) patients. METHODS: We measured the ghrelin and obestatin levels of 31 Crohn's disease patients and 22 patients with ulcerative colitis using a radioimmunoassay method. Circulating levels of the 2 hormones and their ratio were correlated with the disease type and activity, disease localization, and treatment. RESULTS: The mean ghrelin value was statistically significantly higher in patients with active disease (402.4 +/- 462.6 pg/mL) than in patients in remission (148.2 +/- 59.6 pg/mL) P = 0.0290, alpha = 0.05, whereas obestatin mean values were not (217.4 +/- 59.8 pg/mL in active disease and 189.0 +/- 46.8 pg/mL in patients with inactive disease P = 0.0607). When we evaluated the obestatin/ghrelin ratio between active and inactive disease, it was found that the ratio in active disease was statistically significantly lower (0.8 +/- 0.3) than in patients in remission (1.4 +/- 0.3) P < 0.001, alpha = 0.05. There is also a statistically significantly correlation between obestatin/ghrelin ratio and disease activity (P < 0,001). CONCLUSIONS: Ghrelin and obestatin seem to play a significant role in IBD pathogenesis. Further studies are needed to elucidate the role of these hormones as new biological markers of activity of IBD.

The efficacy and safety of total thyroidectomy in the management of benign thyroid disease: a review of 932 cases.

BACKGROUND: Total thyroidectomy is currently the preferred treatment for thyroid cancer, multinodular goitre and Graves disease; however, many surgeons choose not to perform total thyroidectomy to treat benign thyroid diseases owing to the associated risk of postoperative hypoparathyroidism and recurrent laryngeal nerve damage. We reviewed 932 total thyroidectomies performed for benign thyroid diseases when surgery was indicated. We sought to assess whether the results support the hypothesis that total thyroidectomy is safe and can be considered as the optimal surgical approach for treating benign thyroid diseases. METHODS: A total of 932 patients underwent thyroidectomy between 1985 and 2005. We excluded patients with thyroid cancer or suspicion of thyroid malignancy. We evaluated indications for total thyroidectomy, cancer incidence, complication rates, local recurrence rate and long-term outcome after total thyroidectomy. RESULTS: Diagnoses before surgery were multinodular goitre (n = 734, 78.8%), Graves disease (n = 166, 17.8%) and recurrent (after previous partial thyroidectomy) nodular goitre (n = 32, 3.4%). The incidence of permanent bilateral recurrent laryngeal nerve palsy was 0% and that of permanent unilateral recurrent laryngeal nerve palsy was 0.2%, whereas the incidence of temporary unilateral recurrent laryngeal nerve palsy was 1.3%. Permanent hypocalcemia occurred in 0.3% and overall temporary hypocalcemia occurred in 7.3% of patients. Hemorrhage requiring repeat surgery occurred in 0.2% of patients. There was no wound infection, and postoperative mortality was 0%. We observed no disease recurrences during a median follow-up of 9 (range 2-20) years. CONCLUSION: Total thyroidectomy is safe and is associated with a low incidence of disabilities. Complication rates for recurrent laryngeal nerve palsy and hypoparathyroidism are similar to results of specialist endocrine surgery units. Furthermore, total thyroidectomy seems to be the optimal procedure, when surgery is indicated, for Graves disease and multinodular goitre, as total thyroidectomy has the advantages of immediate and permanent cure and no recurrences.

Parathyroid apoplexy, the explanation of spontaneous remission of primary hyperparathyroidism: a case report.

Primary hyperparathyroidism due to parathyroid adenoma represents an endocrine disease that is usually treated by surgical intervention (parathyroidectomy). In a very few patients, primary hyperparathyroidism can be spontaneously remit either by infraction or hemorrhage of the adenoma,a fact that is almost certain that will not lead to complete and definite cure. We describe a similar case of a 59-year-old male patient who underwent surgery for a cystic degeneration of a parathyroid adenoma, with substantial preoperative reduction of parathyroid hormone and calcium serum levels,and the diagnostic and treatment modalities are discussed, with a brief review of the current literature.

Complicated Crohn's-like colitis, associated with Hermansky-Pudlak syndrome, treated with Infliximab: a case report and brief review of the literature.

INTRODUCTION: Hermansky-Pudlak syndrome (HPS) is a rare autosomal recessive inherited disorder consisting of a triad of albinism, increased bleeding tendency secondary to platelet dysfunction, and systemic complications associated with ceroid depositions within the reticuloendothelial system. HPS has been associated with gastrointestinal (GI) complications related to chronic granulomatous colitis with pathologic features suggestive of Crohn's disease. This colitis can be severe and has been reported to be poorly responsive to medical therapies including antibiotics, corticosteroids, sulfasalazine, mesalamine and azathioprine. CASE PRESENTATION: We report a patient with HPS which was complicated by inflammatory bowel disease with clinical and pathologic features of Crohn's disease, refractory to antibiotics, corticosteroids and azathioprine. A trial of infliximab was attempted and repeated infusions produced a complete response. CONCLUSION: The occurrence of ileitis and perianal lesions and also the histopathological findings in our case suggest that HPS and Crohn's disease may truly be associated. Given this similarity and the failure of the standard medical therapy of corticosteroids and azathioprine, our patient received infliximab with marked clinical improvement.

De-escalation therapy rates are significantly higher by bronchoalveolar lavage than by tracheal aspirate.

OBJECTIVE: To assess outcomes with de-escalation therapy in ventilator-associated pneumonia (VAP). DESIGN: Prospective observational study. SETTING: Multidisciplinary intensive care unit. PATIENTS AND PARTICIPANTS: VAP was diagnosed by positive quantitative cultures of both tracheal aspirate and bronchoalveolar lavage (BAL) and treated appropriately for all significant isolates of tracheal aspirate and BAL in 143 patients who were assigned to de-escalation therapy by BAL or tracheal aspirate. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Antibiotic therapy was de-escalated in 58 patients (40.5%), who had decreased mortality at day 15 (5.1% vs. 31.7%) and day 28 (12% vs. 43.5%) and shorter intensive care unit (17.2 +/- 1.2 vs. 22.7 +/- 6.3 days) and hospital (23.7 +/- 2.8 vs. 29.8 +/- 11.1 days) stay (p < 0.05). Of the 81 patients assigned to tracheal aspirate, the 17 (21%) who achieved de-escalation of therapy had reduced 15-day mortality (5.8% vs. 34.3%), reduced 28-day mortality (11.6% vs. 45.3%), and shorter intensive care unit (17.2 +/- 1.6 vs. 22.4 +/- 6.4 days) and hospital (23.1 +/- 4.4 vs. 29.9 +/- 11.1 days) stay (p < 0.05). Of the 62 patients assigned to BAL, the 41 (66.1%) who achieved de-escalation of therapy had decreased 15-day mortality (4.8% vs. 23.8%), decreased 28-day mortality (12.1% vs. 38%), and shorter intensive care unit (17.2 +/- 1.1 vs. 23.2 +/- 6 days) and hospital (23.8 +/- 2.4 vs. 29.8 +/- 11.4 days) stay (p < 0.05). CONCLUSIONS: For patients with VAP who have had appropriate treatment and shown a favorable clinical response, mortality and duration of stay can be further improved by de-escalation therapy.

Peptic ulcer perforation as the first manifestation of previously unknown primary hyperparathyroidism.

A patient admitted for acute abdomen was incidentally found with elevated serum calcium level. In surgery, under conservative treatment of the hypercalcemia, a perforated duodenal ulcer was found and simple closure was performed. Postoperatively, calcium level continued to rise, parathyroid hormone was elevated and ultrasonographic examination showed a lesion in the right anterior neck, while serum gastrin level was normal, thus documenting the diagnosis of primary hyperparathyroidism. Conservative treatment had no effect on calcium level and the patient was subjected to emergency neck exploration, where a large parathyroid adenoma was removed. After surgery, calcium and PTH levels were normalized and the patient was discharged on the 5th postoperative day. Peptic ulcer and its complications are usual manifestations of primary hyperparathyroidism, with or without increased gastrin level. On the other hand, cases of a perforation of peptic ulcer as the first clinical manifestation of primary hyperparathyroidism are extremely rare.

Enterolith small-bowel obstruction caused by jejunal diverticulosis: Report of a case.

We report the successful surgical treatment of intestinal obstruction caused by enteroliths formed in jejunal diverticula. A 78-year-old man with bowel obstruction of unknown etiology was initially managed conservatively, but suffered recurrence of the obstruction. Thus, we performed a laparotomy, which revealed multiple diverticula in the jejunum, with one enterolith inside a diverticulum and one enterolith in the terminal ileum. There was no abnormal communication between the gallbladder and the intestinal tract, excluding the possibility of a gallstone ileus. The stone in the terminal ileum could not be broken manually, so we performed an enterotomy to remove the stones. Intestinal obstruction caused by enteroliths in small-bowel diverticula is a rare event, which is difficult to diagnose and manage. To our knowledge, only 35 such cases have ever been reported.

Perforated GIST of the small intestine as a rare cause of acute abdomen: Surgical treatment and adjuvant therapy. Case report.

A case of perforated gastrointestinal stromal tumor (GIST) of small intestine causing acute abdomen is described, with a brief review of the literature. A male patient presented with symptoms of acute abdomen. After evaluation, a laparotomy was performed, where perforation of a tumor in the ileum was found. The perforated part along with the tumor was resected and the cytopathological examination showed that the tumor was GIST. Postoperatively, the patient received treatment, using imatinib. Gastrointestinal stromal tumors are relatively rare and often present with vague symptoms. Their first clinical manifestation as acute abdomen due to their perforation is extremely rare. In emergency laparotomy, a R0 resection is required and adjuvant therapy with imatinib must be considered.

Lateral subcutaneous internal sphincterotomy in the treatment of chronic anal fissure: our experience.

BACKGROUND: Chronic anal fissure is the most common cause of anal pain associated with internal anal sphincter hypertonia. Reduction of hypertonia favours fissure healing. Temporary reduction in sphincter tone can be achieved by conservative treatment. Surgical sphincterotomy achieves permanent reduction of sphincter hypertonia and is very successful at healing anal fissures, but requires an operation with associated small morbidity. METHODS: A study was undertaken on 246 patients (120 men, 126 women, mean age 48.3 years), undergoing subcutaneous lateral internal sphincterotomy for a chronic fissure-in-ano from January 1, 1981 to December 31, 2004. Therapeutical outcome, postoperative course and early and long-term results were recorded. RESULTS: During the study period, the 246 patients underwent total subcutaneous lateral internal sphincterotomy, 62 of them under general anesthesia (1981-1991), and the remainder under local anesthesia. Two-hundred-forty-two patients returned for their postoperative visits at 2, 6, 24 and 48 weeks, while four patients were lost to follow-up. At 3 months postoperatively, 97.5% of fissures had healed; 224 fissures were healed by 6 weeks, 10 by 7 weeks and 2 by 3 months. Pain was significantly reduced in all patients at Day 1 postoperative. Minor complications included hematoma (0.8%) and pain (0.4%). New minor incontinence was seen in 7.02% of patients at 48-week follow up. Patients' satisfaction was 91.7%. CONCLUSIONS: Total subcutaneous internal sphincterotomy is a safe and effective treatment for chronic anal fissures, that only rarely impairs continence to flatus.

Extrahepatic biliary obstruction due to a solitary pancreatic metastasis of squamous cell lung carcinoma. Case report.

A 53-year old male, with a history of squamous cell lung carcinoma, was presenting with jaundice. Examinations showed a pancreatic tumor infiltrating the common bile duct and a percutaneous biopsy proved that the lesion was metastatic from the lung carcinoma. The decision was taken to perform a laparotomy. During laparotomy, a palliative operation was performed to relieve the jaundice. According to the literature, symptomatic metastatic lesions of the pancreas from squamous cell carcinoma of the lung are infrequent.

Both early-onset and late-onset ventilator-associated pneumonia are caused mainly by potentially multiresistant bacteria.

OBJECTIVE: To compare the causative pathogens of early-onset and late-onset ventilator-associated pneumonia (VAP) diagnosed by bronchoalveolar lavage quantitative cultures. Most previous reports have been based on endotracheal aspirate cultures and gave uncertain findings. DESIGN: Prospective evaluation of consecutive patients with clinical suspicion for VAP. SETTING: Multidisciplinary intensive care unit of a university hospital. PATIENTS AND PARTICIPANTS: During a 3-year period 473 patients with clinical suspicion of VAP entered the study. Diagnosis of VAP was confirmed by cultures of bronchoalveolar lavage (> 10(4) cfu/ml) specimens in 408 patients. INTERVENTIONS: Protected bronchoalveolar lavage samples were taken. Initial antibiotic therapy was modified upon bronchoalveolar lavage culture results. MEASUREMENTS AND RESULTS: Among 408 patients 191 had early-onset (< 7 days mechanical ventilation) and 217 late-onset (> or = 7 days) VAP. Potentially multiresistant bacteria, mainly Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA), were the most commonly isolated pathogens in both types of VAP. No difference was noted in the contribution of potentially multiresistant pathogens (79% vs. 85%), P. aeruginosa (42% vs. 47%), or MRSA (33% vs. 30%) between early-onset and late-onset VAP. Initial antibiotic therapy was modified in 58% of early-onset VAP episodes and in 36% of late-onset VAP episodes. No difference in mortality was found between the two types of VAP. CONCLUSIONS: Both early-onset and late-onset VAP were mainly caused by potentially multiresistant bacteria, most commonly P. aeruginosa and MRSA. Antimicrobial agents against these pathogens should be prescribed empirically, at least in our institution.