Complicated Carriage with Methicillin-Resistant Staphylococcus aureus: Evaluation of the Effectiveness of Decolonization Regimens Advised in the Dutch National Guideline.

Methicillin-resistant Staphylococcus aureus (MRSA) colonization leads to increased infection rates and mortality. Decolonization treatment has been proven to prevent infection and reduce transmission. As the optimal antimicrobial strategy is yet to be established, different regimens are currently prescribed to patients. This study aimed to evaluate the efficacy of the decolonization treatments recommended by the Dutch guideline. A retrospective multicenter cohort study was conducted in five Dutch hospitals. All patients who visited the outpatient clinic because of complicated MRSA carriage between 2014 and 2018 were included. We obtained data on patient characteristics, clinical and microbiological variables relevant for MRSA decolonization, environmental factors, decolonization regimen, and treatment outcome. The primary outcome was defined as three negative MRSA cultures after treatment completion. Outcomes were stratified for the first-line treatment strategies. A total of 131/224 patients were treated with systemic antibiotic agents. Treatment was successful in 111/131 (85%) patients. The success rate was highest in patients treated with doxycycline-rifampin (32/37; 86%), but the difference from any of the other regimens did not reach statistical significance. There was no difference in the success rate of a 7-day treatment compared to that with 10 to 14 days of treatment (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.39 to 2.53; P = 1.00). Side effects were reported in 27/131 (21%) patients and consisted mainly of mild gastrointestinal complaints. In a multivariable analysis, an immunocompromised status was an independent risk factor for failure at the first treatment attempt (OR, 4.65; 95% CI, 1.25 to 17.25; P = 0.02). The antimicrobial combinations recommended to treat complicated MRSA carriage yielded high success rates. Prolonged treatment did not affect treatment outcome. A randomized trial is needed to resolve whether the most successful regimen in this study (doxycycline plus rifampin) is superior to other combinations.

[Peritoneal tuberculosis]. / Peritonitis tuberculosa.

Peritoneal tuberculosis was diagnosed in a 38-year-old man from Curaçao, a 42-year-old Dutch man and a 38-year-old woman from Surinam. All patients had been living in the Netherlands for over a decade at the time of diagnosis. Time to diagnosis and treatment varied between patients. Factors contributing to delayed diagnosis were nonspecific symptoms, failure to consider tuberculosis exposure, consulting of more than one physician and delay in obtaining adequate material for histopathologic and microbiologic tests. These cases show that peritoneal tuberculosis can represent a diagnostic challenge. Considering the rising incidence of tuberculosis in the Netherlands, general practitioners and medical specialists will encounter patients with extrapulmonary tuberculosis more frequently. We recommend that tuberculosis exposure should always be considered by clinicians, even in patients originating from non-endemic countries. In case of suspected peritoneal tuberculosis, laparoscopy with peritoneal biopsy is the diagnostic tool of choice and should be performed without delay.

[Lymphoma-induced antiphospholipid syndrome as a cause of splenic infarction]. / Lymphom-induziertes Antiphospholipidsyndrom als Ursache von Milzinfarkten.

HISTORY AND ADMISSION FINDINGS: A 71-year-old man presented with bilateral sialadenosis of the parotid gland, episodes of fever up to 39 °C, general malaise and weight loss of 5 kg within the last 6 weeks. At physical examination peripheral lymph nodes were not palpable. INVESTIGATIONS: Laboratory studies revealed a normal white blood cell count, anemia and thrombocytopenia. Serum C-reactive protein and lactate dehydrogenase were elevated on admission and rose further. Plasmatic coagulation was characterized by prolonged partial thromboplastin time and reduced prothrombin time. Abdominal computed tomography showed an enlarged spleen with irregular hypodense areas, indicating splenic infarctions. Enlarged lymph nodes were noted at the paraaortic region and in the splenic hilum. DIAGNOSIS: As the patient`s condition deteriorated from day to day a diagnosis had to be enforced. Splenectomy was thus performed which confirmed the CT findings of numerous infarcted areas. A marginal zone lymphoma was found within the splenic hilar lymph nodes. High titer serum antibodies against cardiolipin confirmed the diagnosis of secondary antiphospholipid syndrome (APS). TREATMENT AND COURSE: Oral anticoagulation with phenprocoumone was started; in addition, chemotherapy with rituximab, cyclophosphamide, vincristin and prednisolone (R-CHOP) was initiated. Despite clinical recovery serological markers of APS remained elevated. The lymphoma recurred only six months after chemotherapy had been completed, and the patient died two months later. CONCLUSION: Because of its potentially fatal consequences anticoagulation and treatment of the underlying disease are crucial in secondary APS.

Regression of HIV-associated grade IV T cell lymphoma with combined antiretroviral therapy only.

The present report describes repeated long-term remissions of a high-grade T cell lymphoma in an HIV-positive patient upon cART only, without additional chemotherapy. A review of cases from the literature further illustrates the anti-tumor effects of cART through the induction of a strong immune reconstitution in HIV-infected patients.

[Solitary liver tumor as a manifestation of polyarteritis nodosa]. / Solitärer Lebertumor als Manifestation der Panarteriitis nodosa.

HISTORY: A 65-year-old female was admitted with fever of unknown origin. DIAGNOSTIC PROCEDURES: Abdominal computed tomography showed a solid mass (7.5 cm in diameter) with central fluid, located in the right lobe of the liver. Fine-needle aspiration cytology was unremarkable. Further work-up procedures for suspected liver abscess included colonoscopy, which surprisingly revealed adenocarcinoma at 13 cm from the anal orifice. THERAPY AND CLINICAL COURSE: Both lesions in the rectum and liver were resected. While a moderately differentiated (G2) adenocarcinoma of the rectosigmoid junction (stage T3/ N0) was confirmed, histology of the hepatic mass showed liver infarction due to polyarteritis nodosa of the medium-sized arteries. Treatment with 20 mg/d prednisolone was initiated and tapered off over the next three months. The clinical course after discontinuation of corticosteroids was unremarkable over a 6-month follow-up. CONCLUSION: It is suggested that polyarteritis nodosa of the liver occurred in this patient as a paraneoplastic phenomenon and subsided after resection of colorectal cancer and short-term immunosuppression with prednisolone.

Oral valganciclovir as pre-emptive therapy has similar efficacy on cytomegalovirus DNA load reduction as intravenous ganciclovir in allogeneic stem cell transplantation recipients.

The efficacy and safety of oral valganciclovir was compared to ganciclovir i.v. in pre-emptive treatment of cytomegalovirus (CMV) in T-cell-depleted allogeneic stem cell transplant (allo-SCT) recipients. A therapeutic guideline was developed to allow the safe application of valganciclovir in allo-SCT recipients requiring CMV therapy. In total, 107 consecutive transplant recipients were evaluated. Cytomegalovirus DNA load in plasma was monitored longitudinally; details on antiviral therapy and treatment responses were analyzed retrospectively. Fifty-seven CMV treatment episodes were recorded in 34 patients: 20 with valganciclovir (900 mg twice-daily) and 37 with ganciclovir (5 mg/kg twice-daily). Median CMV DNA load reduction was 0.079 and 0.069 log10 copies/ml/day in the ganciclovir and valganciclovir group, respectively. Good response on CMV DNA load (reduction below 3.0 log10 copies/ml) was observed in 75.7% of ganciclovir and 80.0% of valganciclovir treatment episodes. Severe adverse effects were not observed and CMV-related disease did not occur. However, the percentage of patients receiving erythrocyte transfusion was higher in the group of patients receiving ganciclovir as compared to valganciclovir (41 versus 20%, P=0.116). In conclusion, pre-emptive treatment with valganciclovir and ganciclovir, led to similar reduction of CMV DNA load. Oral valganciclovir is an attractive and safe alternative for pre-emptive CMV treatment in T-cell-depleted allo-SCT recipients.

Randomized clinical trial comparing lightweight composite mesh with polyester or polypropylene mesh for incisional hernia repair.

BACKGROUND: Polymer mesh has been used to repair incisional hernias with lower recurrence rates than suture repair. A new generation of mesh has been developed with reduced polypropylene mass and increased pore size. The aim of this study was to compare standard mesh with new lightweight mesh in patients undergoing incisional hernia repair. METHODS: Patients were randomized to receive lightweight composite mesh, or standard polyester or polypropylene mesh. Outcomes were evaluated at 21 days, 4, 12 and 24 months from patient responses to the Short Form 36 (SF-36) and daily activity questionnaires. Complications and recurrence rates were recorded. RESULTS: A total of 165 patients were included in an intention-to-treat analysis (83 lightweight mesh, 82 standard mesh). Postoperative complication rates were similar. The overall hernia recurrence rate was 17 per cent with the lightweight mesh versus 7 per cent with the standard mesh (P = 0.052). There were no differences in SF-36 physical function scores or daily activities between 21 days and 24 months after surgery. CONCLUSION: The use of the lightweight composite mesh for incisional hernia repair had similar outcomes to polypropylene or polyester mesh with the exception of a non-significant trend towards increased hernia recurrence. The latter may be related to technical factors with regard to the specific placement and fixation requirements of lightweight composite mesh.

Contrast echocardiography as a useful additional diagnostic tool in evaluating a primary cardiac tumor.

The current report describes a case of a primary cardiac lymphoma. For early and appropriate treatment of a cardiac mass it is not only important to determine its localization and extension but also to differentiate between malignant and benign lesions. This report demonstrates that not only transthoracic echocardiography but also the other different forms of echocardiography such as transesophageal echocardiography, as well as contrast and intracardiac echocardiography, are useful tools in the diagnostic workup of cardiac masses.

[Linezolid, an agent from a new class of antibiotics]. / Linezolid, een middel uit een nieuwe klasse van antibiotica.

Linezolid is the first of a new class of antibacterial agents, the oxazolidinones, to become available. Linezolid has a unique mechanism of action in its inhibition of bacterial protein synthesis in Gram-positive and a number of anaerobic bacteria. Because of this unique mechanism of action, linezolid exhibits no cross-resistance with other antibiotics and is effective against methicillin-resistant staphylococci, penicillin-resistant pneumococci and vancomycin-resistant enterococci. The excellent bioavailability after oral administration (almost 100%) makes it suitable for outpatient treatment and treatment by general practitioners. In the Netherlands, however, the indications for linezolid are limited by its high cost, the availability of other effective antibiotics for the treatment of sensitive micro-organisms, and the toxicity associated with a prolonged treatment period. Resistance to the new agent was reported rather quickly after the introduction of linezolid.

[Sharp increase in the number of syphilis cases in The Netherlands: early recognition and treatment is of great importance]. / Sterke toename van het aantal syfilispatiënten in Nederland: vroegtijdige herkenning en behandeling van groot belang.

Syphilis was diagnosed in three men having sex with men, aged 36, 38 and 58 years, who had a variety of skin lesions and other symptoms. In a woman aged 38 years and her 39-year-old husband, syphilis was found during routine pregnancy screening. All patients were successfully treated with intramuscular (benzathin) benzylpenicillin. Early recognition and treatment as well as advice on avoiding high-risk sexual behaviour are important in preventing further spread of the disease. Although generally the risk of HIV transmission during unprotected oral sexual contact is believed to be low, the transmission of Treponema pallidum during this type of contact is possible and is probably the most important transmission route amongst men having sex with men.

[A case of diphtheria in the Netherlands due to an infection with Corynebacterium ulcerans]. / Difterie door infectie met Corynebacterium ulcerans in Nederland.

A 58-year-old woman was admitted due to a pseudomembranous pharyngitis. The patient had not been vaccinated against diphtheria. Corynebacterium ulcerans was cultured from a throat swab. The production of diphtheria toxin by these bacteria was demonstrated with PCR and an immunoprecipitation test. The patient was cared for in respiratory isolation and was treated with benzylpenicillin. She quickly recovered and was discharged four days after admission. A contact investigation did not reveal any dissemination of the toxin-producing C. ulcerans and a source was not found. In spite of the large-scale vaccination against diphtheria which has taken place in the Netherlands since 1953, a physician has to consider diphtheria in the differential diagnosis of patients who present with a clinical syndrome compatible with this disease. Either Corynebacterium diphtheriae or C. ulcerans could be the pathogen responsible.

[How to treat a patient with indications for an infectious viral hemorrhagic fever]. / Hoe te handelen bij een patiënt met aanwijzingen voor een besmettelijke virale hemorragische koorts.

Lassa, Ebola, Marburg and Crimean-Congo haemorrhagic fever viruses are the most important causes of viral haemorrhagic fever which is transmitted from person to person through contact with blood or excreta. A non-specific fever may be the initial symptom of viral haemorrhagic fever. By means of carefully noting where the patient has travelled, possible exposure to ill persons, vectors or an animal reservoir, and the incubation period (< or = 21 days versus longer), it is possible to estimate the risk of infection with one of these viruses. Using this approach it is possible to diagnose high-risk patients in good time and to take appropriate measures.

[A man with fatal Lassa fever following a stay in Sierra Leone]. / Een man met fatale Lassa-koorts na een verblijf in Sierra Leone.

A 48-year-old-man returned to the Netherlands from Sierra Leone and was admitted with nausea, crampy abdominal pain, myalgia, arthralgia, headache and watery diarrhoea. This was the first case of Lassa fever diagnosed in the Netherlands since 1980. Despite treatment with ribavirin, the patient died on the 16th day of illness. Prompt diagnosis of Lassa fever is critical for the timely administration of ribavirin which improves diagnosis considerably, and for the timely implementation of isolation measures. Recently, a reverse transcriptase polymerase chain reaction (RT-PCR) has become available for the rapid diagnosis of acute Lassa fever, which was implemented to diagnose this patient.

Is laparoscopic cholecystectomy a mature operative technique?

BACKGROUND: More than 10 years after its introduction, laparoscopic cholecystectomy has become the method of choice for the treatment of cholecystolithiasis. However intraoperative difficulties with dramatic postoperative consequences have been reported. The aim of this study was to identify what role the two-dimensional view, the surgeon's experience, the instruments, technical tools and their (time) influence exercised on the operation course in daily laparoscopic operations. METHODS: The operative times for 30 laparoscopic cholecystectomies were investigated by ergonomic sequence analysis and analyzed statistically with the use of the Wilcoxon test. RESULTS: Comparing experienced and less experienced surgeons, a significant difference in the duration of the operation was observed (56 +/- 24 min compared to 75 +/- 13 min p = 0,025), especially in the laparoscopic intra-abdominal phase of the operation. The prolonged duration of the operation (15-20%) was mainly due to problems with the technical tools (40%) and the use of instruments (23.5%). Visualization had a minor influence (14.4%) on the duration of the operation, and the negative effect of the two-dimensional view (0.5%) was negligible. The last two factors did not cause any complications. CONCLUSIONS: The recognized difficulties still cause a loss of time and in some cases complications, which can only partly be compensated by the surgeon's experience. This leads to reluctance in the application of laparoscopic cholecystectomy in more complicated stages of the disease. Two-dimensional view satisfies the surgeon's demands for a safe procedure.

A novel gene on human chromosome 2p24 is differentially expressed between androgen-dependent and androgen-independent prostate cancer cells.

Identification of genes involved in the transition from androgen-dependent to androgen-independent prostate cancer is important to extend our current knowledge of the disease. Using differential display RT-PCR analysis between androgen-dependent and androgen-independent prostate cancer cells, we have identified a novel gene, designated GC109. GC109 harbours a putative Cys-His cluster, a nuclear localisation signal, a leucine zipper and a ret finger protein (rfp)-like domain. GC109 mRNA expression in normal human tissues was found not to be restricted to the prostate. However, using a variety of 15 human cancer cell lines, GC109 mRNA was preferentially expressed in androgen-dependent LNCaP-FGC, compared with androgen-independent LNCaP-LNO, DU145 and PC3 human prostate cancer cells. Finally, the GC109 gene was mapped on human chromosome 2p24. Based on its protein domain structure and chromosomal localisation, we hypothesise that GC109 may be involved in chromosomal rearrangements in prostate cancer.

Does loperamide affect motor activity after proctocolectomy and ileal pouch-anal anastomosis? An experimental study in dogs.

This study investigated the effect of loperamide on the motor function of small intestine and J-pouch. Proctocolectomy and ileal pouch-anal anastomosis were performed in four dogs. Motility was recorded by serosal electrodes and strain gauge transducers. The intestinal transit time was determined radiologically. Multiple measurements were performed before and during chronic administration of loperamide. This treatment led to a significant decrease in median stool frequency from 11 (10-13) to 9 stools/day (8-12) and a tendential increase in intestinal transit time from 60 (50-105) to 70 min (60-90). This was not accompanied by significant changes in fasted or postprandial motility. There were no significant differences in the characteristics of the migrating myoelectric complex or in the fed pattern, either in the small intestine or in the pouch. Loperamide thus does not significantly affect intestinal motility after ileal pouch-anal anastomosis. The reduction in stool frequency seems to be due to antisecretory effects in the first line.