Operative management of isolated posterior cruciate ligament injuries improves stability and reduces the incidence of secondary osteoarthritis: a systematic review.

PURPOSE: To evaluate the evidence for operative and non-operative management of isolated posterior cruciate ligament (PCL) injuries. METHODS: Using Pubmed, EMBASE and Cochrane databases, a systematic review was conducted of studies investigating the treatment of isolated PCL injuries published until July 2020. Quality assessment was performed with the Cochrane risk of bias tool (level I), the Newcastle-Ottowa Scale (level II-III) and the National Institute of Health quality assessment tool (level IV). Clinical outcome measures included residual laxity, return to sports, patient-reported outcome measures, subsequent articular degeneration and complications. RESULTS: Twenty-seven studies [23 case series, 2 case-control, 1 cohort study and 1 randomized controlled trial (RCT)] including 5197 patients (5199 knees) with a mean age of 29.5 ± 3.6 years (range 15-68) fulfilled the study requirements. Significantly less residual laxity was found after posterior cruciate ligament reconstruction (PCLR) compared to non-operative management (3.43 vs. 5.47 mm, CI: 1.84-2.23, p < 0.001). Both treatment modalities yielded satisfying functional outcomes and a high return to sports (64-77%, mean: 70.3, CI: 67.8-72.2). Osteoarthritis (OA) occurred less frequently following PCLR (21.5 vs. 44.1%, p < 0.001). CONCLUSION: In the absence of level I RCTs, this systematic review suggests that surgical management for selected isolated PCL injuries is a reasonable option to consider, especially when the surgeon aims at minimizing residual laxity and presumably secondary osteoarthritis. LEVEL OF EVIDENCE: IV.

How small modifications in laboratory workflow of blood cultures can have a significant impact on time to results.

Rapid identification and antimicrobial susceptibility testing of micro-organisms causing bloodstream infections is crucial in the management of septic patients. In this study, we compared a period of twice-daily and a period of thrice-daily reading of subculture agar plates. In 2016, 10,644 positive blood cultures bottles (bioMérieux) from 2608 patients were analyzed at UZ Leuven. Identification and antimicrobial susceptibility testing were performed by MALDI-TOF MS (Bruker Daltonics) and Vitek 2 (bioMérieux) respectively. In period 1 (January to June), subculture plates were read at 8:30 a.m. and 2:00 p.m. during the weekdays. In period 2 (August until December), reading was performed at 8:30 a.m., 2:00 p.m., and 5:00 p.m. Time to identification and time to AST results after positivity were compared. In period 1, median time to identification of all organisms was 22.8 h compared to 20.2 h in period 2 (p < 0.01). Moreover, micro-organisms were identified before 12 h in 9% of samples in period 2, a significant increase compared to 2% in period 1 (p < 0.01). In period 2, AST results were known within 36 h in 39% of samples, compared to 31% in period 1 (p < 0.01). Optimization of the reading frequency of subcultures of blood cultures significantly decreases time to results. Further optimization can be done by introducing lab automation. We will use the data of this study as a baseline to analyze the impact of introducing WASPLab (Copan Diagnostics) automation on time to results.

Added diagnostic value and impact on antimicrobial therapy of 16S rRNA PCR and amplicon sequencing on resected heart valves in infective endocarditis: a prospective cohort study.

OBJECTIVES: For adequate management and therapy of infective endocarditis (IE), identification of the causative pathogen is crucial but molecular testing results are not currently included in diagnostic criteria. The added diagnostic value and impact on antimicrobial therapy of 16S rRNA PCR and amplicon sequencing (16S rRNA PCR) performed on excised heart valves from patients with IE was evaluated alongside the effect of pre-operative antibiotics on the performance of blood culture (BC), valve culture (VC) and 16S rRNA PCR. METHODS: All patients undergoing valve surgery for definite or possible IE, according to modified Duke Criteria, were prospectively included from July 2013 up to and including June 2016. RESULTS: In all, 127 patients were included. Sensitivity for detecting the causative micro-organism in 120 post-operative definite IE patients was 26% for VC and 87% for BC and 16S rRNA PCR. 16S rRNA PCR, VC and BC were equally sensitive for different valve types and causative pathogens. In 27 (21%) definite IE patients, 16S rRNA PCR clarified discrepant culture results or was the only method identifying the causative pathogen. In 12 (10%) post-operative definite IE cases, molecular testing results influenced antimicrobial therapy. CONCLUSIONS: The very good performance characteristics, added diagnostic value and impact on antimicrobial therapy of molecular testing of heart valves should support the incorporation of molecular testing in diagnostic criteria and guidelines for IE.

Performance of three generations of Xpert MRSA in routine practice: approaching the aim?

The aim of this study was to evaluate retrospectively the performance of the Xpert MRSA assay in routine practice and its current use in the intensive care unit (ICU) setting of our hospital, since a pre-emptive isolation strategy has been applied. A total of 6473 patients were routinely screened with ESwab for methicillin-resistant Staphylococcus aureus (MRSA) using three generations of rapid real-time polymerase chain reaction (PCR) (Cepheid GeneXpert) over three consecutive periods of time. Performance was evaluated using broth enrichment culture as the reference method. Our results show that the last generation of Xpert MRSA (NxG) assay is more specific (99.2% vs. 97.9%) but not more sensitive (77.8% vs. 86.9%) than the third generation. Considering the low prevalence of MRSA in our hospital, we obtained an overall low positive predictive value. In conclusion, it remains difficult to abandon the reference method in routine practice considering the possible implications of an erroneous MRSA result in the ICU.

Characterisation of Staphylococcus aureus isolates from bloodstream infections, Democratic Republic of the Congo.

Staphylococcus aureus is known worldwide as an invasive pathogen, but information on S. aureus from bloodstream infections in Central Africa remains scarce. A collection of S. aureus blood culture isolates recovered from hospitals in four provinces in the Democratic Republic of the Congo (2009-2013) was assessed. A total of 27/108 isolates were methicillin-resistant S. aureus (MRSA), of which >70% were co-resistant to aminoglycosides, tetracyclines, macrolides and lincosamides. For MRSA and methicillin-susceptible S. aureus (MSSA) isolates, resistance to chloramphenicol and trimethoprim-sulphamethoxazole (TMP-SMX) was <10%. However, 66.7% (72/108) of all isolates harboured the trimethoprim resistance gene dfrG. More than three-quarters (84/108, 77.8%) of isolates belonged to CC5, CC8, CC121 or CC152. Genetic diversity was higher among MSSA (31 spa types) compared to MRSA (four spa types). Most MRSA (23/27, 85.2%) belonged to CC8-spa t1476-SCCmec V and 17/23 (73.9%) MRSA ST8 were oxacillin susceptible but cefoxitin resistant. Among MRSA and MSSA combined, 49.1% (53/108) and 19.4% (21/108) contained the genes encoding for Panton-Valentine leucocidin (lukS-lukF PV, PVL) and toxic shock syndrome toxin-1 (tst, TSST-1), respectively. PVL was mainly detected among MSSA (51/53 isolates harbouring PVL were MSSA, 96.2%) and associated with CC121, CC152, CC1 and CC5. TSST-1 was associated with CC8-spa t1476-SCCmec V. The immune evasion cluster (IEC) genes scn, sak and chp were detected in 81.5% of isolates (88/108, equally represented among MSSA and MRSA). The present study confirms the occurrence of MRSA with high levels of multidrug co-resistance and PVL-positive MSSA among invasive S. aureus isolates in Central Africa.

Binary toxin and its clinical importance in Clostridium difficile infection, Belgium.

Binary toxin-producing Clostridium difficile strains such as ribotypes 027 and 078 have been associated with increased Clostridium difficile infection (CDI) severity. Our objective was to investigate the association between presence of the binary toxin gene and CDI severity and recurrence. We performed a laboratory-based retrospective study including patients between January 2013 and March 2015 whose fecal samples were analyzed by polymerase chain reaction (PCR) for the presence of the genes for toxin B and binary toxin and a deletion in the tcdC gene, specific for ribotype 027. Clinical and epidemiological characteristics were compared between 33 binary toxin-positive CDI patients and 33 binary toxin-negative CDI patients. Subsequently, the characteristics of 66 CDI patients were compared to those of 66 diarrhea patients who were carriers of non-toxigenic C. difficile strains. Fifty-nine of 1034 (5.7 %) fecal samples analyzed by PCR were binary toxin-positive, belonging to 33 different patients. No samples were positive for ribotype 027. Binary toxin-positive CDI patients did not differ from binary toxin-negative CDI patients in terms of disease recurrence, morbidity, or mortality, except for a higher peripheral leukocytosis in the binary toxin-positive group (16.30 × 109/L vs. 11.65 × 109/L; p = 0.02). The second part of our study showed that CDI patients had more severe disease, but not a higher 30-day mortality rate than diarrhea patients with a non-toxicogenic C. difficile strain. In our setting with a low prevalence of ribotype 027, the presence of the binary toxin gene is not associated with poor outcome.

Development of a national EUCAST challenge panel for antimicrobial susceptibility testing.

A challenge panel of bacterial strains useful for clinical laboratories to validate their European Committee on Antimicrobial Susceptibility Testing (EUCAST) antimicrobial susceptibility test (AST) system was established. A total of 117 strains, obtained from Belgian Reference Centres (n = 57) and from routine clinical samples (n = 60) was selected based on resistance pattern. These strains were analysed in seven different laboratories by three different automated AST systems (Vitek (n = 2), Phoenix (n = 2) and Microscan (n = 2)) and by disc diffusion from five different manufacturers (Rosco (n = 2), Becton-Dickinson (n = 2), Biomérieux (n = 1), Bio-rad (n = 1) and i2a (n = 1)). To select the challenge panel, selection criteria were set for categorical agreement between the different systems and the number of very major errors, major errors and minor errors. Very major and major errors for at least two antibiotics were observed in 43% of all strains, leading to the exclusion of these strains from the selected panel. In only 10% of all tested strains was there 100% categorical agreement for all antibiotics. Finally, 28 strains (14 Gram-positive and 14 Gram-negative) covering a wide spectrum of resistance mechanisms were selected. Pilot-testing of this challenge panel in 20 laboratories mainly confirmed the results of the validation study. Only six strains withheld for the pilot study could not be used as challenge strain due to an overall (very) major error rate of >5% for a particular antibiotic (n = 5) or for two antibiotics (n = 1). To conclude, this challenge panel should facilitate the implementation and use of EUCAST breakpoints in laboratories.

Transportal femoral drilling creates more horizontal ACL graft orientation compared to transtibial drilling: A 3D CT imaging study.

BACKGROUND: The principle of anatomic anterior cruciate ligament (ACL) reconstruction is to create a femoral and tibial tunnel that resembles the insertion of the native ACL. Anatomic reconstruction leads to a more horizontal graft orientation that provides more rotational stability. The aim of this study is to investigate the best method to achieve anatomical reconstruction of femoral insertion of the ACL and thus, a more horizontal orientation of the ACL. We compared tunnel position and orientation between transportal femoral drilling technique and transtibial technique. METHODS: Thirty-two patients were included. Post-operative CT scans were obtained and femur, tibia and ACL tunnels were reconstructed. The position and orientation of tibial and femoral tunnels were quantified using the quadrant method, and femoral tunnel length, ellipticity and posterior wall breakage were assessed. We also investigated clinical outcome. RESULTS: Analyses show that transportal drilled femoral tunnels were situated significantly lower than transtibial drilled tunnels (p<0.0001), resulting in a significantly more horizontal oriented ACL in the transportal group in coronal (p<0.0001) and sagittal plane (p=0.01). No differences were observed in depth of femoral tunnel position (p=0.44). Femoral tunnel length was shorter in the transportal group (p=0.01) with a more ellipsoidal femoral aperture (p=0.01). There were no differences between both groups in tibial position. There were no differences in clinical outcome measure between the transportal and transtibial groups. CONCLUSION: This study indicates that transportal drilling of the femoral tunnel leads to a more horizontal graft orientation of the ACL, without differences in clinical outcome.

TruFit Plug for Repair of Osteochondral Defects-Where Is the Evidence? Systematic Review of Literature.

OBJECTIVE: Treatment of osteochondral defects remains a challenge in orthopedic surgery. The TruFit plug has been investigated as a potential treatment method for osteochondral defects. This is a biphasic scaffold designed to stimulate cartilage and subchondral bone formation. The aim of this study is to investigate clinical, radiological, and histological efficacy of the TruFit plug in restoring osteochondral defects in the joint. DESIGN: We performed a systematic search in five databases for clinical trials in which patients were treated with a TruFit plug for osteochondral defects. Studies had to report clinical, radiological, or histological outcome data. Quality of the included studies was assessed. RESULTS: Five studies describe clinical results, all indicating improvement at follow-up of 12 months compared to preoperative status. However, two studies reporting longer follow-up show deterioration of early improvement. Radiological evaluation indicates favorable MRI findings regarding filling of the defect and incorporation with adjacent cartilage at 24 months follow-up, but conflicting evidence exists on the properties of the newly formed overlying cartilage surface. None of the included studies showed evidence for bone ingrowth. The few histological data available confirmed these results. CONCLUSION: There are no data available that support superiority or equality of TruFit compared to conservative treatment or mosaicplasty/microfracture. Further investigation is needed to improve synthetic biphasic implants as therapy for osteochondral lesions. Randomized controlled clinical trials comparing TruFit plugs with an established treatment method are needed before further clinical use can be supported.

A large community outbreak of gastroenteritis associated with consumption of drinking water contaminated by river water, Belgium, 2010.

SUMMARY On 6 December 2010 a fire in Hemiksem, Belgium, was extinguished by the fire brigade with both river water and tap water. Local physicians were asked to report all cases of gastroenteritis. We conducted a retrospective cohort study among 1000 randomly selected households. We performed a statistical and geospatial analysis. Human stool samples, tap water and river water were tested for pathogens. Of the 1185 persons living in the 528 responding households, 222 (18·7%) reported symptoms of gastroenteritis during the time period 6-13 December. Drinking tap water was significantly associated with an increased risk for gastroenteritis (relative risk 3·67, 95% confidence interval 2·86-4·70) as was place of residence. Campylobacter sp. (2/56), norovirus GI and GII (11/56), rotavirus (1/56) and Giardia lamblia (3/56) were detected in stool samples. Tap water samples tested positive for faecal indicator bacteria and protozoa. The results support the hypothesis that a point-source contamination of the tap water with river water was the cause of the multi-pathogen waterborne outbreak.

Enteroaggregative Shiga toxin-producing Escherichia coli of serotype O104:H4 in Belgium and Luxembourg.

In 2011, a large outbreak of infections caused by Shiga toxin-producing Escherichia coli (STEC) O104:H4 occurred in Germany. This exceptionally virulent strain combined virulence factors of enteroaggregative E. coli (EAggEC) and STEC. After the outbreak only a few sporadic cases of infection with this rare serotype were reported, most of which were related to travel to the Middle East or North Africa. Here we describe two cases of enteroaggregative STEC (Agg-STEC) O104:H4 infection that occurred in Belgium in 2012 and 2013 respectively. In both cases travel in a Mediterranean country preceded the infection. The first strain was isolated from the stool of a 42-year-old woman presenting bloody diarrhoea, who had travelled to Tunisia the week before. The second case involves a 14-year-old girl who, upon her return from Turkey to Belgium, suffered from an episode of bloody diarrhoea and haemolytic uraemic syndrome. Extended typing of the isolates with pulsed field gel electrophoresis revealed that the strains were closely related, though not exactly the same as the 2011 outbreak strain. This report supports the previously made hypothesis that Agg-STEC has a human reservoir and might be imported by travellers coming from an area where the pathogen is endemic. Furthermore, it emphasizes the concern that these bacteria may cause future outbreaks as evenly virulent O104:H4 isolates seem to be widespread.

Epidemiology and outcome of invasive pneumococcal disease among adults in Belgium, 2009-2011.

This epidemiological study examined morbidity and case fatality of invasive pneumococcal disease (IPD) in adults in Belgium as well as distribution and antibiotic susceptibility of Streptococcus pneumoniae serotypes.Adults hospitalised with microbiologically proven IPD were prospectively enrolled. The study started in 2009 with patients aged ≥50 years, whereas in 2010 and 2011, patients aged ≥18 years were included. The clinical presentation, patient profile, treatment, outcome, and mortality were recorded during hospitalisation.Outcome was also assessed one month afterdischarge. Of the 1,875 patients with IPD identified, 1,332 were included in the analysis. Bacteraemic pneumonia, affecting 1,049 of the patients, was the most frequent IPD type (79%), and chronic obstructive pulmonary disease and cancer were the main comorbidities.One-third of patients required admission to intensive care unit. A total of 208 (16%) patients died during hospitalisation and an additional 21 (2%) within one month after discharge. Case fatality rates of ≥20%were observed in patients with chronic heart failure, hepatic disease, and renal insufficiency. Serotypes 7F, 1, 19A, and 3 were the most prevalent and together accounted for 47% (569/1,214) of all IPD cases and 42% (80/189) of mortality. Of the patient isolates, 21% (255/1,204) were resistant to erythromycin and 22% (264/1,204) to tetracycline. Penicillin non-susceptibility was mostly found in serotype 19A isolates. These baseline data are essential when assessing the impact of pneumococcal conjugate vaccination in adults in the future.

Laboratory diagnosis of schistosomiasis and Katayama syndrome in returning travellers.

The gold standard for laboratory diagnosis of schistosomiasis is the presence of typical eggs in stool or urine. The laboratory diagnosis of schistosomiasis and Katayama syndrome in returning travellers is difficult because the number of excreted eggs is often very limited. In early infections and in patients with only a few contacts with contaminated water, the total number of parasites, migrating larvae or schistosomulae, and adult worms, is very low. Eggs can only be found in faeces or urine when there is at least one pair of adult worms at the final location. The number of parasites increases as a function of the number of contacts with infected water. The exact latency between contamination and egg production is unknown. It is estimated that excretion of eggs starts after 40-50 days. The specific diagnosis of early schistosomiasis and Katayama fever relies essentially on serologic tests or preferably on PCR (if available). These assays are much more sensitive (up to four times) in the early phase of schistosomiasis than microscopic examination for typical eggs. Eosinophilia (sometimes exceeding 50%) is often present in patients with acute schistosomiasis (Katayama fever), but may be limited or absent in late fibrotic manifestations of the disease.

Stimulation of the i.v. to oral switch of bioavailable drugs by phone calls in a Belgian tertiary care hospital.

INTRODUCTION: Early switch from intravenous to oral administration of drugs with an almost complete oral bioavailability, can have important benefits. Drugs with almost complete bioavailability, like clindamycin (Dalacin), levofloxacin (Tavanic) and paracetamol (Perfusalgan/Dafalgan), are very suitable for an early intravenous to oral switch in patients whose gastrointestinal absorption is intact. The aim of this study was to investigate the impact of direct phone contact between pharmacist and clinician on the intravenous to oral switch and to evaluate the reasons, mentioned by clinicians, that prevented an early switch. MATERIALS & METHODS: The project was initiated in a Belgian 1900-bed tertiary care hospital with a poster, communicated through the hospital's intranet and spread to every hospital ward. During one month, all prescriptions for intravenous clindamycin, levofloxacin and paracetamol were evaluated. The treating clinician was contacted by phone to evaluate if an intravenous to oral switch was possible. RESULTS: Clinicians were contacted concerning 377 patients. For 58.7% of patients, the switch from intravenous to oral administration was made. In case of refusal, several reasons were mentioned by the clinician, some more appropriate than others. CONCLUSION: Despite several appropriate reasons preventing an early intravenous to oral switch, there are still some aberrant opinions circulating in the hospital environment. Active interventions of pharmacists to stimulate intravenous to oral switch, using phone contact with the treating clinicians, can possibly be an adequate technique to stimulate intravenous to oral switch, but this needs to be further optimized.

Identification of coryneform Actinomyces neuii by MALDI-TOF MS: 5 case reports and review of literature.

OBJECTIVES: We describe five cases of Actinomyces neuii, isolated from different clinical specimens over a period of five months (from June to October 2011), followed by a review of literature on infections with this micro-organism. METHODS: All Actinomyces neuii strains were cultured or subcultured on horse blood agar. Identification took place using matrix-assisted laser desorption ionisation time-of-flight mass spectrometry (MALDI-TOF MS). Identification was confirmed by conventional biochemical tests and API Coryne test strips (BioMérieux SA). Susceptibility testing was performed on Mueller-Hinton agar supplemented with horse blood, using E-tests (BioMérieux SA). The minimal inhibitory concentrations were determined after 24 and 48 hours of incubation in a 5% CO2 environment. RESULTS: Isolation of this micro-organism was associated with abscesses in two patients and chronic osteomyelitis in one patient. The remaining two patients had positive blood cultures which grew Actinomyces neuii, either as contamination or as catheter-related infection. All Actinomyces neuii identifications were obtained by MALDI-TOF MS and were confirmed by conventional biochemical and API Coryne tests. Identification of one isolate was also confirmed by 16S rRNA sequencing. All strains were susceptible to penicillin. One strain showed heteroresistance for macrolides and lincosamides. Minimal inhibitory concentrations were more reliable and easier to read after 48 hours of incubation, as compared to 24 hours. CONCLUSION: MALDI-TOF MS analysis allows rapid and reliable identification of Actinomyces neuii, even at subspecies level.

Antimicrobial resistance to benzylpenicillin in invasive pneumococcal disease in Belgium, 2003-2010: the effect of altering clinical breakpoints.

The Belgian data (2003-2010) for the European Antimicrobial Resistance Surveillance Network (EARS-Net) showed a significant decreasing trend in the proportion of penicillin non-susceptible Streptococcus pneumoniae (9·4% to <1%) from blood and CSF isolates. We found that 75% of this decrease was explained by a change in Clinical and Laboratory Standards Institute (CLSI) breakpoints as the trend disappeared if only the new breakpoints were applied. Applying only European Committee on Antimicrobial Susceptibility Testing (EUCAST) breakpoints also resulted in a relatively stable proportion of penicillin non-susceptibility (average 5%), but this proportion was 7-13 times higher than with the new CLSI breakpoints. When the new CLSI breakpoints alone are used, fewer than 1% of bacteraemia isolates were penicillin non-susceptible during the entire period, but the proportion of non-susceptible meningitis isolates rose from 6·3% in 2003 to 15·9% between 2003 and 2010. Changing breakpoints should lead to retrospective analysis of historical data to minimize wrongly interpreting resistance trends.

Comparison of two treatment regimens for eradication of Pseudomonas aeruginosa infection in children with cystic fibrosis.

UNLABELLED: In patients with cystic fibrosis (CF), treatment of new Pseudomonas aeruginosa (Pa) infection postpones the occurrence of chronic infection, but the best eradication regimen is unknown . AIM OF THE STUDY: Compare 2 Pa eradication regimens in children with new Pa infection. METHODS: Children with CF (0-18 years) and a new isolation of Pa from sputum, cough swab or BAL were randomized to treatment with tobramycin inhalation solution for 28 days (TIS) or inhaled sodiumcolistimethate (2×2millU/day) plus oral ciprofloxacin (30 mg/kg/day) for 3 months (CC). Airway cultures were taken for 6 consecutive months, then every 3 months. The primary outcome was Pa eradication at the end of treatment. Secondary outcome parameters were: time to Pa relapse from end of treatment, total and Pa specific IgG, FEV(1), BMI and Pa status at 2year follow-up. RESULTS: 58 patients with new Pa isolation were randomized. Their median age was 9 years (IQR 4.7-13.1) and their median FEV(1) 98% predicted (IQR 87-107). Eighteen treatments concerned the first Pa isolation 'ever' (TIS: 8; CC: 10). For the remaining, median time since previous Pa was 19 months (IQR 9-41). Eradication at end of treatment was similar for both treatments: 26/29 CC and 23/29 in TOBI treated patients (p=0.47). Median time to recurrence of Pa was 9 months (95% CI 0.0-19.0) for CC and 5 months (95% CI 1.7-8.3) for TIS (p=0.608). After 1 year, the 2 groups did not differ in change in total and Pa specific IgG, FEV(1) and BMI. After 2 years, 10% of patients had chronic Pa infection. CONCLUSION: In children with CF and new Pa infection, inhalation of TIS (28 days) or CC (3 months) resulted in similar eradication success at the end of treatment (80 and 90% respectively) and similar clinical evolution during the first 2 years of follow-up.

Comparison of different phenotypic assays for the detection of extended-spectrum ß-lactamase production by inducible AmpC-producing Gram-negative bacilli.

Routine detection of extended-spectrum ß-lactamase (ESBL) production by AmpC-producing Enterobacteriaceae in microbiology laboratories is still a problem. The aim of this study was to compare the performance of four different phenotypic ESBL confirmation assays within this group of Enterobacteriaceae. A total of 83 AmpC-inducible Enterobacteriaceae were included in this study (58 clinical isolates with presumptive ESBL production and 25 molecularly characterized ESBL-producing isolates). Each isolate was tested for the presence of an ESBL enzyme by four phenotypic ESBL confirmation assays: ESBL Etests and combined double-disk synergy tests (CDDST), both on Mueller-Hinton (MH) agar with and without the use of cloxacillin, an AmpC inhibitor. Our study showed that performing a CDDST on MH agar with cefotaxime as the only indicator cephalosporin is not a reliable way to detect ESBL-encoding genes among chromosomal AmpC-producing Enterobacteriaceae due to its low sensitivity (52 %). The use of cloxacillin in this CDDST could only significantly increase the specificity of the CDDST when used with ceftazidime as the indicator [sensitivity (SN), 92 %; specificity (SP), 93 %]. Regarding ESBL Etest® strips, the sensitivity of the cefepime strip (80 %) was significantly higher compared to the cefotaxime and ceftazidime strips (16 % and 32 %, respectively). Adding cloxacillin to the MH agar improved the ESBL detection of each of these strips. We recommend the CDDST on MH agar supplemented with cloxacillin and ceftazidime or cefepime as the indicator cephalosporin as the most cost-efficient strategy to confirm ESBL production in inducible AmpC-producing Enterobacteriaceae.

A forgotten disease in a returning traveler from Thailand.

Cutaneous diphteria is a forgotten disease. We must consider this in our differential diagnosis, not only when a patient presents with a cutaneous ulcer and has travelled to tropical areas, but also in patients who subsist in low socio-economic conditions, especially in homeless people and people with a history of alcohol or drug abuse. Vigilance for this forgotten disease is warranted because most physicians in developed countries have never seen one case. In an era of increasing globalisation, we might see more cases in the future. We report a case of a foot infection with a non toxigenic C. diptheriae biovar gravis in a 16 year old girl, who has travelled to Thailand.

High incidence of bloodstream infection detected by surveillance blood cultures in hematology patients on corticosteroid therapy.

PURPOSE: The aim of our study was to evaluate the frequency of "occult" bacteremia/fungemia as well as the diversity of pathogens involved in hematology patients treated with corticosteroids. METHODS: Daily surveillance blood cultures were taken from patients treated with corticosteroids as part of their intensive chemotherapy or during graft-versus-host disease following hematopoietic stem cell transplantation during a 3-year period (2006-2009). We reviewed the frequency of occult bacteremia/fungemia as well as the pathogens involved. RESULTS: During the 3-year period, 3,821 bottles were cultured from 215 patients and 4.9 % of the bottles tested were positive. Surveillance blood cultures revealed bloodstream infection in 24 % of the patients (definite bloodstream infection in 16 %). Seventy-five percent of patients were still afebrile when microorganisms were detected. The main risk group was acute lymphocytic leukemia patients undergoing remission induction chemotherapy. The pathogens cultured most frequently were coagulase-negative staphylococci, enterococci, Escherichia coli, and Pseudomonas aeruginosa. CONCLUSIONS: A high incidence of occult bacteremia was detected by surveillance blood cultures. Further studies are needed to evaluate if a strategy based on surveillance blood cultures can reduce mortality related to bloodstream infections.