Acute hepatitis C in the Netherlands: characteristics of the epidemic in 2014.

Within the Dutch Acute HCV in HIV Study, a surveillance system was initiated to estimate the incidence of hepatitis C virus (HCV) infections in 2014. Following the Dutch HIV treatment guidelines, HIV-positive men having sex with men (MSM) in 19 participating centers were screened. Ninety-nine acute HCV infections were reported, which resulted in a mean incidence of 11 per 1000 patient-years of follow-up. Unfortunately, the HCV epidemic among Dutch HIV-positive MSM is not coming to a halt.

Cutaneous hyperpigmentation induced by doxycycline: a case series.

Cutaneous hyperpigmentation is a well-known side effect of tetracyclines, but doxycycline-induced cutaneous hyperpigmentation has only been described in one patient with a therapeutic dosage of doxycycline, and in one patient using suprapharmacological doses. We describe four patients with cutaneous hyperpigmentation in previously unaffected skin, and speculate that this was due to treatment with doxycycline in therapeutic doses. After cessation of therapy, the hyperpigmentation diminished in all four patients, illustrating the need for recognition and timely cessation of therapy.

A combination of interferon-gamma and interleukin-2 production by Coxiella burnetii-stimulated circulating cells discriminates between chronic Q fever and past Q fever.

Infection with Coxiella burnetii may lead to life-threatening chronic Q fever endocarditis or vascular infections, which are often difficult to diagnose. The present study aims to investigate whether measurement of in-vitro interferon-gamma (IFN-γ) production, a key cytokine in the immune response against C. burnetii, differentiates chronic from a past cleared infection, and whether measurement of other cytokines would improve the discriminative power. First, C. burnetii-specific IFN-γ production was measured in whole blood of 28 definite chronic Q fever patients and compared with 135 individuals with past Q fever (seropositive controls) and 908 seronegative controls. IFN-γ production was significantly higher in chronic Q fever patients than in controls, but with overlapping values between patients and seropositives. Secondly, the production of a series of other cytokines was measured in a subset of patients and controls, which showed that interleukin (IL)-2 production was significantly lower in patients than in seropositive controls. Subsequently, measuring IL-2 in all patients and all controls with substantial IFN-γ production showed that an IFN-γ/IL-2 ratio >11 had a sensitivity and specificity of 79% and 96%, respectively, to diagnose chronic Q fever. This indicates that a high IFN-γ/IL-2 ratio is highly suggestive for chronic Q fever. In an additional group of 25 individuals with persistent high anti-Coxiella phase I IgG titres without definite chronic infection, all but six showed an IFN-γ/IL-2 ratio <11. In conclusion, these findings hold promise for the often difficult diagnostic work-up of Q fever and the IFN-γ/IL-2 ratio may be used as an additional diagnostic marker.

Combined infection of vertebroplasty and aortic graft after intravesical BCG treatment.

We report a 58-year-old man with spondylodiscitis by Mycobacterium bovis-BCG 3 years after intravesical BCG treatment, and shortly after a vertebroplasty. Further examination showed a psoas abscess and oedema around an endovascular aortic graft, which had been placed 1 year earlier. Puncture of the psoas abscess also grew M bovis-BCG. The patient recovered with a combination of antituberculous treatment and surgery. With hindsight a mycotic aneurysm had been present at the time of aortic graft placement and spondylodiscitis at the time of vertebroplasty. This case shows that low grade and longstanding infections may occur following intravesical BCG installation.

Chronic Q fever: review of the literature and a proposal of new diagnostic criteria.

A review was performed to determine clinical aspects and diagnostic tools for chronic Q fever. We present a Dutch guideline based on literature and clinical experience with chronic Q fever patients in The Netherlands so far. In this guideline diagnosis is categorized as proven, possible or probable chronic infection based on serology, PCR, clinical symptoms, risk factors and diagnostic imaging.

Adherence to local hospital guidelines for surgical antimicrobial prophylaxis: a multicentre audit in Dutch hospitals.

OBJECTIVE: To study the adherence to local hospital guidelines for antimicrobial prophylaxis in surgery, and explore reasons for non-adherence. METHODS: A prospective, multicentre audit of elective procedures, without prior suspicion of infection, was carried out in 13 Dutch hospitals. By reviewing medical, anaesthetic and nursing records, and medication charts, the prescription of antibiotics was compared with the local hospital guideline on antibiotic choice, duration of prophylaxis, dose, dosing interval and timing of the first dose. RESULTS: Between January 2000 and January 2001, 1763 procedures were studied. Antibiotic choice, duration, dose, dosing interval and timing of the first dose were concordant with the hospital guideline in 92%, 82%, 89%, 43% and 50%, respectively. Overall adherence to all aspects of the guideline, however, was achieved in only 28%. The most important barriers to local guideline adherence were lack of awareness due to ineffective distribution of the most recent version of the guidelines, lack of agreement by surgeons with the local hospital guidelines, and environmental factors, such as organizational constraints in the surgical suite and in the ward. CONCLUSION: This study shows that, although adherence to separate aspects of local hospital guidelines for surgical prophylaxis in the Netherlands is favourable, overall adherence to all parameters is hard to achieve. Adherence to guidelines on dosing interval and timing needs improvement, in particular. To increase the quality of antimicrobial prophylaxis in surgery, effort should be put into developing guidelines acceptable to surgeons, in adequately distributing the guidelines and to facilitating logistics. Audits of surgical prophylaxis may help hospitals identify barriers to guideline adherence.

[Optimizing antibiotics policy in the Netherlands. V. SWAB guidelines for perioperative antibiotic prophylaxis. Foundation Antibiotics Policy Team]. / Optimaliseren van het antibioticabeleid in Nederland. V. SWAB-richtlijnen voor perioperatieve antibiotische profylaxe.

The Stichting Werkgroep Antibioticabeleid (SWAB, Foundation Antibiotics Policy Team) has issued guidelines for perioperative antibiotic prophylaxis in Dutch hospitals. Antibiotic prophylaxis is generally recommended for surgical procedures with relatively high postoperative infection rates and those in which consequences of infection are really serious. Studies have revealed that prophylaxis given within two hours before incision is most effective. Short-term, preferably single-dose prophylaxis, is as effective as multiple-dose prophylaxis in most procedures. For reasons of cost effectiveness and prevention of induction of resistance, single-dose prophylaxis is recommended. The antimicrobial agent of choice for perioperative prophylaxis should not be widely used as a therapeutic agent, should be selectively active against micro-organisms most frequently isolated from surgical site infections, and should have a plasma-half-life that makes single-dosing possible for most operations. Therefore cefazoline is an agent that is widely used for perioperative prophylaxis.

[Optimizing the antibiotics policy in the Netherlands. IV. SWAB- guidelines for antimicrobial therapy of adults with sepsis in hospitals. Foundation Antibiotics Policy Work Group]. / Optimaliseren van het antibioticabeleid in Nederland. IV. SWAB-richtlijnen voor antimicrobiële therapie in het ziekenhuis bij volwassenen met sepsis.

The Stichting Werkgroep Antibioticabeleid (SWAB, Foundation Antibiotic Policy Team) issued guidelines for empirical antimicrobial therapy in the hospital of sepsis in adults. A distinction is made between sepsis in patients with and patients without neutropenia. Patients without neutropenia are subdivided according to the setting where they contracted sepsis: at home, in the hospital or in the intensive-care unit. Because of the diversity in antibiotic spectrum of the different classes of cephalosporins, they can be used in all the categories of sepsis. The use of antibiotics with a very broad spectrum, like carbapenems and piperacillin-tazobactam, or antibiotics which can be applied in infections with microorganisms difficult to treat, like quinolones and glycopeptides, is limited in the empirical treatment of sepsis in order to combat development of resistance. It is crucial to streamline antibiotic therapy as soon as the causative agent of the sepsis is known; this includes choosing an antibiotic with the narrowest possible spectrum.

[Optimizing antibiotics use policy in the Netherlands. I. The Netherlands Antibiotics Policy Foundation (SWAB)]. / Optimaliseren van het antibioticabeleid in Nederland. I. De Stichting Werkgroep Antibioticabeleid (SWAB).

The worldwide problem of antibiotic resistance of bacteria is a point of concern in the Netherlands as well. Responsible use of existing antibiotics was the incentive to establish a foundation, with the acronym SWAB, the primary goal of which is to optimize the use of antibiotics in the Netherlands in order to diminish the development of antibiotic resistance. One of the SWAB projects is the development of national guidelines for the use of antibiotics in hospitals. These guidelines are prepared by a committee of experts and reviewed by external consultants: infectious disease specialists, medical microbiologists and pharmacists. The revised version of the guidelines is submitted for publication in this journal. The SWAB hopes that these guidelines will make the prevention of antibiotic resistance a major factor in the choice of the antibiotic. Streamlining antibiotic therapy is an important tool in this respect.

[Optimization of the antibiotics policy in the Netherlands. II. SWAB guidelines for the antimicrobial therapy of pneumonia in patients at home and as nosocomial infections. The Netherlands Antibiotic Policy Foundation]. / Optimaliseren van het antibioticabeleid in Nederland. II. SWAB-richtlijnen voor antimicrobiële therapie bij thuis opgelopen pneumonie en bij nosocomiale pneumonie.

The Netherlands Antibiotic Policy Foundation issued guidelines for empirical antimicrobial therapy of adult pneumonia patients in hospitals. A distinction is made between pneumonia contracted at home or in hospital because of the differences in micro-organisms and resistance patterns. These two categories are subdivided further with an empirical antibiotic treatment being chosen on the basis of the causative agents to be expected. For instance, pneumonia contracted at home is mostly caused by Streptococcus pneumoniae, to be treated with benzylpenicillin or amoxicillin. With regard to nosocomial pneumonia, treatment varies according to whether a pneumonia has or has not been contracted in the intensive care unit. Combating development of resistance is alloted an important place. Emphasis is laid on 'streamlining' the therapy, i.e. its adjustment (including choosing an antibiotic with the narrowest possible spectrum) once the causative agent is known.

[Optimizing of antibiotics policy in the Netherlands. III. SWAB guidelines for antimicrobial therapy in adults hospitalized with bronchitis. Foundation Antibiotics Policy Work Group]. / Optimaliseren van het antibioticabeleid in Nederland. III. SWAB-richtlijnen voor antimicrobiële therapie bij volwassenen met bronchitis in het ziekenhuis.

The Stichting Werkgroep Antibioticabeleid (SWAB, Foundation Antibiotics Policy Team) has issued guidelines for empirical antimicrobial therapy of adult patients with bronchitis in hospital. Acute bronchitis is rarely caused by bacteria: therefore antibiotic treatment is not indicated in most cases. In an exacerbation of asthma or chronic obstructive pulmonary disease (COPD), the primary treatment aims at combating the inflammatory reaction and the bronchospasm. In case of increasing dyspnoea, (increase of) sputum production and (increase of) purulence of the sputum, antibiotic treatment may lead to shortening of the symptoms and sickness duration. Doxycycline is to be preferred because of its spectrum, easy dosage and favourable price. If the patient has not had antibiotics earlier, amoxicillin also is a good choice. Macrolide antibiotics are no preparations of first choice because large-scale use readily leads to resistance.

[Rational use of antibiotics by the dentist can prevent microbial resistance]. / Rationeel antibioticagebruik door tandarts kan resistentie voorkomen.

Worldwide resistance of microorganisms to antibiotics is becoming a problem of major concern. An antibiotic policy which tries to control the development of resistance by rational use is needed in all fields where antibiotics are prescribed. In dental practice, apart from endocarditisprophylaxis, prophylaxis is leukopenic patients and prophylaxis after dental implants, antibiotics can be used to support local therapy of an dentoalveolar abscess or refractory periodontitis. In the majority of these cases, a small spectrum penicillin is therapy of choice.

[Current antimicrobial drugs]. / Nieuwe antimicrobiële geneesmiddelen.

In the past few years several new antibiotics became available, but no major inventions as to new treatment strategies were made. There are a few new broad-spectrum antibiotics for the intravenous route like piperacillin-tazobactam, the carbapenem meropenem and the fourth-generation cephalosporins. cefepime and cefpirome. New oral antibiotics include the third-generation cephalosporins ceftibuten, cefetamet and cefpodoxime and the macrolides clarithromycin and azithromycin. The last two have the great advantage of less frequent dosing and fewer side effects than erythromycin. Of the two new quinolones, sparfloxacin and trovafloxacin, trovafloxacin is the more promising. In the treatment of Gram-positive infections the glycopeptide teicoplanin became available and the combined derivatives quinupristin-dalfopristin may prove valuable in the future.

Epithelioid haemangioendothelioma of the lung: clinical and pathological pitfalls.

In 1973, a 10 year old boy presented with numerous bilateral lung nodules, diagnosed as histiocytosis X by open lung biopsy. The patient was treated with prednisone until 1984. In 1993, he developed severe pain in the neck. A biopsy of the spine revealed the same tumour morphology as was seen in the lung in 1973. Immunohistological examination of the former and present biopsy led to the definitive diagnosis of epithelioid haemangioendothelioma of the lung with metastases to spine and liver. Epithelioid haemangioendothelioma of the lung is a rare soft tissue tumour of vascular origin, readily mistaken for carcinoma or, as in this case, histiocytosis. The tumour has an intermediate malignant potential. Although metastases of epithelioid haemangioendothelioma of the lung are well-known, metastatic spread to bones, as in our case, has not previously been mentioned in the literature.

Long term follow up of radiosynovectomy with yttrium-90 silicate in haemophilic haemarthrosis.

OBJECTIVES: The aim of this study was to evaluate the long term effect of radiation synovectomy with yttrium-90 silicate in haemophiliac patients with recurrent haemarthrosis. METHODS: The bleeding frequency and the mobility of the joint were recorded in 16 joints of 14 patients 1 year before radiosynovectomy and during follow up, which ranged from 3 to 6 years. Patients evaluated the effect of their own treatment by completing a questionnaire. Radiographs of the joints were scored by an independent radiologist before treatment. RESULTS: A satisfactory reduction of the frequency of haemorrhage was achieved in 94% of joints during the first year after treatment and was maintained in 63% until the end of the follow up period. In general there was no decrease in mobility attributable to radiosynovectomy, and the patients' own evaluations agreed with the evaluations based on the frequencies of haemarthrosis in 75%. Patients who had only minor, or no, radiological abnormalities of the joints before treatment showed the best results. One patient developed synovitis as a complication of the radiosynovectomy. CONCLUSION: Radiosynovectomy is an effective and safe treatment for recurrent haemarthrosis in haemophiliac patients, especially in those who have joints with no or minor radiological damage.