[Epidemiology, diagnostics, therapy, prevention and management of uncomplicated bacterial outpatient acquired urinary tract infections in adult patients : Update 2017 of the interdisciplinary AWMF S3 guideline]. / Epidemiologie, Diagnostik, Therapie, Prävention und Management unkomplizierter, bakterieller, ambulant erworbener Harnwegsinfektionen bei erwachsenen Patienten : Aktualisierung 2017 der interdisziplinären AWMF S3­Leitlinie.

BACKGROUND: Update of the 2010 published evidence-based S3 guideline on epidemiology, diagnostics, therapy and management of uncomplicated, bacterial, outpatient-acquired urinary tract infections in adult patients. The guideline contains current evidence for the rational use of antimicrobial substances, avoidance of inappropriate use of certain antibiotic classes and development of resistance. METHODOLOGY: The update was created under the leadership of the German Association of Urology (DGU). A systematic literature search was conducted for the period 01 January 2008 to 31 December 2015. International guidelines have also been taken into account. Evidence level and risk of bias were used for quality review. RESULTS: Updated information on bacterial susceptibility, success, collateral damage and safety of first- and second-line antibiotics was given. For the treatment of uncomplicated cystitis the first line antibiotics are fosfomycin trometamol, nitrofurantoin, nitroxoline, pivmecillinam, trimethoprim (with consideration of the local resistance rates). Fluoroquinolones and cephalosporins should not be used as first choice antibiotics. In the case of uncomplicated pyelonephritis of mild to moderate forms, preferably cefpodoxime, ceftibuten, ciprofloxacin or levofloxacin should be used as oral antibiotics. CONCLUSION: The updated German S3 guideline provides comprehensive evidence- and consensus-based recommendations on epidemiology, diagnostics, therapy, prevention and management of uncomplicated bacterial outpatient acquired urinary tract infections in adult patients. Antibiotic stewardship aspects have significantly influenced the therapeutic recommendations. A broad implementation in all clinical practice settings is necessary to ensure a foresighted antibiotic policy and thus t improve clinical care.

Outbreak of carbapenem-resistant Acinetobacter baumannii in the intensive care unit: a multi-level strategic management approach.

An outbreak of carbapenem-resistant Acinetobacter baumannii (CRAb) occurred in an interdisciplinary intensive care unit, affecting 10 patients. Within hours of recognition of the spread of CRAb an intervention team was instituted for collection of available data, decision-making, communication and monitoring of all interventions performed, including cohorting, temporary stop of admissions, staff education, and enforcement of infection control measures. An area was defined for cohortation of patients colonized with CRAb, with a separate nursing team and a second set of mobile equipment. New transmissions were no longer observed after only four days into the institution of enhanced infection control measures.

Outcome of patients with acute, necrotizing pancreatitis requiring drainage-does drainage size matter?

AIM: To assess the outcome of patients with acute necrotizing pancreatitis treated by percutaneous drainage with special focus on the influence of drainage size and number. METHODS: We performed a retrospective analysis of 80 patients with acute pancreatitis requiring percutaneous drainage therapy for infected necroses. Endpoints were mortality and length of hospital stay. The influence of drainage characteristics such as the median drainage size, the largest drainage size per patient and the total drainage plane per patient on patient outcome was evaluated. RESULTS: Total hospital survival was 66%. Thirty-four patients out of all 80 patients (43%) survived acute necrotizing pancreatitis with percutaneous drainage therapy only. Eighteen patients out of all 80 patients needed additional percutaneous necrosectomy (23%). Ten out of these patients required surgical necrosectomy in addition, 6 patients received open necrosectomy without prior percutaneous necrosectomy. Elective surgery was performed in 3 patients receiving cholecystectomy and one patient receiving resection of the parathyroid gland. The number of drainages ranged from one to fourteen per patient. The drainage diameter ranged from 8 French catheters to 24 French catheters. The median drainage size as well as the largest drainage size used per patient and the total drainage area used per patient did not show statistically significant influence on mortality. CONCLUSION: Percutaneous drainage therapy is an effective tool for treatment of necrotizing pancreatitis. Large bore drainages did not prove to be more effective in controlling the septic focus.

Outcome of hemato-oncologic patients with and without stem cell transplantation in a medical ICU.

OBJECTIVE: To assess the outcome of a mixed population of critical ill patients with haematological malignancies with special focus on the comparison of patients who underwent stem cell transplantation with non-transplanted patients. METHODS: Retrospective, unicentric analysis of 94 critical ill cancer patients in a tertiary care centre in a period of two years time. RESULTS: We analysed different variables at admission as well as different treatment modalities during the ICU stay. We compared the outcome by using chi-square test by Pearson for categorical variables and Kaplan-Meier as well as Cox-Regression for survival analysis. The general patients characteristics did not significantly differ between transplanted and non-transplanted patients. The overall ICU and hospital mortality were 43% and 54%. Considering just patients with mechanical ventilation we found ICU and hospital mortalities of 65% and 82% in the stem cell transplantation group vs. 67% and 74% in the non-transplanted group, respectively. As risk factors for overall mortality in multivariate analysis only the Simplified Acute Physiology Scale II and the need of ventilation remained significant. Between the underlying diseases mortality did not show significant differences at all. CONCLUSIONS: The outcome and prognosis of critical ill cancer patients has generally slightly improved over the last years. Our data show no statistically significant differences regarding outcome and prognosis between stem cell transplanted and non-transplanted patients receiving ICU treatment. A stem cell transplantation should not be considered a strong contraindication for ICU treatment or artificial ventilation.

[Cholestasis and vomiting: unusual differential diagnosis in a case of Peutz-Jeghers syndrome]. / Cholestase und Erbrechen. Eine ungewöhnliche Differentialdiagnose bei Peutz-Jeghers-Syndrom.

HISTORY AND CLINICAL FINDINGS: A 54-year-old patient with painless jaundice and vomiting had been diagnosed with a Peutz-Jeghers syndrome 20 years before. INVESTIGATIONS: The blood analysis showed a cholestatic constellation as well as increased transaminases. Sonographic, radiological, endoscopic and histological findings indicated multiple hamartomatous polyps of the Peutz-Jeghers' type in the entire small and large bowel with occlusion of the papilla of Vater and the superior gastrointestinal tract by a big polyp. TREATMENT AND COURSE: After an initial percutaneous transhepatic cholangiographic drainage, Whipple's operation and a segmental resection of small and large bowel were performed. A highly differentiated adenocarcinoma of the duodenum was found in the resected specimen. CONCLUSION: This case demonstrates the potentially severe complications of a Peutz-Jeghers syndrome that had been neglected for years.