Factors associated with rifampin resistance in staphylococcal periprosthetic joint infections (PJI): a matched case-control study.

PURPOSE: Rifampin combination therapy plays an important role in the management of staphylococcal periprosthetic joint infection (PJI). However, the emergence of rifampin resistance is a feared complication. We retrospectively analysed predetermined potential risk factors in patients with rifampin-resistant staphylococcal PJI in a multicentre case-control study. METHODS: Cases (n = 48) were defined as PJI caused by rifampin-resistant staphylococci. Rifampin-susceptible controls (n = 48) were matched for microorganism and type of prosthetic joint. Uni- and multivariable conditional logistic regression analyses were performed to estimate odds ratios (OR) with 95 % confidence intervals (95 % CI). RESULTS: Forty-eight cases (31 men; median age 67 years; age range 39-88 years) with hip- (n = 29), knee- (n = 13), elbow- (n = 4), shoulder- (n = 1) or ankle-PJI (n = 1) were enrolled in the study. Staphylococcus aureus and coagulase-negative staphylococci were isolated in ten and 38 episodes, respectively. Most of the cases (n = 44, 92 %) had a previous PJI, and 93 % (n = 41) of these had been treated with rifampin. There was an independent association of emergence of rifampin resistance with male sex (OR 3.6, 95 % CI 1.2-11), ≥ 3 previous surgical revisions (OR 4.7, 95 % CI 1.6-14.2), PJI treatment with high initial bacterial load (inadequate surgical debridement, <2 weeks of intravenous treatment of the combination medication; OR 4.9, 95 % CI 1.6-15) and inadequate rifampin therapy (OR 5.4, 95 % CI 1.2-25). CONCLUSIONS: Based on our results, extensive surgical debridement and adequate antibiotic therapy are needed to prevent the emergence of rifampin resistance.

Factors associated with positive blood cultures in outpatients with suspected bacteremia.

Blood cultures are routinely taken in outpatients with fever and suspected bacterial infections. However, in the majority of cases, they are not informative and of limited value for clinical decision making. The aim of this study was therefore to investigate factors associated with positive blood cultures in outpatients presenting to an outpatient clinic and emergency room. This was a case-control study of all outpatients with positive blood cultures from January 1, 2006 to October 31, 2007 and matched control patients with negative blood cultures in the same time period. Microbiology results and medical charts were reviewed to determine factors associated with positive blood cultures. The presence of a systemic inflammation response syndrome (SIRS) (OR 2.7, 95% Cl 1.0-7.2) and increased C-reactive protein (CRP) (OR 1.1 per 10 mg/l, 95% Cl 1.0-1.2) were the most powerful predictive values for the development of positive blood cultures. In positive cases serum albumin was lower (35 mg/l versus 39 mg/l) than in controls. SIRS, increasing CRP and low albumin were associated with positive blood cultures in outpatients. With simple clinical assessment and few laboratory tests indicative of infection, it is possible to define a group at higher risk for bacteremia in outpatients.

[Headaches and aphasia in an immunocompromised patient]. / Kopfschmerzen und Wortfindungsstörungen bei einem immunsupprimierten Patienten.

We report the case of a 81-year-old, immunocompromised Patient, admitted to our hospital with new-onset headaches and word-finding difficulties. The MRI of the brain revealed a temporal mass on the left with marginal contrast-enhancement. During the next days Listeria monocytogenes grew in the bloodcultures so that the diagnosis of a brain-abscess caused by Listeria was established. Due to the localisation, surgical drainage of the abscess was not possible, so that a prolonged antibiotic therapy lasting over 4.5 months was initiated. The MRI after therapy demonstrated no abscess persistence. Listeria mostly cause infections in the immunocompromised, elderly, newborn or pregnant host. Next to bacteraemia without a focus, CNS-invasion with meningitis, meningoencephalitis or less frequent abcess-formation (5-10%) is the most important manifestation.

[Early gastric cancer--or not]. / Magenfrühkarzinom oder doch nicht?

A 46-year old female patient presented with non-specific epigastric discomfort that had been present for 6 months. Endoscopic work-up showed a small gastric polyp and biopsy samples revealed adenocarcinoma. There was no evidence of metastatic disease or penetration of the muscle layer on endosonography, rating the tumor as early gastric cancer. Endoscopic submucosal dissection was unsuccessful due to bleeding complications and the patient was treated with subtotal gastrectomy. Surprisingly, the final histological diagnosis revealed a highly differentiated neuroendocrine tumor and the initial diagnosis had to be revised.

[Hyperprolactinemia in a man's world]. / Hyperprolaktinämie - in a man's world.

A 60-years old patient was admitted for mamillary pain for several weeks, without galactorrhea. Erectile dysfunction had been present for several years but diminished libido had developed only recently. Ultrasonography of the mamillary gland was not definite for gynecomastia but repeated serum prolactin concentrations were elevated 5-fold the upper limit of normal. Furthermore serum level of testosterone was decreased and levels of luteinizing hormone and follicle-stimulation hormone were within normal range. Magnetic resonance imaging (MRI) of the pituitary gland could not identify a tumoral mass. In review of the laboratory features and the absence of a tumoral mass on MRI, idiopathic hyperprolactinemia was diagnosed and therapy with a dopamine-agonist was started.

[Tuberculous lymphadenitis]. / Zervikale Lymphknotenschwellung.

We report a case of a 49-year-old woman from the Philippines, who has been living for many years in Switzerland, with chronic unilateral swelling of the cervical lymphnodes. After the serological exclusion of several microorganisms, a fine needle aspiration was performed without conclusive result. However, patient history and a strongly positive PPD skin test were highly suspicious for tuberculous lymphadenitis, which was finally confirmed by lymphnode biopsy on histopathological and cultural workup. Therefore tuberculostatic treatment was initiated for 6 months.

[Therapy-refractory arterial hypertension in a young patient]. / Therapierefraktäre arterielle Hypertonie bei einem jungen Patienten.

We report on a 41-year-old patient admitted for refractory arterial hypertension that had developed after a curative chemotherapy regimen due to seminoma stadium IIb four years ago. After exclusion of secondary forms of arterial hypertension (actually unsuccessfully treated with 5 different antihypertensive drugs) we performed a controlled medication intake-trial in our outpatient clinic. 90 minutes after taking the pills the patient complained of dizziness and perspiration while hypotension and bradycardia were measured simultaneously. Due to the difficult psychosocial situation (conflicts with the insurance and in the family, financial problems) and the suspected narcisstic personality disorder the issue of the proven malcompliance was not openly discussed in order to preserve the patient-doctor alliance. The antihypertensive regimen was then reduced to a double regimen. In the second part of the article the most common reasons for refractory arterial hypertension, especially the problem of treatment malcompliance, are summarized.

[Plantar pruritus after trip to Vietnam]. / Plantarer Pruritus nach Vietnamaufenthalt.

A 33 year old man is evaluated for a pruriginous plantar eruption on the right foot. Three weeks ago he walked across a river barefoot in the south of Vietnam. In the clinical examination of the foot a red, serpiginuous dermatitis was seen. Patient history and clinical picture were typical for a larva migrans. After starting a treatment with albendazol the patient felt well and the lesions disappeared.

[Urticaria and parasites: case report and general view over the most common pathogens of chronic urticaria]. / Urtikaria und Parasiten: Fall- bericht und Ubersicht uber die häufigsten parasitären Erreger der chronischen Urtikaria.

Chronic urticaria is a disease with numerous aetiologies. In case of blood hypereosinophilia a parasitosis is probable an should be mentioned. Infections with echinococcus and helminths can cause IgE mediated release of histamine. Different cytokines are involved and lead to chronic urticaria as well. There are only a few case repoorts about chronic urticaria caused by amoebiasis. The transmission of amoebas is faeco oral and the pathogen can be detected with stool examinations or with testing of antigens or molecular methods. This case showed a remission of chronic urticaria after treatment of the amboebiasis with metronidazole and paromomycine. Therfore a direct causal connection of the amoebiasis and chronic urticaria can be assumed.

Is phosphorus recovery from waste water feasible?

Phosphorus (P) recovery from waste water must become a predominant goal of all countries to face the limited resources of this essential nutrient. The induced crystallisation of calcium phosphates straight from the waste water phase applying tobermorite-rich calcium silicate hydrate compounds (CSH) from the construction industry as the trigger material has proved to be a suitable method. Laboratory and semi-technical scale experiments were carried out in fixed bed, stirred reactor and expanded bed mode. P-loads of the crystallisation substrates of up to 13 wt-% total P (P-tot) (30 wt-% P2O5) were achieved. Recycling options of the generated products, both as substitute for phosphate rock in the phosphate industry and as a new fertiliser in agriculture, were demonstrated. Indicative operating and investment costs were estimated for conversion of conventional waste water treatment plants (WWTP) designed for nutrient removal and P-precipitation with iron and aluminium reagents to the proposed new crystallisation technology for simultaneous P-removal and P-recovery.

[Update on tuberculosis: interferon-gamma assays]. / Update Tuberkulose-Diagnostik: Interferon-gamma-Bluttests.

Until recently, skin testing with purified protein derivative of tuberculin was the only practical way of detecting latent tuberculosis infection (LTBI). However, the tuberculin skin test (TST) is subject to considerable variations and other limitations. PPD is a mixture of more than 200 mycobacterial antigens also present in nontuberculous mycobacteria and in the Bacille Calmette-Guérin (BCG) vaccine strains. Therefore false-positive testing results were common. Recently, peripheral blood-derived T-cell interferon-gamma responses to M.tuberculosis-specific antigens have been investigated for the management of tuberculosis. The results suggest that interferon-gamma assays may have advantages over the TST, in terms of higher specificity, better correlation with exposure to M.tuberculosis, and less cross-reactivity due to BCG vaccination and non-tuberculous mycobacterial infection. Furthermore, the interferon-gamma assays are less subject to reader bias and error and can be accomplished after a single patient visit. However, there is inadequate evidence on the value of interferon-gamma assays in the management of immunocompromised individuals for whom an alternative assay to the TST would be of great value.

[Antiviral treatment of influenza in humans]. / Antivirale Medikamente zur Behandlung und Prophylaxe der Influenza.

Antiviral agents are the most effective treatment option for influenza. Two classes of drugs are available, the adamantanes and the neuraminidase inhibitors. Neuraminidase inhibitors were a major breakthrough in the treatment options for influenza and were licensed in the year 2000. They have an excellent safety profile and effectively reduce viral shedding, symptoms, duration of illness, secondary complications, hospitalizations and consumption of antibiotics. Patients have also shown a more rapid return to everyday activities. The therapeutic efficacy is highly dependent on the time between the onset of symptoms and the starting of therapy. Very early initiation is primordial to have a maximal effect. Neuraminidase inhibitors are also effective in primary and secondary prophylaxis during epidemic influenza. They are a key point in the pandemic preparedness. Resistance to neuraminidase inhibitors does occur but has not become an extensive problem so far.

Hearing loss after discontinuing secondary prophylaxis for cryptococcal meningitis: relapse or immune reconstitution?

Relapse and immune reconstitution syndrome are difficult to distinguish in HIV-infected patients treated with antiretroviral therapy (ART). We report on a 26-year-old HIV-infected male (CDC C3) with hearing loss on the right side 2 months after discontinuing secondary prophylaxis for cryptococcal meningitis. CD4 cell counts had increased from 32/microl to stable counts > 200/microl for the preceding 6 months on ART but HIV replication was not fully suppressed (7,000 copies/ml). Magnetic resonance imaging identified lesions at the origin of the right cranial nerve VIII. Lumbar puncture revealed monocytic pleocytosis, slightly increased protein, but normal glucose and lactate levels, negative microbiological studies. Fluconazole was restarted and a new ART regimen was started in order to fully suppress HIV replication. Clinical and radiological signs were reversible during follow-up, and secondary prophylaxis was stopped after 6 months without adverse events. We review 26 published cases of cryptococcal infections with immune reconstitution syndrome and highlight the distinguishing features.

Phosphorus removal and recovery from wastewater by tobermorite-seeded crystallisation of calcium phosphate.

Investigations were focused on the development of a technology for phosphorus (P) recovery straight from wastewater. Facing the finiteness of the natural resources of this essential nutrient, the declared goal must be the sustainable use of available phosphorus sinks such as wastewater treatment plants (WWTP) for the generation of P rock substitutes. A feasible method for simultaneous elimination and recovery of phosphorus from wastewater proved to be the P-RoC process - the phosphorus recovery from wastewater by induced crystallisation of calcium phosphate, applying tobermorite-rich waste compounds of the construction industry. The experiments were performed in fixed bed-, stirred- and expanded bed reactors in laboratory--as well as in pilot-scale experiments. The efficiency and longevity of the P-RoC process was determined by the supply of Ca ions and the initial P concentration. Total P (P-tot) contents in the generated crystallisation products of up to 13% P-tot (30% P2O5) were achieved. Mineralogical investigations proved the formation of a hydroxy-apatite-(HAP)-like coating onto the seed material's surface. Reuse options for the generated crystallisation products, such as substitute for phosphate rock or as new fertiliser, were assessed.

[Worms and the lung]. / Der Wurm in der Lunge.

Due to international travel and migration helminthic infections are increasingly imported to countries were they are not endemic. A vast variety of helminthes may involve the lung. The lungs are either site of the infection or temporarily involved during maturation of helminthic larvae. In many affected patients the clinical picture is not specific and not typical. A thorough patient's history including a detailed travel history will lead to diagnosis, which must be confirmed by detecting the parasite either directly or with serological tests. The appropriate method depends on the parasite suspected and its life cycle within the human body. A combination of these methods will show the best results for most helminthes. As specific therapy is widely available for most helminthiases a precise diagnosis is important.