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Oscar Marchetti,
Stefan Zimmerli,
Michel Glauser,
Martin Täuber,
Christian Ruef,
Thierry Calandra,
Ursula Flückiger,
Alexander Imhof,
Jorge Garbino,
Philippe Eggimann,
Jacques Bille,
Didier Pittet
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ABSTRACT: We report a case series of 11 patients with severe E. faecium infections treated with daptomycin. All strains were resistant to ampicillin (MIC >8 mg/l), but susceptible to vancomycin. Seven out of 11 strains were also highly resistant to gentamicin (MIC >500 mg/l). All patients were treated with multiple broad-spectrum antibiotics prior to isolation of E. faecium and had severe underlying diseases. Our experience suggests that salvage therapy with daptomycin might be a safe and efficacious treatment for E. faecium infections.
Schweizerische medizinische Wochenschrift 01/2012; 142:w13603. · 1.68 Impact Factor
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ABSTRACT: Spinal epidural abscess (SEA) is a rare, but serious, condition with multiple causes. We prospectively studied the aetiology, predisposing factors, and clinical outcomes of SEA in all patients with SEA treated in our hospital's neurosurgical service from 2004 to 2008. For each patient, we recorded the medical history, comorbidities, focus of infection, pathogen(s), and outcome. The 36 patients (19 women and 17 men) ranged in age from 34 to 80 years old (mean 57; median 56). The SEA was primary (i.e., due to haematogenous spread) in 16 patients (44%); it was secondary to elective spinal procedures, either injections or surgery, in 20 patients (56%). The duration of follow-up was 12-60 months (mean 36; median 37.5). The most common pathogen, Staphylococcus aureus, was found in 18 patients (50%). Patients with primary SEA had different underlying diseases and a wider range of pathogens than those with secondary SEA. Only five patients (14%) had no major comorbidity; 16 of the 20 patients with secondary SEA (44% of the overall group) had undergone spinal surgery before developing the SEA; the treatment of the SEA involved multiple surgical operations in all 16 of these patients, and spinal instrumentation in 5 (14%); 22 patients (61% of the overall group) recovered fully.
European Spine Journal 05/2011; 20(12):2228-34. · 1.97 Impact Factor
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ABSTRACT: Deep sternal wound infection (DSWI) is a severe complication after cardiac surgery, mostly caused by staphylococci. Little is known about the optimal antibiotic management.
A 10 year retrospective analysis of 100 patients with staphylococcal DSWI after cardiac surgery in a tertiary hospital. Treatment failure was defined as sternal wound dehiscence or fistula at the end of the prescribed antibiotic therapy, 12 months later, or DSWI-related death.
Most patients were male (83%) and the median age was 72 years [interquartile range (IQR) 63-76]. Coronary artery bypass was the most frequent preceding procedure (93%). The median time to diagnosis of DSWI was 13 days (IQR 10-18) after surgery. Clinical presentation consisted of wound discharge in 77% of patients. Coagulase-negative staphylococci were isolated in 54 and Staphylococcus aureus in 46 patients. All patients received antibiotics and 95% underwent surgical debridement. The median duration of antibiotic treatment was 47 days (IQR 41-78). During follow-up, 21 out of 100 patients experienced treatment failure. Of these, 8/21 patients (38%) died from DSWI after a median of 12 days (IQR 8-30). In the multivariate analysis, a rifampicin-containing antibiotic regimen was the only factor associated with lower risk of treatment failure (hazard ratio 0.26, 95% confidence interval 0.10-0.64, P = 0.004). Prolonged treatment (12 weeks instead of 6 weeks) did not alter outcome (P = 0.716) in patients without prosthetic valve endocarditis.
Treatment of rifampicin-susceptible staphylococcal DSWI with a rifampicin-containing antibiotic regimen may improve the outcome. After surgical debridement an antibiotic treatment of 6 weeks may be adequate for staphylococcal DSWI.
Journal of Antimicrobial Chemotherapy 08/2010; 65(8):1799-806. · 5.07 Impact Factor
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ABSTRACT: We report on a leukemic patient who suffered from a persistent, generalized, and eventually fatal Staphylococcus epidermidis infection during prolonged aplasia. Over a 6-week period, we isolated a genetically and phenotypically unstable S. epidermidis strain related to an epidemic clone associated with hospital infections worldwide. Strikingly, the strain showed a remarkable degree of variability, with evidence of selection and increasing predominance of biofilm-producing and oxacillin-resistant variants over time. Thus, in the early stages of the infection, the strain was found to generate subpopulations which had spontaneously lost the biofilm-mediating ica locus along with the oxacillin resistance-conferring mecA gene. These deletion mutants were obviously outcompeted by the ica- and mecA-positive wild-type genotype, with the selection and predominance of strongly biofilm-forming and oxacillin-resistant variants in the later stages of the infection. Also, a switch from protein- to polysaccharide intercellular adhesin/poly-N-acetylglucosamine (PIA/PNAG)-mediated-biofilm production was detected among ica-positive variants in the course of the infection. The data highlight the impact of distinct S. epidermidis clonal lineages as serious nosocomial pathogens that, through the generation and selection of highly pathogenic variants, may critically determine disease progression and outcome.
Journal of clinical microbiology 07/2010; 48(7):2407-12. · 4.16 Impact Factor
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JAIDS Journal of Acquired Immune Deficiency Syndromes 09/2009; 51(4):506-7; author reply 507-8. · 4.43 Impact Factor
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ABSTRACT: To evaluate outcomes following implementation of a checklist with criteria for switching from intravenous (iv) to oral antibiotics on unselected patients on two general medical wards.
During a 12 month intervention study, a printed checklist of criteria for switching on the third day of iv treatment was placed in the medical charts. The decision to switch was left to the discretion of the attending physician. Outcome parameters of a 4 month control phase before intervention were compared with the equivalent 4 month period during the intervention phase to control for seasonal confounding (before-after study; April to July of 2006 and 2007, respectively): 250 episodes (215 patients) during the intervention period were compared with the control group of 176 episodes (162 patients). The main outcome measure was the duration of iv therapy. Additionally, safety, adherence to the checklist, reasons against switching patients and antibiotic cost were analysed during the whole year of the intervention (n = 698 episodes).
In 38% (246/646) of episodes of continued iv antibiotic therapy, patients met all criteria for switching to oral antibiotics on the third day, and 151/246 (61.4%) were switched. The number of days of iv antibiotic treatment were reduced by 19% (95% confidence interval 9%-29%, P = 0.001; 6.0-5.0 days in median) with no increase in complications. The main reasons against switching were persisting fever (41%, n = 187) and absence of clinical improvement (41%, n = 185).
On general medical wards, a checklist with bedside criteria for switching to oral antibiotics can shorten the duration of iv therapy without any negative effect on treatment outcome. The criteria were successfully applied to all patients on the wards, independently of the indication (empirical or directed treatment), the type of (presumed) infection, the underlying disease or the group of antibiotics being used.
Journal of Antimicrobial Chemotherapy 05/2009; 64(1):188-99. · 5.07 Impact Factor
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Nathan Cantoni,
Maja Weisser,
Andreas Buser,
Caroline Arber,
Martin Stern,
Dominik Heim,
Jörg Halter,
Susanne Christen,
Dimitrios A Tsakiris,
Armin Droll,
Reno Frei,
Andreas F Widmer, Ursula Flückiger,
Jakob Passweg,
André Tichelli,
Alois Gratwohl
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ABSTRACT: Nursing in 'live islands' and routine high dose intravenous immunoglobulins after allogeneic hematopoietic stem cell transplantation were abandoned by many teams in view of limited evidence and high costs.
This retrospective single-center study examines the impact of change from nursing in 'live islands' to care in single rooms (SR) and from high dose to targeted intravenous immunoglobulins (IVIG) on mortality and infection rate of adult patients receiving an allogeneic stem cell or bone marrow transplantation in two steps and three time cohorts (1993-1997, 1997-2000, 2000-2003).
Two hundred forty-eight allogeneic hematopoetic stem cell transplantations were performed in 227 patients. Patient characteristics were comparable in the three cohorts for gender, median age, underlying disease, and disease stage, prophylaxis for graft versus host disease (GvHD) and cytomegalovirus constellation. The incidence of infections (78.4%) and infection rates remained stable (rates/1000 days of neutropenia for sepsis 17.61, for pneumonia 6.76). Cumulative incidence of GvHD and transplant-related mortality did not change over time.
Change from nursing in 'live islands' to SR and reduction of high dose to targeted IVIG did not result in increased infection rates or mortality despite an increase in patient age. These results support the current practice.
European Journal Of Haematology 04/2009; 83(2):130-8. · 2.61 Impact Factor
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ABSTRACT: Approximately 25% of Staphylococcus aureus carriers have exclusive throat carriage. We aimed to identify the populations at risk for exclusive throat carriage to improve sensitivity to detect carriers.
Four groups underwent nasal and throat screening for S. aureus. Three groups of individuals in the community (n = 2632) with different estimated levels of exposure to the health care system (HCS) were screened, including 1500 healthy blood donors, 498 patients from a school of dental medicine, and 634 health care workers (HCWs) at a trade fair. The fourth group comprised in-hospital patients and HCWs (n = 832) and was considered the group with the highest estimated exposure to the HCS. As a primary outcome, we analyzed risk factors for exclusive throat carriage in exclusive throat carriers vs all nasal carriers.
Of 3464 individuals screened, 428 (12.4%) had exclusive throat carriage, and 1260 (36.4%) had carriage in the nares only or in the nares and the throat. The most important independent risk factor for exclusive throat carriage was age 30 years or younger (odds ratio, 1.66; P < .001). Exposure to the HCS was a significant protective factor for exclusive throat carriage (odds ratio, 0.67; P = .001). Healthy blood donors were almost twice as likely to have exclusive throat carriage than in-hospital patients and HCWs (30.2% vs 18.4% of all carriers, P < .001).
Absence of exposure to the HCS and younger age predicted exclusive throat carriers, a population at high risk for community-onset methicillin-resistant S. aureus. Screening for S. aureus should include swabs from the anterior nares and from the throat to improve the likelihood of detecting carriers.
Archives of internal medicine 02/2009; 169(2):172-8. · 11.46 Impact Factor
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ABSTRACT: Potent antiretroviral therapy (ART) has dramatically improved the prognosis of HIV-1-infected individuals. However, 10% to 30% of patients in Western countries still present late for care, when CD4 T cells are below 200 cells/mm(3) and symptomatic HIV disease has occurred. Clinical considerations for advanced HIV disease are paramount as morbidity and mortality are directly correlated with a low initial CD4 T cell count, which is commonly associated with the simultaneous occurrence of co-morbidities, particularly opportunistic infections. Upon start of ART, the clinical entity of immune reconstitution inflammatory syndrome may occur and, in this context, raise the question of early versus delayed ART in patients treated for opportunistic infections. Recent data clearly indicate that an earlier start of ART is warranted in this latter situation. Guidelines for specific antiretroviral treatment for late-presenting patients are lacking. Knowledge about drug-drug interactions and co-morbidities should guide treatment choices and influence the clinical management and monitoring of drug-related side effects and interactions. Importantly, the outlook of patients who present late is very much dependent upon the initial response to ART. Nevertheless, even if optimal response to treatment has been achieved, long-term prognosis may be impaired in patients who initially presented with advanced HIV disease. We encourage physicians to perform HIV testing more frequently in order to detect HIV-infected individuals in time.
Journal of Antimicrobial Chemotherapy 08/2008; 62(1):41-4. · 5.07 Impact Factor
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ABSTRACT: Alpha-toxin (Hla, encoded by hla) is a major virulence factor of Staphylococcus aureus. The activity of the hla promoter was analyzed using luxABCDE on an integration vector. The phla-lux construct was introduced in S. aureus Newman and its isogenic sae and sigB regulator mutants. Promoter activity was monitored by bioluminescence in vitro and in the murine tissue-cage model. Hla promoter activity could be followed in real time at repeated time points of infection. The activation of hla in the sigB-deficient strain and the repression to background levels in a sae-deficient strain relative to hla expression in the wild type could be demonstrated in vivo. Subinhibitory concentrations of teicoplanin, imipenem and ciprofloxacin enhanced hla promoter activity in vitro whereas clindamycin and rifampicin did not. Our approach proved to be rapid and adequate to study promoter activity in vitro and in vivo under conditions where high bacterial numbers are reached.
International journal of medical microbiology: IJMM 04/2008; 298(7-8):599-605. · 2.80 Impact Factor
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ABSTRACT: The anterior nares are the most important screening site of colonization with Staphylococcus aureus. We screened 2966 individuals for S. aureus carriage with swabs of both nares and throat. A total of 37.1% of persons were nasal carriers, and 12.8% were solely throat carriers. Screening of throat swabs significantly increases the sensitivity of detection among carriers by 25.7%.
Clinical Infectious Diseases 09/2007; 45(4):475-7. · 9.15 Impact Factor
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ABSTRACT: Bacteriophages serve as a driving force in microbial evolution, adaptation to new environments and the pathogenesis of human bacterial infections. In Staphylococcus aureus phages encoding immune evasion molecules (SAK, SCIN, CHIPS), which integrate specifically into the beta-haemolysin (Hlb) gene, are widely distributed. When comparing S. aureus strain collections from infectious and colonizing situations we could detect a translocation of sak-encoding phages to atypical genomic integration sites in the bacterium only in the disease-related isolates. Additionally, significantly more Hlb producing strains were detected in the infectious strain collection. Extensive phage dynamics (intragenomic translocation, duplication, transfer between hosts, recombination events) during infection was shown by analysing cocolonizing and consecutive isolates of patients. This activity leads to the splitting of the strain population into various subfractions exhibiting different virulence potentials (Hlb-production and/or production of immune evasion molecules). Thus, phage-inducing conditions and strong selection for survival of the bacterial host after phage movement are typical for the infectious situation. Further in vitro characterization of phages revealed that: (i) SAK is encoded not only on serogroup F phages showing a conserved tropism for hlb but also on serogroup B phages which always integrate in a distinct intergenic region, (ii) the level of sak transcription correlates to phage inducibility but is independent of the phage localization in the chromosome, and (iii) phages can be stabilized extra-chromosomally during their life cycle.
Molecular Microbiology 10/2006; 61(6):1673-85. · 5.01 Impact Factor
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Ursula Flückiger,
Oscar Marchetti,
Jacques Bille,
Philippe Eggimann,
Stefan Zimmerli,
Alexander Imhof,
Jorge Garbino,
Christian Ruef,
Didier Pittet,
Martin Täuber,
Michel Glauser,
Thierry Calandra
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ABSTRACT: A panel of infectious disease specialists, clinical microbiologists and hospital epidemiologists of the five Swiss university hospitals reviewed the current literature on the treatment of invasive fungal infections in adults and formulated guidelines for the management of patients in Switzerland. For empirical therapy of Candida bloodstream infection, fluconazole is the drug of choice in non-neutropenic patients with no severe sepsis or septic shock or recent exposure to azoles. Amphotericin B deoxycholate or caspofungin would be the treatment option for patients with previous azole exposure. In neutropenic patients, empirical therapy with amphotericin B deoxycholate is considered first choice. In patients with severe sepsis and septic shock, caspofungin is the drug of first choice. For therapy of microbiologically-documented Candida infection, fluconazole is the drug of choice for infections due to C. albicans, C. tropicalis or C. parapsilosis. When infections are caused by C. glabrata or by C. krusei, caspofungin or amphotericin B deoxycholate are first line therapies. Treatment guidelines for invasive aspergillosis (IA) were stratified into primary therapy, salvage therapy and combination therapy in critically ill patients. Voriconazole is recommended for primary (ie upfront) therapy. Caspofungin, voriconazole (if not used for primary therapy) or liposomal amphotericin B are recommended for salvage therapy for refractory disease. Combination therapy with caspofungin plus voriconazole or liposomal amphotericin B should be considered in critically ill patients. Amphotericin B deoxycholate is recommended as initial therapy for the empirical therapy in patients with neutropenia and persistent fever with close monitoring of adverse events.
Swiss medical weekly: official journal of the Swiss Society of Infectious Diseases, the Swiss Society of Internal Medicine, the Swiss Society of Pneumology 08/2006; 136(29-30):447-63. · 1.89 Impact Factor
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ABSTRACT: The alternative sigma factor sigma(B) of Staphylococcus aureus controls the expression of a variety of genes, including virulence determinants and global regulators. Genetic manipulations and transcriptional start point (TSP) analyses showed that the sigB operon is transcribed from at least two differentially controlled promoters: a putative sigma(A)-dependent promoter, termed sigB(p1), giving rise to a 3.6-kb transcript covering sa2059-sa2058-rsbU-rsbV-rsbW-sigB, and a sigma(B)-dependent promoter, sigB(p3), initiating a 1.6-kb transcript covering rsbV-rsbW-sigB. TSP and promoter-reporter gene fusion experiments indicated that a third promoter, tentatively termed sigB(p2) and proposed to lead to a 2.5-kb transcript, including rsbU-rsbV-rsbW-sigB, might govern the expression of the sigB operon. Environmental stresses, such as heat shock and salt stress, induced a rapid response within minutes from promoters sigB(p1) and sigB(p3). In vitro, the sigB(p1) promoter was active in the early growth stages, while the sigB(p2) and sigB(p3) promoters produced transcripts throughout the growth cycle, with sigB(p3) peaking around the transition state between exponential growth and stationary phase. The amount of sigB transcripts, however, did not reflect the concentration of sigma(B) measured in cell extracts, which remained constant over the entire growth cycle. In a guinea pig cage model of infection, sigB transcripts were as abundant 2 and 8 days postinoculation as values found in vitro, demonstrating that sigB is indeed transcribed during the course of infection. Physical interactions between staphylococcal RsbU-RsbV, RsbV-RsbW, and RsbW-sigma(B) were inferred from a yeast (Saccharomyces cerevisiae) two-hybrid approach, indicating the presence of a partner-switching mechanism in the sigma(B) activation cascade similar to that of Bacillus subtilis. The finding that overexpression of RsbU was sufficient to trigger an immediate and strong activation of sigma(B), however, signals a relevant difference in the regulation of sigma(B) activation between B. subtilis and S. aureus in the cascade upstream of RsbU.
Journal of Bacteriology 01/2006; 187(23):8006-19. · 3.83 Impact Factor
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ABSTRACT: This article reports an unusual presentation of bowel perforation.
We report the case of a 30-year-old HIV-infected male who suffered from an advanced state of CD4 cell depletion (29 CD4 cells per 106/l). Abdominal pain and diarrhea led to further examinations.
Colonoscopy revealed a severe tuberculous ileocecal inflammation. Tuberculosis and HIV infection were treated. The patient's response to antiretroviral therapy was excellent. After 11 months of potent antiretroviral treatment and 12 months of antituberculous therapy he suffered from acute abdominal pain with fever and ileus. Laparotomy revealed two intestinal perforations of the jejunum and inflammation of the whole ileocecal region.
Immunopathologic reactions caused by immune restoration are novel presentations of highly active antiretroviral treatment as shown here. The presented patient is an unusual case with a very late onset of inflammatory response, which led to intestinal perforation.
Diseases of the Colon & Rectum 08/2002; 45(7):977-8. · 3.13 Impact Factor
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ABSTRACT: PURPOSE: This article reports an unusual presentation of bowel perforation.
METHODS: We report the case of a 30-year-old HIV-infected male who suffered from an advanced state of CD4 cell depletion (29 CD4 cells per 106/l). Abdominal pain and diarrhea led to further examinations.
RESULTS: Colonoscopy revealed a severe tuberculous ileocecal inflammation. Tuberculosis and HIV infection were treated. The patients response to antiretroviral therapy was excellent. After 11 months of potent antiretroviral treatment and 12 months of antituberculous therapy he suffered from acute abdominal pain with fever and ileus. Laparotomy revealed two intestinal perforations of the jejunum and inflammation of the whole ileocecal region.
CONCLUSION: Immunopathologic reactions caused by immune restoration are novel presentations of highly active antiretroviral treatment as shown here. The presented patient is an unusual case with a very late onset of inflammatory response, which led to intestinal perforation.
Diseases of the Colon & Rectum 01/2002; 45(7):977-978. · 3.13 Impact Factor
