Antibiotic misuse in medium-sized Swiss hospitals.

Antibiotics account for a substantial proportion of hospital drug expenditures and tend to be misused or overused, generating unnecessary costs and causing the emergence of resistant bacteria. Antibiotic use was evaluated in a one-day prevalence study performed on the surgical and medical wards of eight Swiss non-university hospitals. 173 of the 695 inpatients present (25%) were on antibiotics and 163 could be evaluated. 35 prescriptions were secondary to an infectious disease consultation. 60 of the remaining 128 (47%) were considered inappropriate, of which 17 (28%) lacked any indication for antibiotic use. The rates of misuse were higher in surgery than in medicine (58 vs. 34%; OR = 2.5 [95% CI: 1.1-5.9]), and higher for prophylaxis than for treatment (72 vs. 41%; OR = 4.1 [95% CI: 1.3-15.5]). Savings of 545 euros (95% CI: from -116 to 1,206 euros) on the study day and 6,256 euros (95% CI: from -2,221 to 14,732 euros) for the total treatments or prophylaxis administered would have resulted from infectious disease consultations.

Collagenous colitis and cutaneous polyarteritis nodosa in the same patient.

Collagenous colitis is associated with chronic diarrhoea and inflammatory changes detected by colonic biopsy, but no endoscopic abnormalities. Cutaneous polyarteritis nodosa shows the same histopathology as systemic polyarteritis nodosa, but is limited to the skin. Both diseases are rare and of unknown aetiology. Collagenous colitis has been described in association with different autoimmune disorders. We report on a case of collagenous colitis and cutaneous polyarteritis nodosa. To our knowledge, this association has not been reported previously.

Evaluation of do not resuscitate orders (DNR) in a Swiss community hospital.

OBJECTIVE: To evaluate the effect of an intervention on the understanding and use of DNR orders by physicians; to assess the impact of understanding the importance of involving competent patients in DNR decisions. DESIGN: Prospective clinical interventional study. SETTING: Internal medicine department (70 beds) of the hospital of La Chaux-de-Fonds, Switzerland. PARTICIPANTS: Nine junior physicians in postgraduate training. INTERVENTION: Information on the ethics of DNR and implementation of new DNR orders. MEASUREMENTS AND MAIN RESULTS: Accurate understanding, interpretation, and use of DNR orders, especially with respect to the patients' involvement in the decision were measured. Junior doctors writing DNR orders had an extremely poor understanding of what DNR orders mean. The correct understanding of the definition of a DNR order increased from 31 to 93% (p<0.01) after the intervention and the patients' involvement went from 17% to 48% (p<0.01). Physicians estimated that 75% of their DNR patients were mentally competent at the time of the decision. CONCLUSION: An intervention aimed at explaining the ethical principles and the definition of DNR orders improves understanding of them, and their implementation, as well as patient participation. Specific efforts are needed to increase the involvement of mentally competent patients in the decision.

Disappearance rate of catecholamines, total metanephrines, and neuropeptide Y from the plasma of patients after resection of pheochromocytoma.

BACKGROUND: Plasma free metanephrines are a more reliable analyte to measure than catecholamines for the biochemical diagnosis of pheochromocytomas. We hypothesized that the long persistence of total (sulfate-conjugated plus free) metanephrines in the blood might have a significant diagnostic value. METHODS: We measured plasma concentrations of catecholamines and total metanephrines (sulfate-conjugated plus free forms) by HPLC with amperometric detection, and neuropeptide Y (NPY) by an amplified ELISA in seven patients before and after removal of their pheochromocytomas. The results for catecholamine, total metanephrines, and NPY in each patient were analyzed for up to 120 min, starting from the time of tumor vessel clamping. The persistence of analytes was quantified as the area under the concentration-time curve over 120 min. RESULTS: On the basis of the upper reference limit for each variable, plasma free norepinephrine (NE) and epinephrine (E) concentrations were increased preoperatively in at least one sample in seven and six patients, respectively. Total normetanephrine (NMN) and metanephrine (MN) were increased in all samples in seven and six patients, respectively. NPY was increased 2- to 465-fold. After removal of the tumor, MN and NMN showed a higher average relative increase above the upper limit of the reference interval than NE and E (P = 0.05), whereas NPY was intermediate. The persistence of increased values was significantly shorter for catecholamines than for metanephrines. The half-life estimated by nonlinear regression was 12.3 +/- 7.8 min for NPY. Significant correlations were observed among NE, E, NMN, MN, and NPY concentrations, but parent markers (E and MN or NE and NMN) did not appear significantly intercorrelated. CONCLUSIONS: A larger increase and a longer persistence of total metanephrines (reflecting predominantly sulfo-conjugated metanephrines) than catecholamines and NPY in plasma may contribute to their greater diagnostic accuracy in pheochromocytoma.

No serological evidence of association between chlamydia pneumonia infection and acute coronary heart disease.

Today's medical literature shows more and more evidence that Chlamydia pneumoniae plays a role in coronary atherosclerotic disease. This cross-sectional study examines the serostatus for C. pneumoniae of patients with an acute cardiovascular event. A total of 58 patients with acute myocardial infarction or with proven unstable angina (occlusion > or = 70% of at least 1 vessel at coronary angiography) ('patients') were compared with 58 age- and sex-matched patients without a cardiovascular event ('controls'). Serological testing for C. pneumoniae was performed by a microimmunofluorescence test during the first week of the event and 4-6 weeks later. Although more patients from the cardiovascular event group showed a positive history of a respiratory tract infection during 6 weeks preceding hospitalization (18/58 patients, 8/58 controls, p = 0.03), there was no significant difference between the two groups for an acute, chronic or past infection by C. pneumoniae (19/58 patients, 24/58 controls, p = 0.93). In conclusion, contrary to previous published papers, this study could not confirm an association of C. pneumoniae infection with an acute coronary event. Serological testing alone may not be the best way to demonstrate this association. An acute infection by C. pneumoniae, which should have been detected by serological testing, is probably not the origin of the rupture of an atheromatous plaque.

[Intractable vomiting, convulsions and megaloblastic anemia: anamnesis, key to diagnosis]. / Vomissements incoercibles, convulsions et anémie mégaloblastique: l'anamnèse, clé du diagnostic.

In July 1996 a 43-year-old illiterate Hispanic woman presented with uncontrollable vomiting, palpitations and confusion. In 1994, despite several hospitalisations in other medical centres where a cerebral CT-scan, oesogastroduodenoscopy, colonoscopy and abdominal ultrasound were performed, no satisfactory diagnosis could be found. A psychiatric origin was finally considered. On admission, the laboratory findings showed severe metabolic alkalosis with associated hypokalaemia, confirmatory evidence of vomiting. The ECG showed tremendous P waves (5 mV) in the standard derivations, which can be explained by the hypokalaemia, with multiple supraventricular extrasystoles. Echocardiography and pulmonary scintigraphy ruled out pulmonary hypertension and a pulmonary embolus. After additional discussion with her daughter we discovered that the patient had been treating chronic headaches for years with 4-5 Cafergot-PB suppositories per day. This drug contains 2 mg ergotamine tartrate, 100 mg butalbital, 100 mg caffeine and 0.25 mg belladona alkaloids. As is known, vomiting is a classical symptom of ergotamine intoxication. After rehydration we discovered a megaloblastic anaemia with a folate deficiency compatible with chronic barbiturate intoxication. Folate and iron supplementation allowed a rapid normalisation of the haemoglobin values. Five months after having stopped the Cafergot-PB, the patient was well and did not vomit anymore. The headaches were treated with chlorpromazine with a good result. Despite sophisticated technical means, the diagnosis could only be established after a thorough history taking. This message should be heard in times when high tech medicine tends to obscure the place of a good history taking!

[Cerebral hemorrhage and "ecstasy"]. / Hémorragie cérébrale et "Ecstasy".

We report the case of an acute cerebral hemorrhage after one "ecstasy" tablet in a 21 year old woman without any relevant medical or surgical history. The status showed a right sensorimotor syndrome. The CT-scan and the MRI revealed a left cerebral hemorrhage. The patient only partially recovered her neurological functions after one year. The discussion deals with the effects and dangers of 3,4-methylenedioxymethamphetamine (MDMA, ecstasy) which is systematically used in night parties or "raves".

Two-to-one AV block associated with the congenital long QT syndrome.

INTRODUCTION: Conduction abnormalities associated with long QT syndrome (LQTS) have been reported as "pseudo 2:1 AV block" due to sinus intervals shorter than ventricular refractoriness. METHOD AND RESULTS: We report the electrophysiologic characteristics of a patient suffering from congenital LQTS with episodes of true 2:1 AV block. Induction of 2:1 infra-Hisian blocks and return to 1:1 conduction were observed using single atrial and ventricular extrastimuli. The block was located in the Purkinje network but not in the myocardium. CONCLUSION: The His-Purkinje system of our LQTS patient displayed dynamic properties with a strong increase in refractoriness for short-long sequences and a decrease for long-short sequences that triggered intermittent 2:1 AV blocks.

[Antibiotics and some popular beliefs]. / Antibiotiques et quelques croyances populaires.

Although rarely studied, popular beliefs play a role in treatment compliance. In order to clarify this problem in the field of anti-infectious agents we sent a questionnaire to 200 patients and 100 nurses of the community hospital in La Chaux-de-Fonds, Switzerland. We tried to test the influence, in poor patient compliance, of wrong beliefs concerning side effects and drug elimination. Eleven and twenty percent of patients suffered at least once from an episode of "allergy" and from another possible side effect respectively. Fatigue, often mentioned, has not been proved being a side effect and allergy is vastly overdiagnosed. Almost 50% of patients believe that antibiotics remain in the organism for months. Nurses are more intolerant to antibiotics than patients. In order to gain some insight on the role of cultural differences, the same questionnaire was submitted to nurses of the Moubda hospital in Cameroun. Their answers are very different from those of their swiss collegues: less side effects and allergies are reported. Nevertheless 17% would refuse an antibiotic therapy in case of a severe infection as compared to only 8% of swiss nurses. The reason for theses differences warrants further study.

Clarithromycin versus amoxicillin-clavulanic acid in the treatment of community-acquired pneumonia.

In an open, prospective, randomised study, the clinical and bacteriological efficacy of intravenously administered clarithromycin was compared with that of amoxicillin-clavulanic acid in 112 patients with community-acquired pneumonia requiring hospitalisation. Clinical cure or improvement occurred in 86% (48/56) of the clarithromycin-treated patients and 84% (47/56) of the amoxicillin-clavulanic acid-treated patients. The rate of bacteriologic eradication was similar for the two drugs as were the rapidity of a clinical response and the rate of improvement of radiological signs. Clarithromycin had a slightly higher rate of side-effects mainly due to phlebitis caused by the intravenous treatment, but treatment could be continued in all cases. Clarithromycin should be used with caution in patients being treated with digoxin because of a significant risk of bradycardia resulting from drug interaction.

[Level of stethoscope contamination in the hospital environment]. / Taux de contamination des stéthoscopes en milieu hospitalier.

The aim of this study was to determine the extent of the contamination of stethoscopes and their possible role in transmission of microorganisms. The stethoscopes of the medical doctors of the hospital of La Chaux-de-Fonds, Switzerland, were cultured and the date of the last cleaning recorded. 38 of the 62 stethoscopes surveyed were contaminated with microorganisms (61%). The majority of isolated organisms were gram-positive bacteria, primarily Staphylococcus species (89%). The cleaning of the stethoscopes was frequent for 32% of the doctors, rare for 46% and non-existent for 22%. After more than one day without cleaning of the stethoscope, the level of contamination rose from 0% to 69%. Stethoscope use may be an important factor in the spread of infectious agents, so that regular disinfection should be carried out (once a day at the very least).

Pasteurella multocida endocarditis: report of a case and review of the literature.

We report on a cirrhotic patient who presented with an aortic valve endocarditis due to Pasteurella multocida. This disease entity is rare and we take this opportunity to review the 6 cases published to date.

[Meningoencephalo-myeloradiculitis due to Flavivirus: bi-brachial paralysis and respiratory insufficiency]. / Méningo-encéphalo-myélo-radiculite à flavivirus: parésie bi-brachiale et insuffisance respiratoire.

3 patients developed rapid onset of fever and nuchal stiffness. Paresis of brachial muscles occurred within 4 days and all patients had respiratory failure that needed mechanical ventilation. At the peak of the disease there were bilateral asymmetrical severe atrophy of brachial, shoulder and neck muscles, cranial nerve pareses and absent or weak deep reflexes in the upper extremities. CSF analyses showed sterile lymphocytic pleocytosis. In 2 cases the patients suffered a tick bite in Switzerland and the third was probably bitten by an insect while opening a package received from Indonesia. Patients had rapid defervescence and serological tests were found to be highly positive for IgM and then IgG ELISA FSME (Frühsommer-Meningoenzephalitis). The patients were ventilated for 2 to 5 weeks before a progressive improvement was seen. However, on follow-up at 12, 18 and 30 months respectively, proximal muscles were still atrophied and quite weak. Our cases underline that: (1) FSME-ELISA results may cross-react with the Japanese and Central European encephalitis virus species; (2) Flaviviruses do induce unusual and preferential long-term paralysis of the upper extremities simulating poliomyelitis; (3) in the 2 patients studied electrophysiologically, there were signs of axonal reinnervation not seen in lower motor neuron syndrome which were important for reinnervation to permit progressive, but late, motor improvement; (4) there is no evidence of extension of the endemic foci of tick-borne encephalitis in Switzerland.

[Voluntary poisoning with dexfenfluramine (Isomeride)]. / Intoxication volontaire à la dexfenfluramine (Isomeride).

Dexfenfluramine is one of the most widely prescribed appetite suppressant drugs in Switzerland because of its enhancing effect on certain weight-reducing diets. Nevertheless, the effects of acute intoxication are not well documented. We recently observed a young adolescent girl who ingested large quantities of the drug to achieve a rapid weight loss. She presented with tachycardia, high blood pressure, mydriasis, fever and behavioral disorders. All signs and symptoms cleared after 48 hours. The clinical picture is akin to amphetamine intoxication, in view of the similarity of the two drugs' metabolites.

[Primary cardiac lymphoma with obstructive cardiac insufficiency]. / Lymphome cardiaque primaire avec insuffisance cardiaque obstructive.

A 80 year old man, in general good health, presented with a rapidly progressive congestive heart failure, without response to treatment. At echocardiography, there were masses in the right atrium and ventricle. The patient deceased two months after the first clinical manifestations. At autopsy, we found a massive right-sided atrio-ventricular infiltration by a malignant non-Hodgkin's lymphoma of centroblastic type, causing a subtotal obstruction of the tricuspid and pulmonary valves. We observed also four intestinal metastases without other manifestations of lymphoma.

Cost containment: Europe. Switzerland.

Thanks to Switzerland's very favorable economic situation over the last 20 yrs, intensive care medicine in the country has reached a very satisfactory level. The country is covered by a dense network of ICUs certified by the Swiss Society of Intensive Care Medicine (SSICM). Bed allocation is generous, technological equipment plentiful, and nurses are well trained in a specialized certification program. Rules imposed on physician training by the SSICM have recently become more stringent. A large supply of money in Switzerland has made cost containment efforts a low priority; no well defined program to reduce intensive care costs is in effect. Due to an increasingly difficult economic situation in the future, Switerland's near optimal healthcare system may change; cost containment will probably have to be dealt with seriously in the near future.

[Decrease in general health status, febrile state and sinusitis in renal insufficiency]. / Baisse de l'état général, état fébrile et sinusite chez un insuffisant rénal.

UNLABELLED: A 59-year old man, dialysed for 9 years because of chronic renal failure of unknown etiology, was also suffering from a hypertensive cardiopathy and anemia. He has received more than 70 units of blood over the past few years. An elevated blood aluminium level prompted treatment with desferrioxamine for 3 years. Following episodes of melena, an intestinal-wall lesion, located 8 cm above the ileo-caecal valve was discovered. Blood serotonin levels were elevated; biopsy of the liver revealed tumor cells with round-shaped nuclei which stained positive for synaptophysin, findings compatible with a carcinoid tumor or a pancreatic islet-cells tumor. Considering the whole clinical situation, aggressive diagnostic of therapeutic measures were not pursued any further. The patient lost 8 kg over the next few months and was finally hospitalised with fever. Physical examination revealed ascites, edema and a gingival abscess which was drained. Blood cultures grew Klebsiella pneumoniae. Antibiotics were prescribed. A month later the patient complained again of fever accompanied by myalgias, edema and pain of the eyelids, mainly on the right side, pain in the maxillary area and on right eye motion. ENT examination revealed a necrotic lesion of the right middle turbinate which on histology was diagnosed as acute purulent rhinitis without granuloma or vasculitis. A CT-scan demonstrated mucosal thickening of the left sphenoidal, ethmoidal, frontal and maxillary sinuses without any osteolytic lesions. The patient suffered a sudden right eye blindness with signs of retinal ischemia accompanied by an elevated sedimentation rate of 130 mm. Steroid treatment for suspicion of a temporal arteritis was introduced. 2 days later the patient was rehospitalized in a semi-comatose condition. No new information was gained from the usual laboratory investigations and the physical examination was comparable to the previous hospital stay. Blood cultures remained sterile. He died a few hours later. DISCUSSION: The discussant, A. de Torrenté MD, accepts the diagnosis of a hypertensive cardiopathy, renal failure of unknown origin and a carcinoid of the terminal ileum with hepatic metastases. The role of iron overload as a contributory factor for the cardiac disease is discussed. More problematic are the manifestations of the terminal disease with involvement of the sinuses, the eyes and the mouth. The "lethal midline granuloma" (a syndrome and not a disease entity) covers many different diseases which can be considered in this case: Wegener's granuloma, various lymphomas, parasitic, bacteria- and fungus-induced diseases.(ABSTRACT TRUNCATED AT 400 WORDS)